Understanding Donation after Circulatory Death (DCD)

As more than 100,000 people await transplant, Donation after Circulatory Death (DCD) plays a significant role in our nation’s donation and transplant system. Last year, more than 7,200 DCD donors made up 43 percent of all deceased donors.

DCD refers to the recovery of organs from a patient who has died due to the irreversible loss of circulatory and respiratory function — when the heart has stopped beating and cannot be restarted. This is distinct from Donation after Brain Death (DBD), where death is declared based on irreversible loss of brain function. Both definitions of death are recognized under the Uniform Determination of Death Act (UDDA), which has guided state laws for over 40 years.

Typically, DCD is an option after a patient has suffered a catastrophic neurologic injury but does not meet the medical criteria for brain death.

The first step in the DCD process is the determination by the patient’s doctor that continued life-sustaining support of circulatory and lung function for this patient is futile, is not in the patient’s best interest, and that it should be withdrawn. If the patient’s doctor makes that determination according to their medical training and judgement, the doctor discusses withdrawing life-sustaining care with the patient’s legal next of kin.

It is important to note that individuals from the organ procurement organization (OPO), the organ recovery team, and the transplant team may not participate in the discussions or the decisions to withdraw life-sustaining care from a patient. Only after the next of kin has consented to withdraw care may members of the OPO enter into discussions with the next of kin to consider the option of organ donation if the patient dies after care is withdrawn.

If the next of kin want to pursue the option of organ donation, they must give consent to do so. The decision to withdraw care must occur before any discussions about consent to donate organs.

If the next of kin decide to withdraw care, the patient is typically moved to an operating room by the hospital nursing staff, where the patient’s doctor directs the hospital nursing staff to disconnect the patient from artificial ventilatory support. As the patient’s blood pressure and blood oxygenation levels fall, different organs will tolerate different periods of oxygen deprivation. After a patient’s heart has stopped beating, the treating physician makes the determination that the patient has suffered circulatory death. Circulatory death determination varies between states and hospitals but generally there is a requirement for 2-5 minutes of sustained cessation of heartbeat before a person is declared dead. Declaration of death is made solely by the treating physician. Only after death is declared, the OPO and organ recovery team may enter the operating room. At that point, organ recovery begins.

Many transplant centers have adopted a defined acceptable time limit between withdrawal of care and cessation of heartbeat (cardiac asystole) for donated organs to be acceptable for transplantation. If this limit is exceeded, the patient will not be eligible for organ donation. In 30-40% of potential DCD cases, organ donation is cancelled for this reason.

The United Network for Organ Sharing (UNOS) has long served as a federal contractor for the U.S. Health Resources and Services Administration to support the national Organ Procurement and Transplantation Network; however, UNOS has no involvement in death declaration, nor does UNOS create policy or law related to death declaration. UNOS is not a healthcare provider, and as such, does not make any clinical decisions related to patient care or organ donation. UNOS does not provide clinical care, participate in decisions to withdraw life-sustaining treatment or regulate hospitals.

UNOS remains steadfast in its support of improving outcomes for patients and increasing safe access to life-saving organ transplants with our proposed reforms that would strengthen many aspects of the organ donation and transplantation ecosystem both within and outside the purview of the Organ Procurement and Transplantation Network. To read more about these reforms please visit our advocacy agenda and our action agenda.

Andrew Klein is Chief Medical Officer for the United Network for Organ Sharing. He received a bachelor’s degree from Duke University, an M.D. and an MBA from Johns Hopkins University.