donation after cardiac death

A donor after cardiac death (DCD) is a donor who has suffered devastating and irreversible brain injury and may be near death, but does not meet formal brain death criteria. In these cases, the family has decided to withdraw care. When the patient's heart stops beating, the organs are then recovered in the operating room. The surgeons involved in transplantation cannot be part of the end-of-life care or in the declaration of death. This type of donation does not cause or hasten death. Organs recovered from a donor after cardiac death have some degree of oxygen deprivation during the time after the heart stops beating. This may make kidneys from this type of donor "slow to start".

When your physician determines that your loved one has no chance for recovery, and, as the next of kin you decide to withdraw life-support, you may be offered the opportunity of Donation After Circulatory Death.

The Gift of Life Transplant Coordinator will engage you and your family in a donation conversation that provides full information on the power, meaning and life-transforming nature of the donation decision, share questions that other families of potential donors commonly ask and answers any questions that you may have about any aspect of this process.

Your loved one’s physicians and Gift of Life professionals will work with you to decide on the time to discontinue life-support. The withdrawal of treatment process is most often moved to the operating room so that the organ recovery process can begin as soon as possible after the patient’s heart stops and the patient’s doctor has determined they have died. The patient’s physician and nurse will be in attendance, providing end-of-life support and care exactly as they would have in the critical care unit.

Today, organ donation after circulatory death has increased the donation of life-saving organs; mostly kidneys, livers and pancreas. Thanks to advances in research and technology, we are now also able to transplant lungs and hearts using the DCD pathway to donation.

The gift of organ and tissue donation can change someone's life and rewrite their story. Here, donor families, transplant recipients and others share inspiring stories about how donation and transplant transforms lives.

Everyone knows what “brain dead” means: a person whose brain no longer works is brain dead. The term is used so frequently and in so many different contexts that we should not be surprised that two thirds of people incorrectly believe that someone who is brain dead is not legally dead, and more than half believe that a comatose patient is brain dead.1 Such misunderstandings and confusions make it easy to comprehend why there is still a good deal of controversy about the relationship between determination of death and organ donation. At a more fundamental level, however, there is good reason to question the logic and rationality of our current definitions of death and related concepts, such as the so-called “Dead Donor Rule” (DDR), which lies at the heart of current organ procurement policy.2 The controversy surrounding these issues has become heated enough that clinicians should understand the basis of the controversy and how it might affect their practices.

I will make several points in this discussion: When we pronounce individuals dead by neurological criteria, they are not really dead. When we pronounce individuals dead by neurological criteria, they are not really dead.

The era of clinical organ transplantation began in 1954 when Joseph Murray transplanted a kidney from one identical twin into another. Liver and heart transplantation, both of which require organs that could be obtained only from people who are already dead, became realities, respectively, in 1963 (Thomas Starzl) and 1967 (Christiaan Barnard). Survival rates after both liver and heart transplantation remained low until the introduction of cyclosporine in 1980. This drug, in combination with existing less effective immunosuppressive drugs, markedly increased survival rates and led to rapid expansion of the organ transplantation field. This, in turn, generated demand for increasing numbers of organs, especially from dead individuals, producing a paradox: “the need for both a living body and a dead donor.”3 The groundwork required to resolve this paradox had been laid in 1968 by Henry Beecher and the Harvard Ad Hoc Committee's proposal that a person could be diagnosed as dead when there was irreversible cessation of the function of the entire brain.4 This status has since become known as brain death, and has been codified in the law of every state by their adoption of the Uniform Determination of Death Act (UDDA) after its promulgation in 1981:

An individual who has sustained either (1) irreversible cessation of circulatory and respiratory functions, or (2) irreversible cessation of all functions of the entire brain, including the brain stem, is dead. A determination of death must be made in accordance with accepted medical standards.

There is only one kind of death — when one is dead, one is dead — but death can be determined in the two different ways described in the law. A brain dead individual who is warm and pink with heart beating and lungs ventilating is just as dead, legally, as an individual whose body has turned cold after the heart has permanently stopped beating.

The DDR is the formalization of the widely held belief that it is wrong to kill one person to save the life of another, leading to the conclusion that people should already be dead before vital organs are removed, an act that would certainly kill them. The DDR is neither a law nor a regulation — it is a description of an ethical norm: an organ donor must be dead before vital organs are removed. The UDDA in combination with the DDR assures patients, families, physicians, and other health professionals that a patient who is brain dead is in fact dead, making removal of organs for life-saving transplantation legally and ethically acceptable.

The current system has been in effect for over 30 years, and seems to be working satisfactorily. Yet, there remains considerable controversy about the validity of the DDR, to the point that some have recommended that the DDR be abandoned.5 First, the diagnosis of brain death may be unreliable. Many patients who meet all the criteria for brain death do not in fact have “irreversible cessation of all functions of the entire brain,” because some of the brain stem’s homeostatic functions remain, such as temperature control and water and electrolyte balance.6 To counter this observation, some argue that not all the functions of the brain need to be lost for a patient to be dead, only those that are critical to maintaining integration of the body functions; loss of these critical functions will inevitably lead over hours or days to cardiac arrest, even with continuing intensive life-support.7 Yet, even though this is often true, the bodies of some patients who meet all the criteria for brain death can survive for many years with all their bodily functions intact except for consciousness and brain stem reflexes.8

Over the past 15 years, as the shortage of organs for transplantation has become more acute, there has been an increasing emphasis on donation after cardiac death (DCD). Patients who have severe brain injuries but who are not brain dead may still be organ donors if the patient, by advance directive, or the patient's family decides that life support should be withdrawn. After that decision is made, consent for organ donation is obtained. The patient is brought to the operating room, life support is withdrawn, and when the heart stops after a few minutes to an hour without ventilation or other support, the physician observes the patient for a few minutes to ensure that the heart does not start beating again spontaneously. If there continues to be no circulation for 2–5 minutes, the physician pronounces the patient dead. At this point, the transplant team enters the operating room and removes organs, usually the kidneys and liver, from the now dead patient.9

The UDDA requires “irreversible” cessation of circulatory and respiratory functions, yet, under the circumstances of DCD, clearly the heart has not irreversibly arrested, as cardiopulmonary resuscitation ordinarily can restore cardiac function after an arrest of 10–15 minutes or longer. To avoid violating the DDR, it has been argued that a suitable substitute for the term “irreversible” is “permanent,” and if there is no intention to revive the heart, then the absence of function is permanent and the patient can be pronounced dead.10 The only reason this rhetorical device is needed is to satisfy the DDR — if there were no DDR, semantic manipulation would not be necessary. Moreover, if there were no DDR, organ donation would still be ethical because the decision to remove life support was made appropriately and consent for organ donation was properly obtained.

Ever since the New Jersey Supreme Court's decision in the Karen Ann Quinlan case in 1976, a generally accepted ethical norm is that withdrawal of life support does not cause the patient’s death, rather, withdrawing life support allows the patient to die — it is the disease that causes the patient’s death, not the physician. Yet, this view cannot be correct, because the agent that is the proximate cause of the patient's death is the physician.11 Miller and Truog illustrate this by hypothesizing two patients who are in identical clinical situations; both are ventilator-dependent.5 One patient is disconnected from the ventilator by someone who wants to kill the patient, and the other is disconnected by a physician responding to the patient's request to remove unwanted end-of-life technology. It is patently inconsistent to claim that in the first case, death was caused by the person who disconnected the ventilator (thus being guilty of murder), yet in the second case, the death was not caused by the physician who disconnected, but by the disease. There is obviously an enormous moral difference between the two acts, but the agent causing death in both cases is the person who withdrew support.

Although withdrawal of life support (not the patient's disease) causes death, it is not a legally or morally culpable act. The claim that if withdrawing life support causes death, it is unethical is a non sequitur because the central issue here is not causation, but is the overriding principle of respect for the patient's autonomy. The principle of self-determination as it applies to one's own body has long been recognized in U.S. law. The right of self-determination can be exercised by a competent person directly or through an advance directive, or by a proxy appointed by the patient or a legally authorized surrogate agent. This process is firmly established in ethics and law, and is not altered or undermined by recognizing that withdrawal of life support is the cause of death. Thus, the physician who withdraws life-support causes the patient's death, but is neither legally nor morally culpable.

If brain dead patients are near death but not really dead, recovering vital organs is nevertheless ethically well-grounded. Since 1968, the diagnosis of brain death has been understood to validate both withdrawal of life support and recovery of vital organs, and this does not change at all when brain dead individuals are understood to be in a state of irreversible coma, although still alive — they still satisfy the conditions of the UDDA. Given valid consent for withdrawing life support and for organ donation, if it is acceptable to cause a brain dead patient's death by withdrawing life support, then it logically must be acceptable to cause the patient's death by recovery of vital organs before withdrawal of life support. The cause of death is irrelevant because the ethics of self-determination and informed consent that underlies withdrawal of life support are of paramount importance.

In the case of DCD, the same rationale is valid if the patient is near death and supported by artificial ventilation. If the patient or her proxy-surrogate decision maker exercises the right of self-determination by first consenting to withdrawal of life support and then consenting to recovery of vital organs, a chain of events is set in motion that causes the death of the patient. No harm or wrong is done to the patient or to others by this chain of events, so they should not be seen as a criminal act.

The facts that brain dead patients are not really dead before organs are recovered and that DCD donors are imminently dying but not yet dead means that current practices of organ donation from both brain dead and DCD donors are not consistent with the DDR, yet these practices are ethically and legally well-grounded. Once this is recognized and accepted, the DDR, being neither a statute nor a regulation, can be discarded and physicians need not feel as though they are ethically or legally at fault.

Clearly, the DDR is incoherent with respect to brain death as currently defined. It could be could be saved as ethical policy, however, by changing the standard from the UDDA’s “irreversible cessation of all functions of the entire brain, including the brain stem” to a higher brain standard, that is, to permanent loss of consciousness, without requiring loss of brain stem function. The single biggest problem with this move, however, is that a higher brain definition of death is no less counterintuitive than the whole brain definition. For example, patients in a persistent vegetative state would fall into this category because they are permanently unconscious, but they breath spontaneously, do not require artificial ventilation, have normal bodily functions, and have wake-sleep cycles in which the eyes remain open in a state of apparent wakefulness and close during what appears to be sleep. These patients do not even vaguely resemble a state of death.

A higher brain definition of death also carries a great deal of diagnostic uncertainty, as new sophisticated technologies have shown unsuspected cognitive function in patients believed to be permanently unconscious.12 Moreover, there have been major advances in recent years in treating brain injuries, which could eventually lead to the recovery of some such patients.13 There seems to be no sense in which a patient who is “permanently unconscious” could be understood to be “dead.” A higher brain standard of death would provide no more solid support for the DDR than does the whole brain standard.

such as: withdrawal of life support does not cause a patient's death but is simply allowing the patient to die; brain death is identical to circulatory death; and cessation of cardiac function in DCD donors is irreversible, so is consistent with actual death

The rationale for abandoning the DDR has radical theoretical implications: the physician who withdraws life support causes the patient's death (not the underlying disease), brain death does not constitute death of a person, and surgeons recover organs from DCD donors who are dying, not actually dead. Practically, however, repealing the DDR has but a few implications. The only change in organ donation by brain dead organ donors would be the absence of declaration of death before organs are recovered. In DCD donation, there would be no declaration of death before organs are recovered, which would do away with the sometimes lengthy delays while waiting for cardiac arrest and then waiting for declaration of death, resulting in shorter warm ischemic times and healthier organs for transplantation. It might also expand the organ donor pool by adding back the donors who fail the current time requirements for pronouncing death.

We do not know whether abandoning the DDR would lead to an overall increase or a decrease in organ donors — there are no data one way or the other. But that is a secondary issue. The main purpose in leaving it behind is to honor and pursue truth. The same reason leads us to require physicians to be honest and forthcoming in dealing with patients and to discipline physicians who give false, deceptive, or misleading testimony on a judicial witness stand. Once physicians understand that brain dead and DCD donors are not really dead, they could claim otherwise only at the cost of undermining integrity and diminishing character.

The driving force behind rejecting the DDR is the ethical norm that physicians should not cause the death of a patient. Yet, we do exactly that when we ethically and justifiably withdraw life support at the request of the patient or proxy-surrogate, or when we remove organs from brain dead or DCD donors who are not actually dead. Once we recognize that the ethical prohibition against physicians causing death of a patient is not absolute and that the guiding principles are respect for patients’ self-determination and voluntary informed consent, we can withdraw life support in intensive care units and recover organs from consenting donors without appeal to the DDR and its underlying fictions. Abandoning the DDR will eliminate all of the public’s and health care professionals’ confusion and misunderstanding about definitions of death and deciding when someone is dead. We could then return to the traditional single standard of death that is well understood by everyone: the irreversible absence of circulation.

The lifesaving benefits of organ donation and transplantation are widely known and accepted. What many don’t realize is how critical and complex the time frame for transplanting organs from donor to recipient can be. If you’re wondering how long organs are viable after death, the short answer is – it depends.

Thanks to advances in medical technology, recovered organs can be transported hundreds, or even thousands of miles to give the gift of life to recipients in need. However, each organ is different, so the UNOS allocation criteria is unique to account for the medical complexity of each organ. For example, thoracic organs like the heart and lungs, can only remain viable for transplant after being outside of the body for four to six hours, while the liver can function for up to 12 hours and kidneys up to 36 hours. Therefore, the location of the donor and the potential recipient is more critical for matching hearts and lungs than it is for kidneys or livers.

In addition to medical urgency, blood type and other biological factors, those waiting for a heart transplant are also matched based on location because of the critical timing for this organ. The heart is only viable for 4-6 hours. Body size is also significant in heart matching, as the donor’s heart must fit comfortably inside the recipient’s ribcage.

Similar to heart matching, location and body size are also important considerations in lung allocation, since the lungs are viable for 4-6 hours after donation. That information is combined with the criteria listed above to determine a donor recipient.

Candidates who need a liver transplant are assigned a MELD or PELD score (Model for End-Stage Liver Disease or Pediatric End-Stage Liver Disease) that indicates how urgently they need the organ. A donor liver is offered first to the candidate who matches on the common matching criteria and has the highest MELD or PELD score. Location is also taken into consideration, but since the liver can function for a longer time (8-12 hours) outside of the body, it is able to travel farther than the heart and lungs.

Kidney allocation is heavily influenced by waiting time, or how long the recipient has been listed for transplant. Fortunately there is a bridge treatment for many in end-stage renal disease, called dialysis, which allows candidates to survive while awaiting a transplant. In addition, blood type and other biological factors, as well as body size of the donor and recipient are always key factors. Medical urgency and location are also factors but less so than other organs as they kidney can remain viable outside the body for 24-36 hours under the proper conditions.

The waiting list is not simply a list of people who are eligible for transplant. It’s a dynamic, complex algorithm based on carefully developed policy that ensures scarce organs are allocated to recipients as fairly and accurately as possible within highly constricted time frames. Learn more about the waiting list and how patients are added here.

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Donation after Circulatory Death (DCD), previously referred to as donation after cardiac death or non-heartbeating organ donation, refers to the retrieval of organs for the purpose of transplantation from patients whose death is diagnosed and confirmed using cardio-respiratory criteria.

There are two principal types of DCD, controlled and uncontrolled. Uncontrolled DCD refers to organ retrieval after a cardiac arrest that is unexpected and from which the patient cannot or should not be resuscitated.

In contrast, controlled DCD takes place after death which follows the planned withdrawal of life-sustaining treatments that have been considered to be of no overall benefit to a critically ill patient on ICU or in the Emergency Department.

World-wide, there is considerable variation in the contributions that DCD makes to deceased donation overall. While some countries have no DCD programmes whatsoever, in others such as the UK, Netherlands and Australia the contributions are significant.

Relative contributions of donation after brain death (DBD) and donation after circulatory death (DCD) to deceased donation in various countries around the world, as measured by donors per million population (pmp) in 2019. Source: Council of Europe – Transplant Newsletter

The relatively high potential for controlled DCD in the UK is likely to be a reflection of the number of deaths in intensive care that follow a decision to limit or withdraw life-sustaining treatments that are considered to be of no overall benefit to a critically ill patient

The success of the UK DCD programme can be attributed to the resolution of the apparent legal, ethical and professional obstacles to this model of donation. The underpinning principle of the programme is that donation can on many occasions be legitimately be viewed as part of the care that a person might wish to receive at the end of their lives.

Various publications and professional documents have supported the introduction of controlled DCD programmes into the UK, and they should form the basis for the local policies that describe how this type of donation is incorporated into a patient’s end of life care. Important national documents relating to DCD include:

In the UK, an average of 2.7 transplantable organs are retrieved from DCD donors, compared to 3.3 from DBD donors. The biggest contribution of DCD is to kidney transplantation, with 36% of all deceased donor kidney transplants coming from this source in 2020-2021.

The lower donation potential of DCD donors is in large part a result of the ischaemic injury suffered by solid organs in the time interval between treatment withdrawal and cold perfusion, with the liver and pancreas being particularly vulnerable.

For kidney grafts this is reflected in a higher incidence of delayed graft function (requiring a short period of post-implantation renal support), although long term outcomes are similar to DBD grafts.

Although some of this is dependent upon post mortem interventions such as regional normothermic recirculation and ex vivo reperfusion, a closer adherence to the standards for the confirmation and diagnosis of death as defined by the Academy of the Medical Royal College report and described in the Consensus statement on DCD from the Intensive Care Society and British Transplantation Society will also make an important contribution by limiting the initial warm ischaemic injury.

Due to a combination of factors the number of hearts available to transplant in the United Kingdom (UK) falls significantly short of demand. In order to balance the limited supply of donated hearts with the increasing demand alternative approaches continue to be explored.

The UK is the world leader in DCD heart retrieval and transplantation, to date the UK has carried out over 125 heart transplants. The outcome for recipients are comparable to hearts following DBD transplants and significantly has allowed many more donors to give a lifesaving transplant, an important outcome for donor families.

DCD donors account for a high percentage of the total deceased donor pool in the UK and in an attempt to increase organ supply a 12-month UK wide pilot has been launched to support Cardio-Thoracic (CT) centres to successfully utilise hearts from DCD donors.

CT teams have worked together to develop and implement the national pilot to facilitate heart retrieval and transplantation from DCD donors. In collaboration with stakeholders, including critical care and abdominal transplant teams, a DCD heart retrieval protocol and passport have been developed to support consistent and successful outcomes in this pilot phase.

Increasing the supply of organs available for transplant serves the interests of patients and the public and is in keeping with physicians’ ethical obligation to contribute to the health of the public and to support access to medical care. Physicians should support innovative approaches to increasing the supply of organs for transplantation, but must balance this obligation with their duty to protect the interests of their individual patients.

Organ donation after cardiac death is one approach being undertaken to make greater numbers of transplantable organs available. In what is known as “controlled” donation after cardiac death, a patient who has decided to forgo life-sustaining treatment (or the patient’s authorized surrogate when the patient lacks decision-making capacity) may be offered the opportunity to discontinue life support under conditions that would permit the patient to become an organ donor by allowing organs to be removed promptly after death is pronounced. Organ retrieval under this protocol thus differs from usual procedures for cadaveric donation when the patient has died as a result of catastrophic illness or injury.

Donation after cardiac death raises a number of special ethical concerns, including how and when death is declared, potential conflicts of interest for physicians in managing the withdrawal of life support for a patient whose organs are to be retrieved for transplantation, and the use of a surrogate decision maker.

Avoid actual or perceived conflicts of interest by: ensuring that the health care professionals who provide care at the end of life are distinct from those who will participate in retrieving organs for transplant; ensuring that no member of the transplant team has any role in the decision to withdraw treatment or the pronouncement of death.

Ensure that the decision to withdraw life-sustaining treatment is made prior to and independent of any offer of opportunity to donate organs (unless organ donation is spontaneously broached by the patient or surrogate).

Obtain informed consent for organ donation from the patient (or surrogate), including consent specifically to the use of interventions intended not to benefit the patient but to preserve organs in order to improve the opportunity for successful transplantation.

Background Organ donation after cardiac death (DCD) refers to organ donation from a deceased donor who has been declared dead on the basis of cardio-pulmonary criteria (permanent cessation of circulatory and respiratory function) rather than on neurological “brain death” criteria (permanent cessation of brain function – see Fast Fact #115). This Fast Fact reviews key elements of the DCD process.

Donation after death by neurologic criteria occurs when a comatose patient meets brain death criteria. After obtaining consent from the family, the donor is brought to the operating room on the ventilator. Organ procurement occurs in the operating room while the patient remains intubated with a beating heart.

Donation after cardiac death occurs when a decision is made to discontinue mechanical ventilation/other life-sustaining treatments in a comatose or gravely ill patient who is expected to die quickly after cessation of life-support. Depending on hospital policy, the patient may be extubated in the operating room (OR) to minimize the time between death and organ procurement and thereby optimize donor organ viability for transplantation. Most organ procurement organizations (OPO) have guidelines governing the amount of time between extubation and death during which the organs are considered viable for transplantation. This is generally 60 minutes. If the patient survives longer than that, excessive organ ischemia occurs rendering the patient an unsuitable donor. The patient is then returned to the ICU or other appropriate location for end-of-life care.

Selecting Patients for DCD Appropriate patients are generally comatose patients for whom a decision has been made to discontinue life-sustaining treatments with the expectation of imminent death. The decision to discontinue life-sustaining treatments is made prior to any discussions of organ donation. Most institutions have policies and procedures which alert the OPO of potential donors. After discussion with their medical director and recipient transplant centers, the OPO determines donor suitability. Trained professionals – usually OPO representatives – approach the family about organ donation, and consent the family/patient decision makers for organ donation. Potential donors are generally between 0 and 60 years of age. Patients should not meet the criteria for death by neurologic criteria (they are candidates for organ donation via brain death protocols). The OPO staff prognosticate whether the patient is sufficiently likely to die within the 60 minute window after cessation of life-prolonging treatments. This estimate is based on physiologic parameters including spontaneous respiratory rate, negative inspiratory force, age, oxygen saturation, level of hemodynamic instability, and body mass index (BMI).

Families are counseled about what to expect during the discontinuation of life-sustaining treatments and what to expect as the patient receives comfort care. Hospitals may have policies requiring the patient to have a DNR order while awaiting the DCD procedure; in others the decision to resuscitate a patient or not in order to attempt to maintain the patient as a viable organ donor is a negotiated decision. Families should be prepared for the possibility that the patient may not die quickly after the ventilator is withdrawn and that the patient may become an unsuitable donor. This occurs in about 20-30% of DCD cases nationally. This can cause added emotional trauma to grieving families who may want both a swift and comfortable death for their loved one as well as the opportunity to help others through organ donation. Families should be reassured that the patient will continue to receive careful symptom management until she or he die no matter how long that takes.

In order to prevent conflicts of interest, members of the OPO and organ recovery teams should not be involved in the decision to discontinue life-support, or in directing the medical care of the patient prior to the declaration of death. Because of this, intensivists, palliative care physicians, or other clinicians may be asked to direct the care of the dying donor after extubation.

Once consent is obtained from a legal surrogate and appropriate teams are ready, discontinuation of life-sustaining treatments begins. Extubation generally occurs in the operating room but may occur in a nearby ICU or recovery area based upon local hospital practice. Many hospital policies allow family members to be present in the operating room until the patient dies.

The patient may be given pre-extubation medications to relieve anticipated distress. These medications, as well as symptom medications given after cessation of life-support, should be given in the exact same way as in non-DCD situations to alleviate signs of pain, labored breathing, and other symptoms (see Fast Facts 33-35).

Declaration of death is based on hospital policy. Usually policies require apnea and 2 to 5 minutes of asystole or pulseless electrical activity. The hospital’s DCD policy will outline the exact criteria for declaring cardiac death.

Following death pronouncement the patient is taken to the OR, or the organ recovery team enters the OR where the patient died and procurement begins. The organ recovery team never encounters the patient’s family during the DCD process.

If the patient does not die in a reasonable amount of time as determined by the organ procurement organization, the patient is returned to a location in the hospital for ongoing symptomatic treatment until death occurs. Ongoing emotional and bereavement support should occur for family members throughout the process.

Fast Facts and Concepts are edited by Sean Marks MD (Medical College of Wisconsin) and associate editor Drew A Rosielle MD (University of Minnesota Medical School), with the generous support of a volunteer peer-review editorial board, and are made available online by the Palliative Care Network of Wisconsin (PCNOW); the authors of each individual Fast Fact are solely responsible for that Fast Fact’s content. The full set of Fast Facts are available at Palliative Care Network of Wisconsin with contact information, and how to reference Fast Facts.

Copyright: All Fast Facts and Concepts are published under a Creative Commons Attribution-NonCommercial 4.0 International Copyright (http://creativecommons.org/licenses/by-nc/4.0/). Fast Facts can only be copied and distributed for non-commercial, educational purposes. If you adapt or distribute a Fast Fact, let us know!

Disclaimer: Fast Facts and Concepts provide educational information for health care professionals. This information is not medical advice. Fast Facts are not continually updated, and new safety information may emerge after a Fast Fact is published. Health care providers should always exercise their own independent clinical judgment and consult other relevant and up-to-date experts and resources. Some Fast Facts cite the use of a product in a dosage, for an indication, or in a manner other than that recommended in the product labeling. Accordingly, the official prescribing information should be consulted before any such product is used.

This statement has been developed as a result of collaboration between the American Society of Anesthesiologists (ASA) Committees on Transplant Anesthesia, Critical Care Medicine, and Ethics. The Society of Critical Care Anesthesiologists supports this statement.

While the concept of organ donation after circulatory death (DCD) has previously generated controversy and concern, clearly written policies aided the development of standardized practice, resolved uncertainties and continue to be required by the Center for Medicare and Medicaid Services (CMS) and the Joint Commission. DCD contributed almost 9% of organs transplanted in 2015.1 As such, the original statement from the Institute of Medicine (1997) has held true in that DCD is “a medically effective, and ethically acceptable approach to reducing the gap that exists now and will exist in the future between the demand for and the available supply of organs for transplantation”.2

The document is intended to serve as an educational guide and template for donation after circulatory death organ recovery and transplantation policies that should be customized by any department or institution choosing to use it. Changes in technology and practice require that such policies and procedures undergo periodic review and revision by clinicians, administration and legal representatives.

The practice of DCD involves the continuum of quality end-of-life care for patients and their families, and withdrawal of treatments that are no longer beneficial or may extend suffering. Optimally, patients presenting for organ donation after circulatory death should receive care from their primary care/critical care attending physician or their designee who has established rapport with the patient, family, and/or agent. “Agent” means an individual authorized to make healthcare decisions on the patient’s behalf by a power of attorney for health care or authorized to make an anatomical gift on the patient’s behalf by any other record signed by the patient.

Institutions should develop a protocol for the provision of end-of-life care by appropriately skilled physicians. Withdrawal of life support is not within the expertise of practice of all anesthesiologists, and is not a common aspect of anesthesia practice within the operating room.

However, anesthesiologists are the natural leaders and facilitators in that environment and should be knowledgeable and informed of the major practical and ethical issues surrounding DCD and organ retrieval. Consequently, anesthesiologists should be involved in the development of protocols within their own hospitals for provision of ethical terminal care for organ donor patients and their families, informed by guidelines developed by the Institute of Medicine and the United Network for Organ Sharing (UNOS)3,4. Anesthesiologists should be respectful of the wishes of donor patients, their families, and their primary care physicians when they are in the operating room setting, but no physician should be required to administer care to these patients.

The President’s Commission on Death Determination supports two separate, but complementary sets of criteria. One is based on irreversible absence of circulation and respiration (Donation after Circulatory Death – DCD), and the other is based on irreversible absence of whole brain function (Donation after Death declared by Neurologic Criteria - DDNC).5 Either is satisfactory for the determination of death before organ donation, and both are supported in law.6

According to the dead donor rule, a patient should not be killed for or by the donation of their organs, and complete single organs should only be procured from dead people. Single lungs, kidneys and lobes of a liver may be donated by living donors in strictly regulated circumstances.

This definition was approved by the American Medical Association in 1980 and by the American Bar Association in 1981. All states within the United States of America adhere to the UDDA or some modification of that.

Irreversibility is recognized by persistent cessation of function during an appropriate period of observation. Based on cardiopulmonary criterion, death occurs when respiration and circulation have ceased and cardiopulmonary function will not resume spontaneously. This meaning of “irreversibility” also has been called the “permanent” cessation of respiration and circulation.

Electrocardiographic (ECG) silence is not required for the determination of death, as it may persist beyond the absence of circulatory activity (pulselessness) which is the criterion for declaring death.

In applying the circulatory criterion of death in circumstances other than DCD, clinical examination alone may be sufficient to determine cessation of circulatory and respiratory functions. However, the urgent time constraints of DCD may require more definitive proof of cessation of these functions by the use of confirmatory tests. Confirmatory tests (e.g. intra-arterial monitoring or Doppler study) should be performed in accordance with the hospital protocol to assure the family and hospital professional staff that the patient is dead.

There is an obligatory period of observation to determine that such circulatory activity will not spontaneously recur, and that subsequently death may be declared. In the context of DCD, guidelines require waiting for longer than two minutes but for no more than five minutes of absent circulatory function before pronouncing the patient dead.

This 2 to 5 minute time interval takes into consideration that there is no literature to support “auto-resuscitation” of the heart following two minutes of circulatory arrest, while observing an end-point of five minutes minimizes warm ischemic damage to perfusable organs. This is in accordance with recommendations from the Institute of Medicine3, the American College of Critical Care Medicine7, the Society of Critical Care Medicine7, and the Canadian Council on Organ Donation8.

Most patients considered for DCD will have been in the intensive care unit (ICU) and are dependent on ventilatory and circulatory support. Many, but not all of these patients, will be neurologically devastated but do not meet the requirements for death declared by neurologic criteria.

Ethically and legally, a patient deemed a potential DCD candidate is not equivalent to a patient declared dead by neurologic criteria – those latter are by definition not conscious or alive and cannot suffer. UNOS guidelines for maintaining perfusion of organs in such patients are well established.

A decision to allow death to occur by forgoing or withdrawing further life-sustaining therapies will have been made in accordance with the wishes of the patient and/or agent (as defined above). This must happen prior to and independent of any discussions about DCD.

The local organ procurement organization (OPO) will have been notified of the patient’s critical state in keeping with CMS Conditions of Participation (§482.45 A-0370, A-0371) prior to discussions of withdrawal of life-sustaining treatments. The OPO cannot thereafter approach patients and/or agents until after the decision to withdraw supportive treatments has been made.

When a consensual decision has been made to withdraw life support, the opportunity for DCD should be available to honor a donor's wishes in every donor service area of the United States. As of January 1, 2007, it is a Joint Commission requirement for hospitals to have and implement a DCD policy with direction from the regional Organ Procurement Organization (OPO) 9.

Donor care and end-of-life decisions are paramount and determined by the primary care attending physician/critical care attending physician and patient or their agent and potentially the hospital ethics committee.

All decisions and actions taken following the decision to consider a patient for DCD should preserve the legal limits of patient autonomy, which refers to the capability and right of patients to control the course of their own medical treatment and participate in the treatment decision-making process through informed consent.

Donor designation is a documented, legally binding commitment by an individual to make an anatomical gift and, just like a will or testament, it can only be revoked by that individual. Presence on the donor registry therefore informs the clinical team and OPO of the desired disposition of organs after death, but does not in itself constitute an authority to affect the mode or manner of dying. It does, however, emphasize and reinforce the imperative towards timely and appropriate communication between clinicians and the OPO.

The decision for withdrawal of treatments must be made before and separate from any discussion and decision to donate organs; one of the ethical axioms of organ donation necessitates adherence to the dead donor rule.

The patient’s primary care /critical care attending physician or their designee is best suited to withdraw life-sustaining treatments, prevent potential suffering throughout this process and should be welcomed into the operating room. The patient’s attending critical care physician/primary care physician or designee should declare and record the time of death. In order to avoid potential conflict of priorities, the physicians caring for a donor should not be involved in any of the donation, organ procurement or transplantation procedures. In order to avoid potential conflict of interest, it would be optimal that participation of the primary care/critical care attending physician or designee in withdrawal of life-sustaining treatments should be avoided if that critical care physician is anticipated to participate in the “planned” care of the recipient.

Determination of death is made by cardiopulmonary criteria. The period of circulatory cessation and the monitoring modality that confirms death is institution specific. Declaration of death should be legally binding according to state requirements.

If the anesthesiologist is not involved in any procurement (including post-mortem intubation) or transplant procedures, they may by prior arrangement and mutual agreement substitute for the primary care/critical care attending physician in the declaration of death and patient management.

Protocols for DCD organ recovery may include the pre-recovery administration of anticoagulants, vasodilators, antioxidants and drugs designed to minimize ischemia- reperfusion injury and preserve vascular endothelium. The optimal timing of administration of these drugs during the DCD process is not known.

The administration of heparin at the time of withdrawal of life-sustaining treatment is the current standard of care. The long-term survival of the transplanted organs may be at risk if thrombi impede circulation to the organ after reperfusion. Most transplant centers specify the timing of heparin administration in DCD, and omission of heparin may hinder the distribution of recovered organs. The use of heparin is considered controversial on the basis of theoretical concerns that it may hasten the death of the donor by causing intracranial hemorrhage or worsening active bleeding. Nevertheless, there are presently no reported cases to suggest that the administration of heparin causes sufficient bleeding after withdrawal of treatment to hasten death of the donor.

Rapid postmortem core cooling of perfusable organs with preservation solutions is essential to limit the warm ischemic insult. Informed consent of the patient or agent is necessary for any premortem cannulation of large arteries and veins or any other medical interventions to support the organs for donation prior to death.

A patient who has a non-recoverable and irreversible neurological injury resulting in ventilator dependency but not fulfilling the definition for death declared by neurologic criteria may be a suitable candidate for DCD.

The decision to withdraw life-sustaining measures must be made by the patient, care team, legal next of kin, or agent and documented in the patient’s chart. This must occur prior to any discussion of organ donation.

If queried, the healthcare team may direct questions regarding organ donation to OPO personnel or designated requestor, who will obtain consent for the donation thereby reinforcing in practice the separation between the role of the primary care team and the OPO.

An assessment should be made as to whether death is likely to occur (after the withdrawal of life-sustaining treatments) within a time frame that allows for organ donation (usually 60 to 120 minutes).

Authorization for organ donation is obtained from the appropriate person or entity according to jurisdictional policy after the decision to withdraw life-sustaining treatments is obtained. A Do Not Resuscitate (DNR) order is entered into the patient’s chart.

Location (intensive care unit, operating room, or other) for the process of withdrawal of life-supporting treatments should be determined after discussion and agreement with the donor’s family or agent.

There should be a plan for patient care and immediate family support if death does not occur within the established timeframe after the withdrawal of life-sustaining treatments which precludes the planned organ procurement. This plan should include logistics and provisions for continued end-of-life care and be discussed with the family and/or agent, who should be educated as to the possibility of non-donation and subsequent management.

End-of-life care is the responsibility of the patient’s primary care/critical care attending physician or their designee. Patients have the right to and should be provided medications that prevent and alleviate pain and suffering (comfort care). Patients may require anticipatory dosing with analgesics, sedatives and/or amnestics prior to considered extubation and may require additional medication administered as necessary, titrated to the observed level of distress. Any medication must be given according to need and with the goal of alleviating any pain and suffering, not with the intention of hastening the dying process.

the OPO should have discussed their requirements for reintubation and have made arrangements for patients who are known to have difficult airways with the attending anesthesiologist overseeing the operating room, well in advance of withdrawal of life-sustaining treatments. Alternatively, the OPO may provide an individual to perform this function (as per institutional DCD protocol). Whosoever performs the reintubation of the patient’s trachea should not be involved in the declaration of death.

If indicated and consent is obtained, a bronchoscopy may be performed prior to withdrawal of support and extubation to determine suitability of the lungs for donation. At some centers, bronchoscopy may be performed after declaration of death. Recommendations for ventilator settings and FiO2 prior to withdrawal may be specified by the attending physician overseeing end-of life care. Ventilation after death will be dictated by OPO protocol.

There must be a determination of the location and process for withdrawal of life- sustaining treatments as a component of the patient’s care. Considerable resources are required to provide optimum end-of-life patient care to implement a DCD protocol in the operating room. In addition, the organ procurement surgery requires multiple personnel and healthcare resources. Communication between the OPO and all others involved in the DCD process and management of the operating room is essential for the success and optimal timing of implementing the DCD process.

The patient’s primary care/critical care attending physician or their designee with expertise in the withdrawal of life support agrees to participate in the withdrawal of life support, and will not be involved in organ retrieval or the intraoperative care of the recipients of this patient’s donated organs.

Family logistics: Ideally, families should be offered the opportunity to be present around the withdrawal of life-sustaining treatments. Practical issues related to accomplishing this in the operating room include the presence of immediate or extended family, escort procedure, attire, and the wishes of the family.

Depending on institutional policy, if informed consent is obtained for pre- mortem isolation or cannulation of femoral vessels, these procedures are usually performed prior to the patient entering the operating room. The surgical procurement team must exit the operating room prior to the family entering. After death, the family must be escorted out of the operating room before the surgical procurement teams enter the room. Families should be told that they will be rapidly escorted out after death for purposes of preserving the donated organs. A member of staff should be identified in advance with the responsibility of escorting the family out of the operating room to an appropriate location. The surgical procurement team must not be present in the operating room during withdrawal of care. After any indicated and consented placement of premortem cannulae, the surgical procurement or transplant teams should have no contact with the patient until after the primary care/critical care attending physician or their designee has declared the patient dead and the written documentation has been completed.

In the event that death has not occurred within one hour after termination of life- sustaining treatments, the patient should be reassessed. A decision is then made to either extend the waiting period for an additional hour or cease the donation process in which case the medical team transports the patient from the operating room to a predetermined location and continues care of the patient. The member of staff tasked with escorting the family should accompany them back to that location.

Once there is a declaration of death, an incision to recover organs should be performed immediately. The transplant surgeons will initiate perfusion of the organs with cold preservation solution and proceed with the donor operation.

Continuity of care for patients presenting for DCD should optimally be provided by the donor patient’s own primary care/critical care attending physician or their designee. The responsibility for withdrawal of life support of the DCD patient also belongs to this individual and should never be transferred to anyone other than a qualified physician who has a preexisting treating relationship with the patient and expertise in end-of-life care. Provision of quality end-of-life care for DCD patients and their families is the absolute priority and must not be compromised by the donation process. Managing the withdrawal of life- sustaining treatments may not be within the expertise or practice of all anesthesiologists. For DCD, determination of death is made using cardiopulmonary criteria and does not require evidence of irreversible cessation of function of the whole brain (the criteria for DDNC).

While anesthesiologists staffing operating rooms should not be required to participate in withdrawal of care or declaration of death, they may be asked to reintubate and ventilate lungs to support and facilitate the DCD process. A role in reintubation would also preclude their involvement in antemortem procedures supporting the donation process, which should normally occur in the ICU prior to transfer to the operating room. Consequently, all anesthesiologists are strongly encouraged to be familiar with the DCD protocols particular to their institution, to determine appropriate methods for management of medical personnel and donor families, as well as timing, communication, and arrangements for care outside the operating room if needed.

While anesthesiologists staffing operating rooms should not be required to participate in withdrawal of care or declaration of death, they may be asked to reintubate and ventilate lungs to support and facilitate the DCD process. A role in reintubation would also preclude their involvement in antemortem procedures supporting the donation process, which should normally occur in the ICU prior to transfer to the operating room. Consequently, all

The death of a patient and donation of their organs should be recognized as a gift that a patient and/or their families are offering to others. All personnel should be respectful of the wishes and privacy of the donor patients and their families, and all those involved in the donation and transplantation process. All should strive to facilitate the donation and transplantation process, mindful of their responsibilities, particular expertise, potential conflicts of interest, and according to the guidelines listed above, institutional policies, and state and federal laws.

Organ Procurement and Transplantation Network Bylaws. United Network for Organ Sharing. Under contract to the Model Elements for Controlled DCD Recovery Protocols, ATTACHMENT III TO APPENDIX B OF THE OPTN BYLAWS. Accessible at

http://www.optn.org/policiesAndBylaws/bylaws.asp. Accessed December 28, 2016.

President’s Commission for the Study of Ethical Problems in Medicine and Biomedical and Behavioral Research, Defining Death: Medical, Legal and Ethical Issues in the Determination of Death, (Washington, D.C.: Government Printing Office, 1981). Available online at https://archive.org/details/definingdeathrep00unit. Accessed December 28, 2016

Shemie SD, Baker AJ, Knoll G, Wall W, Rocker G, Howes D, Davidson J, Pagliarello J, Chambers-Evans J, Cockfield S, Farrell C, Glannon W, Gourlay W, Grant D, Langevin S, Wheelock B, Young KJ, Dossetor J. Donation after cardiocirculatory death in Canada. CMAJ. 2006;175(Suppl):S1–S24.

Joint Commission on Accreditation of Healthcare Organizations. HEALTH CARE AT THE CROSSROADS: Strategies for Narrowing the Organ Donation Gap and Protecting Patients. (The Joint Commission - May 31st 2005). Accessible online at https://www.jointcommission.org/assets/1/18/organ_donation_white_paper.pdf. Accessed December 28, 2016.

Sanchez-Fructuoso AI, Prats D, Torrente J, Perez-Contin MJ, Fernandez C, Alvarez J, et al. Renal transplantation from non-heart beating donors: a promising alternative to enlarge the donor pool. J Am Soc Nephrol 2000;11:350-8.

Many patients die on American transplant waiting lists because there are far fewer hearts donated after brain death than patients who would benefit from transplantation. For this reason, extended criteria donation after brain death hearts, which would otherwise be considered inferior, are routinely transplanted. Examples for extended criteria donation after brain death hearts include older donors, from further distances, with lower cardiac function, and higher risk features, such as hepatitis C. In response to the dire need for donor hearts, a small number of transplant centers in Australia and Europe have pushed the envelope further still by pioneering heart transplantation following donation after cardiac death (DCD).1 Death of DCD donors is declared on the basis of irreversible cardiac arrest rather than irreversible loss of all functions of the entire brain.2 However, because of unique ethical and legal concerns that arise from the surgical techniques for DCD heart procurement, there are no clinically active DCD heart transplantation programs in America.

Interest in DCD heart transplantation was rekindled by the dire donor shortage. Among the earliest indicators that the risks of ischemic injury to DCD donor hearts are controllable was a retrospective cohort study analyzing 38 patients transplanted with hearts from donors who had experienced a recent period of cardiac arrest. The mean duration of donor cardiac arrest was 15 minutes, and the mean interval between donor cardiac arrest and transplantation was 69 hours. The 30-day mortality (2.6%; n=1/38) of these patients was not significantly different from 566 patients transplanted during the same time period with hearts that had not arrested in the donor.5 Moreover, in 2008, the heart of a 53-year-old DCD donor was reanimated using extracorporeal circulatory support after 23 minutes of cardiorespiratory arrest. This effectively converted a DCD heart into a beating donor heart.6 Based on this work, Dhital et al7 performed the world’s first distantly procured DCD heart transplant in 2014. These breakthroughs catalyzed the establishment of several DCD heart transplantation programs in Europe and Australia, with encouraging early results.1,8

With normothermic regional perfusion, the cerebral circulation is interrupted by clamping the innominate and carotid arteries to eliminate the theoretical recovery of brain activity after resuscitation. Subsequently, regional cardiopulmonary bypass is instituted to reperfuse and reanimate the heart inside the donor. After return of a cardiac rhythm, the donor is reintubated, and cardiopulmonary bypass is weaned. This effectively converts an arrested DCD heart into a beating donor heart, which is evaluated for transplantation and retrieved in the usual fashion.8

With direct procurement and perfusion, donor blood is first collected to prime an ex vivo organ perfusion system, such as the TransMedics OCS. The heart is then retrieved from the donor and connected to the ex vivo perfusion system where it is reperfused and reanimated. After return of a cardiac rhythm, the heart is evaluated for transplantation.7

Finally, with transplantation from a colocated donor, preservation of the arrested heart is initiated using topical cold infusion into the donor. The heart is then recovered in the usual fashion, expeditiously transplanted into the recipient in an adjacent operating room, and then reperfused and reanimated in the recipient using cardiopulmonary bypass.9

First, the act of reanimating the donor heart sometime after declaration of cardiac death does not affect its biological condition at the time when death was declared. Therefore, it is counterintuitive to think that the act of reanimating the donor heart outside the donor body, for example, in an ex vivo perfusion system, could retrospectively toggle the state of the donor between dead and alive.

Second, donors invariably lose brain function because of cerebral ischemia after cardiac arrest. Irreversibility of this loss of brain function despite donor heart reanimation is ensured by clamping the innominate and carotid arteries in the case of normothermic regional perfusion and by removing the heart from the donor before reanimation in the case of the other procurement techniques. Therefore, the donor can be considered brain dead before the donor heart is reanimated.

Third, medical interventions to facilitate organ donation are routinely undertaken after declaration of cardiac death. Similarly, cardiac arrest at the time when death is declared should be considered separate from subsequent efforts to resuscitate the heart specifically for donation. This serves the donor's interest by realizing his or her wish to give the gift of life to the recipient.

Fourth, there are no clinical reasons why DCD hearts should be treated differently from other organs, such as the lungs. The heart is no longer vital in the sense that many patients survive long-term without a native heart on a total artificial heart. Conversely, DCD lungs are routinely transplanted after their function is re-established using an ex vivo lung perfusion system.

Finally, legal definitions of death have evolved to accommodate clinical advances in organ transplantation and end-of-life care. Consequently, it should be possible to further refine the American legal framework to accommodate DCD heart transplantation.

DCD heart transplantation remains an area of ethical and legal controversy where well-considered judgments differ widely. Because of the dire need for donor hearts, it is clinically necessary to resolve these controversies as soon as possible. The DCD paradigm has the potential to increase overall heart transplantation volume by over 20%.13,14

Dhital KK, Iyer A, Connellan M, Chew HC, Gao L, Doyle A, Hicks M, Kumarasinghe G, Soto C, Dinale A, Cartwright B, Nair P, Granger E, Jansz P, Jabbour A, Kotlyar E, Keogh A, Hayward C, Graham R, Spratt P, Macdonald P

Messer S, Page A, Axell R, Berman M, Hernández-Sánchez J, Colah S, Parizkova B, Valchanov K, Dunning J, Pavlushkov E, Balasubramanian SK, Parameshwar J, Omar YA, Goddard M, Pettit S, Lewis C, Kydd A, Jenkins D, Watson CJ, Sudarshan C, Catarino P, Findlay M, Ali A, Tsui S, Large SR