While organ donation after brain death (DBD) is the best-known pathway for donation, it is donation after circulatory death (DCD) that has emerged as one of the most promising ways to make more life-savings-transplants possible.
DCD organ donation by New England Donor Services occurs when the donation will take place after a patient is declared deceased based on absence of circulation rather than based on neurological (brain death) criteria. This is typically because the patient has suffered a severe, irreversible brain injury but does not meet the criteria for brain death.
In these instances, the patient’s family, in consultation with hospital care givers, has made a decision to withdraw life-sustaining treatment and allow their loved one to pass away. In such cases, organ donation can occur after death is declared when the patient’s heart stops beating after the patient is removed from ventilator. Importantly, NEDS is not involved in the declaration of death. While a recent New York Times article and Congressional Subcommittee hearing highlighted a small number of instances in other areas of the country where questions about protocol adherence were raised, NEDS works with our hospital partners to assure that patient safety is always the top priority.
An Associated Press article about the Congressional hearing correctly noted the important role hospital staff play in care provided to patients prior to an organ donation, “At issue is how doctors are sure when it’s time to withdraw life support from a dying patient — and the delicate balance of how OPOs interact with hospital staff in preparing for donation once death occurs.” Importantly, the AP notes that it is a hospital physician independent of the OPO who is responsible for accurately determining death and that “Lawmakers stressed most organ donations proceed appropriately and save tens of thousands of lives a year”. The AP story is a more accurate representation of the DCD process than most other coverage and is a worthwhile read. The New York Time received a number of Letters to the Editor questioning their coverage of the issue.
The NEDS DCD process is carefully designed to uphold ethical standards so that organ recovery only begins after the patient has died. The patient’s heart must stop and a predetermined waiting period (typically 5 minutes) must then be observed to confirm the absence of any circulation before death is declared and then donation occurs. WBUR radio in Boston interviewed Dr. Robert Truog, Director Emeritus of Harvard Medical School’s Center for Bioethics and asked if some of the problems noted in the NYT article could happen in Massachusetts. Dr. Truog said, “I can’t imagine it. When this is done in larger hospitals like those we have in Boston they are doing enough of these cases that the clinicians are very experienced … we all know the protocols inside and out. These [other cases] are outliers. It is important we know about them, but I really would not want to see this blown out of proportion.”
Organs such as kidney, heart, liver, lung, and others can then be recovered from DCD donors for transplantation into patients on the national wait list whose only hope for life is an organ transplant.
It should be noted that in some cases a patient removed from the ventilator may continue breathing on their own even without the mechanical support of the ventilator. If, after the withdrawal of the ventilator, the patient does not die with the timeframe compatible with donation, then the patient is returned by hospital staff to the ICU.
In 2024, DCD donations represented over 40% of organ donors and over 30% of all deceased-donor transplants in the U.S. The wide-spread growth in DCD allows more individuals who wanted the legacy of organ donation after their death to become donors and has saved tens of thousands more lives. The expansion of DCD has been supported and encouraged by the federal government as a critical piece of their overall strategy to increase donation.
Combined with advancements in medical technology, such as abdominal normothermic regional perfusion and ex vivo organ preservation, DCD has become an important part of increased donation and transplant here in New England and around the country.
Public and media awareness of DCD is lower than for brain death donation and this lack of knowledge can lead to misunderstandings and even inaccurate media headlines that can undermine trust in the organ donation process. The donation and transplant community is working to increase education about DCD as those on the transplant waitlist are depending on us.