Unlocking the Gift of Life: Demystifying Donation After Circulatory Death

As a critical care nurse who specializes in organ donation and transplantation, I have witnessed firsthand the complexities and challenges unique to Donation after Circulatory Death (DCD) for over 30 years. In recent years, due to medical advancements, improved protocols for organ preservation and increased awareness, DCD has emerged as a valuable pathway for organ donation. DCD provides a way for patients with severe brain injury or devastating illness to donate the gift of life and honor the legacy of others who donate. DCD has increased the number of organs available for transplantation and thus has helped reduce the number of patients waiting. It has also decreased the waiting time for patients to receive a lifesaving transplant, offering hope and renewed life to those with end-stage organ failure. Yet, for many, the concept of DCD may seem shrouded in uncertainty or ambiguity. In this blog, we will demystify DCD by exploring the process, benefits and ethical considerations.

Misconceptions of DCD

There’s a difference between Donation after Brain Death (DBD) and DCD. Unlike DBD, where donors are declared brain dead by neurologic criteria while still on life support, DCD donors are declared dead based on irreversible cessation of circulatory function. Despite the proven effectiveness and lifesaving potential of DCD, there are several potential misconceptions noted below in no order of prevalence:

• Misconception: DCD compromises the quality of end-of-life care.
• Reality: Organ donation is integrated into end-of-life care, with a focus on providing comfort, dignity and respect to donors and their family members. Donors receive palliative care measures to manage symptoms and ensure a peaceful transition, while their family members receive emotional support throughout the donation process.
• Misconception: DCD organs are lower quality and carry higher risks for recipients.
  • DCD organs undergo extensive evaluation and preservation protocols to ensure viability and safety for transplant. Studies show that outcomes using organs from DCD donors are comparable to those from donors who are brain dead.
• Misconception: DCD hastens death or is euthanasia.
  • Reality: DCD is an option only after there is a family decision to withdraw life-sustaining treatment and allow natural death to occur for patients with severe brain damage or devastating illness. The decision to donate organs does not influence the timing or cause of death. The organ recovery team does not participate in withdrawal of life-sustaining treatment. Organ recovery only occurs after death has been confirmed.
• Misconception: DCD donors may wake up or feel pain during the donation process.
  • Reality: End-of-life care during withdrawal of life-sustaining support is no different when a patient will be an organ donor. The focus remains on providing comfort, dignity and respect to the donor and their family members. DCD donors are declared dead by circulatory criteria before the donation takes place. Organ recovery occurs only after death is confirmed.
• Misconception: Organ donation is against religious or cultural beliefs.
  • Reality: Most religions and cultures support organ donation as an act of compassion and generosity. Religious leaders and organizations often endorse organ donation as a way to save lives and promote the well-being of others.
• Misconception: DCD is not ethical.
  • Reality: The DCD process involves specific protocols and procedures to ensure an ethically sound and effective method of organ donation. The process respects the wishes of the patient and their family members to give the gift of life. Hospital and organ procurement agency policies and protocols guide the DCD to ensure the donation is ethical and follows all regulatory standards.
• Misconception: DCD is financially motivated.
  • Reality: All organ donations are strictly regulated and governed by laws and ethical guidelines to ensure they are altruistic and based solely on saving lives rather than financial gain.
• Misconception: The body is mutilated during DCD organ recovery.
  • Reality: DCD donors are treated with dignity and respect during the organ recovery process. The same surgical technique is used as the technique for an autopsy. Only the organs consented for donation are recovered. Families can still have an open-casket funeral if they prefer.
• Misconception: Medical examiner cases cannot be organ donors.
  • Reality: While the medical examiner does have to authorize the procurement of organs for donation, authorization is determined on a case-by-case basis. The organ procurement agency works closely with the medical examiner throughout the organ donation process.

By dispelling these misconceptions and providing accurate information about DCD, we as ICU nurses can promote understanding and alleviate concerns about the donation process to maximize the gift of life. In addition to dispelling any misconceptions about DCD, it is important for ICU nurses to be knowledgeable about the DCD process from the identification of the potential donor through the recovery of organs.

The DCD Process

For ICU nurses involved in the DCD process, several key considerations and responsibilities may include the following:

• Identification: ICU nurses are usually the first to identify when the family is beginning to discuss end-of-life and the potential decision to withdraw life-sustaining treatment after the medical team has given them a poor prognosis for their loved one. When the family begins this discussion with any member of the healthcare team, it is time to refer the patient to the organ procurement agency. An early referral allows the organ procurement agency time to evaluate the patient’s medical suitability for organ donation.
• Collaboration: ICU nurses collaborate closely with the physician and the organ procurement team throughout the organ donation process from the decision to withdraw life-sustaining treatment through organ recovery. Once the decision is made to withdraw life-sustaining support, the ICU nurse facilitates collaboration with the organ procurement team prior to removing life-sustaining measures, including medications, to maintain the option for donation. This collaboration ensures coordination of care, adherence to hospital policy and procedures, and effective communication among team members involved in the donation process. Effective collaboration is crucial to maximize the organs available for transplant and ensures the donation process is handled with compassion and professionalism.
• Communication and Education: ICU nurses have a crucial role in the DCD process, as they are usually the ones who support the family during the decision-making process and notify the organ procurement agency when a patient meets the criteria for referral for organ donation. This role involves providing clear and accurate information about the withdrawal and donation process. The goal is to ensure the family understands the prognosis and withdrawal process so they can make informed decisions about their loved one’s care. Discussions about the potential of organ donation should involve persons educated in the organ donation consent process. Since not all patients meet the criteria for organ donation, discussing donation with the family may give them false hope about their loved one’s ability to donate.
• Consent: ICU nurses help identify who is the legal next of kin for the purposes of organ donation. It is important to realize that it may not be the person who has been making healthcare decisions during the patient’s hospitalization. Prior to the organ donation discussion with the legal next of kin or healthcare surrogate, the organ procurement staff will search the donor registry to determine if the patient is registered to be an organ donor. The registry status to be an organ donor will be honored. ICU nurses usually attend the organ donation discussion with the family to provide support and answer medical questions. The informed consent discussion includes making sure the legal next of kin or healthcare surrogate has made the decision to withdraw life-sustaining treatment before offering the option of organ donation. The patient’s registry status is disclosed, the organ donation process is explained, and all questions are answered. The family’s wishes and preferences regarding organ donation are respected.
• Patient Care: ICU nurses are responsible for providing comprehensive end-of-life care to patients who are potential DCD organ donors. This care includes managing symptoms, providing comfort measures, and ensuring dignity and respect for the donor and the family throughout the donation process.
• Family Support: ICU nurses provide emotional support and guidance to the patient’s family throughout the donation process from the decision to withdraw life-sustaining support to organ recovery. This support includes addressing their concerns, answering questions, and facilitating discussions about end-of-life care as well as the donation process.
• Documentation and Compliance: ICU nurses must maintain accurate and complete documentation of patient assessments, care provided, and communication with the healthcare team and the patient’s family. ICU nurses ensure that hospital policies and protocols regarding organ donation are followed to confirm all legal and ethical standards are maintained.
• Organ Recovery: ICU nurses may help coordinate the organ recovery process through collaboration with the hospital’s primary healthcare provider, the organ procurement team, and the operating room where the organ recovery will occur, ensuring the decision to donate is honored. The ICU nurse provides end-of-life care until the donor’s death is declared according to hospital policy and protocols. Organ recovery occurs after death is declared.
• Ethical and Legal Considerations: ICU nurses must navigate complexities and ethical considerations during the DCD donation process, which starts with the decision to withdraw life-sustaining support and includes notifying the organ procurement agency, participating in the informed consent process, maintaining confidentiality, and adhering to all hospital policies and protocols as well as regulatory standards.

Each of us may have diverse perspectives about DCD, based on factors such as personal beliefs, cultural background, professional experiences and knowledge about organ donation. Caring for DCD donors can evoke a wide range of emotions for the ICU nurse that includes empathy for the donor and their family, pride in being part of the donation process, sadness for the loss of life, and anxiety about the complexities of the DCD process. It is important to know that the decision to donate is based on patient and family wishes to give the gift of life.

DCD represents a valuable and ethically sound approach to organ donation, offering hope to transplant recipients and their families while honoring those who donate. ICU nurses play a pivotal role in caring for patients and families during the DCD process. By understanding this process, its benefits and ethical considerations, ICU nurses can provide compassionate end-of-life care to potential donors and their families, ultimately contributing to the lifesaving mission of organ donation and transplantation.

What can you do to improve perception and care during the DCD donation process in your ICU?