Transplantation of vital human organs is a lifesaving therapy for patients with end-stage organ failure who are medically fit to undergo the surgical procedure. However, deceased donor management remains one of the most neglected areas in transplantation medicine. Brainstem death leads to hemodynamic, metabolic, and immune consequences. Failure to recognize them and provide adequate physiological support accounts for loss of the scarce source of valuable donor organs. Donor optimization leads to increased organ procurement and contributes to improved organ function in the recipient. This article reviews the management advances and controversies of the brainstem-dead donor in an intensive care unit.