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circulatory and lung function for this patient is futile, is not in the patient’s best interest, and that it should be withdrawn.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enter into discussions with the next of kin to consider the option of organ donation if the patient dies after care is withdrawn.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.

Hospitals throughout the United States play vital roles in saving and enhancing lives through organ donation and transplantation. But an individual hospital’s responsibilities can differ, depending on whether it is a donor hospital or a transplant hospital.

Donor hospitals

More than 5,000 hospitals in the United States have the potential to admit and care for people who may become organ donors. These range from small, rural community hospitals to major metro trauma centers – any facility with intensive or advanced acute care capabilities. Potential organ donors may meet medical criteria for donation either via brain death (complete, irreversible loss of brain function) or donation after circulatory death (DCD), occurring and pronounced in a hospital setting.

Donor hospitals are responsible for declaring patient death according to applicable state law and accepted medical practice. In addition, all donor hospitals must comply with state and federal laws and regulations regarding identification and referral of potential organ donors to their assigned organ procurement organization (OPO). In general, donor hospitals are overseen by the Centers for Medicare & Medicaid Services (CMS). CMS provides regulations, including conditions of participation, that apply to all hospitals seeking Medicare reimbursement.

Donor hospitals are not members of the national Organ Procurement and Transplantation Network (OPTN) and are not subject to OPTN policies and requirements unless they are also a transplant hospital. The national OPTN, overseen by the federal Health Resources and Services Administration (HRSA), does not have policies governing donor hospitals. The OPO managing the logistics of the donation process is, however, accountable to CMS requirements and to OPTN policies and bylaws.

Transplant hospitals

There are 251 hospitals in the United States accredited to perform transplants of at least one organ type. Each of these hospitals is accountable to state and federal standards for quality of patient care and ensuring patient safety. CMS has a number of applicable regulations and conditions of participation that apply specifically to transplant hospitals.

Each transplant hospital must also be a member of the OPTN and must abide by the OPTN policies and bylaws that govern the transplant process and standards for ensuring patient safety.

Can a donor hospital also be a transplant hospital?

Yes, an individual institution can be both a donor and a transplant hospital. As a transplant hospital, it must be an OPTN member and meet the standards the OPTN establishes. But if it is functioning in its donor hospital capacity, there are no additional OPTN standards or requirements that would apply to it.

The majority of donor hospitals in the United States are not OPTN members and would not be compelled to become OPTN members by any law or regulation. However, they remain responsible for all other state or federal requirements that apply to any part of the donation process.

UNOS Chief Medical Officer Dr. Andrew Klein wrote an opinion piece sharing his first-hand experiences as a liver transplant surgeon and his thoughts about how Congress could help address some of the challenges he encountered. Dr. Klein served as the founding director of the Johns Hopkins Comprehensive Transplant Center and the Cedars-Sinai Comprehensive Transplant Center.

Below is the beginning of Dr. Klein’s opinion article. The full article is published in Nephrology News and Issues. Learn more about his recommendations to strengthen the system.

Last year, a record number of organ transplants were performed in the United States – more than 48,000, which represents an increase of 23 percent since 2020.

What has changed?

The U.S. has seen an increase in deceased organ donors every year for the past 15 years. As a result, fewer patients are dying each day while waiting for an organ – 13 each day in 2023, compared with 16 per day in 2021. There are still more than 100,000 people waiting for a life-saving organ transplant, and UNOS has proposed a number of reforms aimed at increasing the number of organs available for transplant and improving patient outcomes.

The nation’s organ donation and transplant system is moving in the right direction, but there is still more work to be done to ensure that no patient dies while awaiting a transplant.

Learn about UNOS’ proposed reforms and learn how you can help.

* The latest data available for waiting list deaths from the 2023 OPTN/SRTR annual data report.