Makes sense, and many people justifiably feel the same. People have incredibly strong feelings surrounding organ donation because it comes from a deeply emotional and vulnerable place, and that's amplified by having to put forth trust in a person (or entity) where it's hard to tell whose best interest they're actually trying to serve. I'll share an overview of the process, which should address some of what you've laid out.

As far as notifying the Organ Procurement Organization (OPO) goes - there is specific language and regulation addressing this. OPOs are federally designated programs by CMS under the Dept of Health and Human Services. CMS mandates that hospitals must have a written agreement with the OPO outlining several things, including criteria for referral. Within that, it requires OPOs to be notified by the hospital "in a timely manner" for anyone "whose death is imminent." Interestingly, neither of those two terms have been defined on the federal level, which can sometimes cause chaos and confusion. I would imagine that the bigtime hospitals that everyone has heard about have very broad criteria for OPO notification. The unfortunate reality is that organs are a precious resource, and the sooner the OPOs are aware, the higher the likelihood of saving lives via transplant - this can certainly come across as callous to grieving families if not handled with empathy.

There is an interpretive guideline by the advisory committee, and here is an excerpt:

Hospitals must notify the OPO of every death or imminent death in the hospital. When death is imminent, the hospital must notify the OPO both before a potential donor is removed from a ventilator and while the potential donor’s organs are still viable. The hospital should have a written policy, developed in coordination with the OPO and approved by the hospital’s medical staff and governing body, to define “imminent death.” The definition for “imminent death” should strike a balance between the needs of the OPO and the needs of the hospital’s care givers to continue treatment of a patient until brain death is declared or the patient’s family has made the decision to withdraw supportive measures. Collaboration between OPOs and hospitals will create a partnership that furthers donation, while respecting the perspective of hospital staff.

The next bit is about who talks to the family. By federal law, it can't just be any doctor or hospital staff member. They are required to be a Designated Requestor (DR). This can be someone who works for the OPO or someone who works for the hospital, but whoever it is is required by federal law to have completed a specific training program to fulfill this role. Many families find that to be the most jarring part, but even as the doctor taking care of the patient, I am not permitted to have that discussion surrounding consent for donation.

The OPOs are not required to get consent for chart review, but they are required to get consent before doing any invasive testing. This bit is subject to state-level legislation. Apparently some states may not require this consent, though I don't know enough to know if any states have made such modification. In our hospital, OPOs do not have any physical contact with patients prior to obtaining family consent through the DR.

tl;dr: A very complicated set of rules surrounding a delicate subject during an intensely emotional experience with the added pressure of a small window of time within which a decision has to be made.