Extracorporeal cardiopulmonary resuscitation (ECPR) offers a life-saving option for select patients with refractory cardiac arrest, yet a substantial proportion suffer devastating neurological injury and die despite extracorporeal support. In this context, organ donation may emerge as a potential downstream pathway, introducing complex ethical tensions at the intersection of life-sustaining treatment, end-of-life care, and organ preservation. This narrative review examines the ethical challenges associated with organ donation following ECPR, with particular attention to the transition from resuscitative intent to donation-oriented care. We discuss the clinical and ethical challenges of ECPR programs related to patient autonomy, informed consent, conflicts of interest, and equity of access in both adult and paediatric populations. Building on core principles of biomedical ethics, we propose a structured ethical model to guide clinicians and institutions navigating these scenarios. Central elements include strict separation between resuscitative and donation-related decision-making, transparent prognostication, robust safeguards around treatment intent, and early integration of ethics consultation and structured communication processes. We extend the prior evidence by offering ECPR-specific considerations, including concrete governance triggers, bedside tools, the integration of paediatric perspectives, and the translation of ethical principles into operational guidance. By defining clear ethical boundaries and governance mechanisms, this review aims to support the responsible integration of organ donation pathways following ECPR, while preserving public trust and reaffirming the primacy of patient-centred care.