Donation after circulatory death (DCD) represents a growing pathway for organ transplantation, addressing the persistent gap between the number of individuals needing organs and the available supply. This method expands the donor pool, offering hope to more patients awaiting life-saving transplants.
Understanding Donation After Circulatory Death
Donation after circulatory death occurs when organs are recovered from a patient whose death is determined by the irreversible cessation of circulatory and respiratory functions. This differs from donation after brain death (DBD), where death is declared based on the irreversible loss of all brain function, even if the heart still beats with mechanical support. Both DCD and DBD are recognized definitions of death under the Uniform Determination of Death Act (UDDA).
Patients considered for DCD have suffered a devastating neurological injury or illness but do not meet brain death criteria. The patient’s physician determines that continued life-sustaining support is no longer beneficial and should be withdrawn. This decision is made by the medical team and the patient’s legal next of kin, separate from any discussion about organ donation. Organ procurement organizations (OPOs) and transplant teams are not involved in the decision to withdraw life support.
The DCD Process
The DCD process begins after the decision to withdraw life-sustaining treatment and consent for donation are obtained. Life support, such as mechanical ventilation, is then withdrawn, often in an operating room for rapid organ recovery. The medical team monitors the patient for the cessation of heart and breathing functions.
Once the heart stops beating, a mandatory observation period of 2 to 5 minutes ensures no auto-resuscitation. After this period, a physician, who is not part of the transplant team, declares death based on irreversible circulatory criteria. Immediately following the pronouncement of death, the organ recovery team begins the surgical procedure to retrieve the organs.
Minimizing “warm ischemia time” is an important aspect of the DCD process. This refers to the period when organs are deprived of oxygenated blood after circulation ceases, before they are cooled and preserved. It is calculated from the cessation of circulation until cold perfusion begins. For example, a kidney may have a warm ischemia time of about 60 minutes, a liver’s limit is around 30 minutes, and lungs up to 90 minutes. Medical teams work to keep this time as short as possible to preserve organ viability for transplantation.
Organs Donated and DCD’s Significance
A range of organs can be recovered through DCD, including kidneys, liver, lungs, and pancreas. Kidneys are the most frequently transplanted DCD organs. Advancements have also made heart and lung donation from DCD donors increasingly possible. Historically, hearts were not recovered from DCD donors due to oxygen deprivation. However, new technologies and preservation methods now enable successful DCD heart transplantation with outcomes comparable to those from brain-dead donors.
DCD significantly contributes to the overall organ supply. In the United States, DCD donors made up 43% of all deceased donors in the previous year, with over 7,200 DCD donors. This expansion of the donor pool helps reduce the number of patients on transplant waiting lists and decreases waiting times for life-saving organs. Studies indicate that DCD heart transplantation, for example, can increase the transplant rate and reduce waitlist times for recipients.
Ethical and Legal Frameworks
The practice of DCD is guided by ethical and legal frameworks to ensure patient dignity and public trust. The “dead donor rule” is a key ethical principle, which mandates that organ recovery must not cause the donor’s death and that the donor must be declared dead before organs are procured. This rule is upheld in DCD cases by the mandatory observation period after circulatory arrest before organ recovery begins.
Legal frameworks, such as the Uniform Anatomical Gift Act (UAGA), provide a structure for organ donation across U.S. states, including DCD. This act, adopted by all 50 states, outlines requirements for making an anatomical gift and protects donor and family rights. Organ procurement organizations (OPOs) operate under regulations from bodies like the Organ Procurement and Transplantation Network (OPTN) and the Centers for Medicare and Medicaid Services (CMS). These regulations ensure the process adheres to medical and ethical standards, emphasizing informed consent from the donor or their surrogates.