DCD Organ Donation: Issues & Care Priorities

Organ donation after circulatory death (DCD) has evolved significantly over the past several decades. Advances in donor identification, family communication and organ preservation strategies, and collaboration among healthcare teams, palliative care specialists, organ procurement organizations (OPOs) and transplant programs have helped make DCD an increasingly successful and effective option for organ donation.

For many families, DCD provides an opportunity to find meaning during an incredibly difficult time. Knowing a loved one may help save or improve the lives of others can become an important part of the grieving process and a powerful way to honor that person's legacy.

At its core, DCD offers patients with devastating illnesses or injuries the opportunity to give the gift of life. As awareness and technology continue to advance, DCD is helping expand the donor pool, reduce transplant wait times, and provide hope to patients awaiting lifesaving organs.

In this blog, we'll review what DCD is, how the process works, common questions families may have, and the important role of critical care nurses throughout the donation process.

What Is DCD Organ Donation?

Unlike donation after brain death (DBD), where death is declared using neurologic criteria while organ function is maintained through ongoing physiologic support, DCD donors are declared dead based on the irreversible cessation of circulatory and respiratory function.

After the heart stops beating and circulation ceases, a required protocol-directed observation period is completed to confirm that circulation will not spontaneously return. Death is then formally declared before any organ recovery activities begin.

Although DCD has become an established and lifesaving form of organ donation, misconceptions still exist. Understanding the different types of DCD can help clarify how the process works.

Types of DCD Organ Donation

Controlled Donation After Circulatory Death (cDCD)

Controlled DCD most commonly occurs in hospitalized patients with nonrecoverable illnesses or injuries. These patients are often in an intensive care unit, where a decision was already made by the patient, healthcare surrogate or legal decision-maker to withdraw life-sustaining treatment (WLST).

Once consent for donation has been obtained and WLST occurs, the patient progresses toward circulatory arrest. Following death determination using circulatory and respiratory criteria and completion of the required observation period, organ recovery proceeds according to established clinical protocols.

Uncontrolled Donation After Circulatory Death (uDCD)

Uncontrolled DCD occurs following an unexpected cardiac arrest where resuscitation efforts are unsuccessful.

After death is declared and a mandatory "no-touch" observation period has occurred, organ preservation measures may be initiated if the patient's family supports donation. Once the observation period is complete, organ preservation CPR (OP-CPR) may be performed after death declaration to preserve organ viability, but not to resuscitate the patient, consistent with institutional policies and regulatory requirements.

Normothermic Regional Perfusion (NRP)

One of the most important innovations in DCD donation is normothermic regional perfusion (NRP).

Following death determination and completion of the mandatory "no-touch" observation period, perfusion circuits can be connected to abdominal or thoracic organs to restore oxygenated blood flow to the donated organs. NRP helps minimize ischemic injury that may occur during the dying process and can improve transplanted organ function and outcomes.

Depending on the organs being recovered and the recovery team's assessment, NRP is typically performed for 30 to 60 minutes before organ recovery proceeds.

Who Can Be an Organ Donor?

Identifying potential organ donors is not always straightforward. As transplant outcomes and preservation technologies have improved, donor eligibility has expanded considerably. In fact, there is no strict upper age limit for organ donation. Each potential donor is evaluated individually based on medical history, current clinical condition, and factors that may affect transplantation, such as certain malignancies or transmissible infections.

Advances in machine perfusion and other preservation technologies have further expanded donor opportunities and improved outcomes from DCD donors. Today, outcomes from many DCD transplants are comparable to those from donors with brain death.

With improved education and technology, DCD can now be offered to more patients than ever before. Yet, identifying potential donors often remains challenging.

Unlike brain death, where a patient clearly meets neurologic criteria for death, DCD situations usually arise when treatment options have been exhausted and families are considering WLST.

For some patients, the only remaining options involve long-term mechanical support, tracheostomy, feeding tubes and institutional care. When these outcomes are inconsistent with a patient's expressed wishes, families may decide to transition care toward comfort-focused goals. In these situations, DCD may become an appropriate option.

An especially complex situation involves patients who are awake, neurologically intact and dependent on advanced life-sustaining therapies.

For example, patients waiting for heart or lung transplantation may be supported with extracorporeal membrane oxygenation (ECMO). Some eventually become too ill for transplantation or are no longer considered transplant candidates. In these circumstances, difficult end-of-life (EOL) discussions may occur despite patients remaining alert and interactive.

A few years ago, these patients rarely would have been considered for organ donation. Today, advances in transplantation and donor management increasingly make donation possible, allowing these patients to create meaningful legacies.

Many patients undergoing transplant evaluations already understand the profound impact of organ donation on recipients. Some express a desire to donate even if their own transplant journeys are unsuccessful. Offering donation as an option can therefore be deeply meaningful for patients and families navigating these difficult circumstances.

Because these situations are so complex, early collaboration is essential. In many centers, OPO consultation begins when patients are first placed on ECMO. This consultation helps the OPO become familiar with the patient's course and facilitates timely coordination if EOL discussions emerge later.

Critical Care Nurse's Role in DCD

Critical care nurses play an essential role throughout the DCD process. They help identify potential donors, support patients and families, collaborate with interdisciplinary teams, advocate for high-quality EOL care, and ensure ethical standards are maintained.

Identifying Potential Donors

Critical care nurses are often among the first clinicians to recognize when families are beginning to discuss WLST or a transition to comfort-focused care. When these discussions occur, timely referral to the OPO is important. An early referral allows the OPO adequate time to determine donor suitability and coordinate evaluation efforts while supporting the healthcare team.

Interdisciplinary Collaboration

The DCD process requires close collaboration among physicians, critical care nurses, palliative care specialists, respiratory therapists, social workers, case managers, the OPO and transplant teams.

Throughout this process, critical care nurses continue advocating for patient-centered symptom management and comfort-focused care. They also help maintain clear boundaries between EOL decision-making and organ donation activities to avoid even the appearance of a conflict of interest. Once the WLST decision is made, critical nurses help coordinate communication with the OPO and support ongoing collaboration among all team members.

Strong interdisciplinary communication helps ensure the patient's wishes are honored while supporting the family through a difficult and emotional experience.

Communication and Education

Critical care nurses frequently become trusted sources of information for patients and families. Families often have questions about prognosis, the dying process, WLST and what to expect in the hours that follow. Critical care nurses help provide clear, accurate and compassionate information that supports informed decision-making for families.

It is important to know that conversations specifically related to organ donation authorization should occur through individuals educated and experienced in the consent process, such as OPO representatives. Also, OPOs should determine donation suitability before donation is discussed with families to avoid creating false hope.

Roles in the Consent Process

Critical care nurses, social workers and case managers often assist in identifying legal next of kin and clarifying who is authorized to make donation decisions.

Before donation discussions occur, the OPO reviews donor registry information to determine whether the patient has previously registered as an organ donor. If donor registration exists, the patient's documented wishes are honored according to applicable laws and organizational policies.

Critical care nurses frequently participate in meetings with families, helping answer medical questions while providing emotional support. Throughout the process, the family's questions, concerns and preferences should be respected to ensure a compassionate, patient-centered approach.

Patient Care

The standard of EOL care does not change because a patient is pursuing organ donation. Patients who are potential DCD donors receive the same high-quality symptom management, comfort measures, dignity and respect provided to any other patient at the end of life. The primary goal remains ensuring a peaceful and comfortable death that aligns with the patient's wishes and goals of care.

Family Support

Family support is a critical component of DCD care. Critical care nurses often accompany families throughout the withdrawal process, answer questions, provide emotional support, facilitate communication with healthcare teams, and help families understand what to expect. The OPO coordinator introduces donation-specific information and remains available to address additional questions regarding the donation process.

Documentation and Regulatory Compliance

Accurate documentation is essential throughout the DCD process. Critical care nurses document patient assessments, care provided, family interactions and interdisciplinary communication, while ensuring institutional policies and regulatory requirements are followed. These efforts support ethical practice, regulatory compliance and transparency throughout the donation process.

Organ Recovery

Critical care nurses coordinate closely with the healthcare team, OPO personnel and operating room staff to facilitate transition from EOL care to organ recovery. Importantly, critical care nurses continue providing patient care until a patient's death has been formally declared according to hospital policy and applicable regulations.

Ethical and Legal Considerations

DCD involves numerous ethical and legal considerations, including EOL decision-making, confidentiality, informed consent, donor authorization, and adherence to organizational policies and regulatory standards.

Several ethical principles support DCD donation:

• Autonomy: Respecting patients' and families' healthcare decisions
• Beneficence: Acting in the patient's best interests and honoring their wishes
• Nonmaleficence: Avoiding harm and maintaining compassionate care

DCD follows established policies, regulations and protocols designed to ensure consistency and transparency, and avoid conflicts of interest. Critical care nurses help ensure the donation process remains ethically sound while supporting both patients and families through difficult decisions.

Common Questions About DCD

How Does DCD Fit With EOL Care?

One of the most important DCD principles is the separation between EOL decision-making and organ donation. The decision to choose WLST must be made independently of any donation discussion. EOL care focuses solely on comfort, dignity, symptom management and support for both the patient and family. Donation considerations occur only after these decisions are made and after the OPO's initial assessment indicates donation may be possible.

How Is Death Managed During DCD?

Natural and comfortable death remains the priority throughout the withdrawal process. The patient's healthcare team directs WLST and symptom management. The OPO and the transplant teams do not direct EOL care and are not responsible for determining when life-sustaining treatments should be withdrawn. Organ recovery occurs only after death has been formally declared according to established protocols.

What Does the Donor Experience During DCD?

The DCD donor's experience should be no different than that of any other patient receiving high-quality EOL care. The focus remains on comfort, dignity, symptom control and support for the patient and family. Emotional, spiritual and cultural support resources should be available as needed. After circulatory arrest occurs, death is declared following the required "no-touch" observation period before organ recovery begins.

Are There Religious or Cultural Concerns?

Many religions and cultures support organ donation as an act of generosity, compassion and service to others. However, individual beliefs may vary. Healthcare teams should always explore and respect a patient's and family's cultural, spiritual and religious preferences when discussing EOL care and donation. When questions arise, chaplains, spiritual leaders and cultural advisors can provide valuable guidance.

Do Financial Factors Influence Donation?

No. Organ donation is governed by extensive legal, ethical and regulatory frameworks designed to ensure donation decisions are based solely on the patient's wishes and the goal of helping transplant recipients.

Can Families Still Have an Open-Casket Funeral?

Yes. Organ recovery is conducted respectfully and involves only the organs authorized for donation. In most cases, an open-casket funeral remains an option for the family.

What About Medical Examiner Cases?

In certain circumstances, medical examiner authorization may be required before organ recovery can proceed. The OPO works closely with the medical examiner to ensure donation opportunities are preserved whenever possible, while maintaining forensic and legal responsibilities.

Human Side of DCD

Each of us approaches DCD with our own perspectives shaped by personal experiences, cultural values, professional backgrounds and familiarity with organ donation.

For critical care nurses, caring for DCD donors can evoke a wide range of emotions. You may feel sadness for a family's loss, pride in helping honor a donor's wishes, gratitude for the opportunity to support recipients awaiting transplantation, and anxiety given the complexity of the process itself.

At the center of every DCD case is a simple but powerful principle: The patient's wishes matter. The decision to donate is ultimately about honoring those wishes and supporting families as they navigate one of the most difficult times of their lives.

DCD is an ethically sound and valuable pathway to organ donation. It continues to expand opportunities for transplant recipients, while providing patients and families an opportunity to create lasting legacies through the gift of life.

Critical care nurses are central to this work. Through compassionate communication, expert EOL care, interdisciplinary collaboration and careful attention to ethical practice, nurses help ensure that both donors and recipients are served with dignity, respect and excellence.

By understanding the DCD process and the responsibilities that accompany it, critical care nurses can confidently support patients and families while contributing to the lifesaving mission of organ donation and transplantation.

 How can you improve perception and care during the DCD donation process in your unit?

Acknowledgment: The authors acknowledge the contributions of Richard Arbour, MSN, RN, CCRN, CNRN, CCNS, CCTC, CBRN, FAAN, FCCM, Stephanie Osier, BSN, RN, CCRN, CPTC, and Joseph Paparo in writing this blog.