The purpose of this study was to perform a financial analysis of severe brain injured (SBI) patient management to determine potential reimbursement versus net losses in relation to organ donation and transplantation at a transplant center. We undertook a retrospective analysis of financial records of medically suitable referrals to the organ procurement organization (OPO) from our institution for fiscal years 2002-2003. This included (1) hospital cost and reimbursement, (2) OPO reimbursement for actual donors, (3) financial returns on local transplant activity solely supported by local donor activity and (4) Medicare incentives for local organ donation. There were 48 potential and 18 organ donors for this period. The consent rate reduced from 50% to 25% if family was offered withdrawal of care. After reimbursements from OPO, Medicare incentives and kidney transplant activity solely supported by local organ donation were figured in, the total returns were 244% of total cost of SBI patient management. Aggressive proactive management of severely brain injured patients remains a good medical practice. For Medicare-approved transplant centers, there are additional financial incentives to aggressively treat these patients and pursue organ donation. Prematurely offering withdrawal of care negatively impacts on the organ donation process and hurts institutions financially.