DCD

The organ donation and transplantation process involves surgically removing viable organs from one person (the organ donor) and surgically implanting them into another person (the recipient). The recipient receives the donated organ to replace the recipient’s diseased organ that is no longer adequately functioning. Replacement of diseased organs in the human body with a healthier organ from a human donor provides the recipient with a greater quality of life and increases patient survival over alternative options.¹

Organs can be donated by a living (living donation) or deceased (deceased donation) person. About 6,500 living donations occur each year, the majority of which are kidneys.² A portion of one’s liver or lung, and the uterus can also be donated from a living donor. Very rarely, a segment of a pancreas or the small intestine may be donated through living donation. Most living donations occur between family members or friends; other people donate altruistically to someone they do not know. While living donation is an invaluable gift of life, the number of organs that can be recovered falls short of saving the lives of patients on the waitlist.

The vast majority of organs available for transplant come from deceased donors.² Deceased donors may be able to donate their two kidneys, liver, heart, two lungs, pancreas, small intestines, and vascularized composite allografts (VCAs). The most frequently donated and transplanted organ from a deceased donor is the kidney, followed by the liver. VCA involves the transplant of multiple types of tissue (bone, muscle, nerve, skin, and blood vessels) from one individual to another as a functional unit. Most notable examples are hand, arm, uterus, penile, and face transplants.³

While there has been a steady increase in deceased donor organs available for transplant over the last several years, there has been only a marginal increase in living donor organs (see Figure Intro-1). The increase in Donation after Circulatory Death (DCD) donors is the most significant contributing factor to the increase in available organs. A total of 16,989 people became deceased organ donors nationwide in 2024, representing the 14th consecutive year with the highest number of deceased donors of any prior year, and an increase of 43% over the last 5 years.² Yet, the need for transplants far outweighs the available organs, and sadly, deaths among those waiting for transplants continue to occur (see Figure Intro-2).

Figure Intro- 1. Comparison Of Deceased Donor To Living Donor Transplants Through 2024²

Figure Intro- 2. Transplants vs. Deaths on the National Waitlist by Year²

The first donors resulting in human-to-human organ transplants occurred after circulatory determination of death. At that time, the term “Donation after Circulatory Death” (DCD) was not yet used; it was initially referred to as “non-heart-beating organ donation.”⁷ This was prior to the Uniform Determination of Death Act of 1981,⁸ which also recognized brain death or death by neurologic criteria (BD/DNC) as a form of death.

The first documented attempt of a human-to-human kidney transplant was in 1933 by Dr. Yurii Voronoy. While the kidney briefly produced urine, unfortunately, the recipient died because the donor kidney had a very long warm ischemic time (WIT) and was transplanted across a major blood group mismatch.⁹

In 1950, Dr. Richard Lawler performed a deceased kidney transplant on Ruth Tucker, a 49-year-old with polycystic kidney disease (PKD). This patient was not in terminal renal failure at the time of transplant and had some native kidney function present. The transplanted kidney functioned for 10 months but was then removed for rejection, and she was able to live for 5 more years despite the kidney failing. The kidney produced urine only briefly, and the transplant was neither scientifically significant nor beneficial to the patient.¹⁰ As a result, it is often not recognized as a ‘successful transplant.’

The first transplant that is considered successful was in 1954, when Dr. Joseph Murray led the first living kidney donor transplant between the identical Herrick twin brothers (image below).¹⁰ Then, in 1962, Dr. Joseph Murray and Dr. David Hume of Brigham Hospital in Boston used a kidney from a patient following circulatory death—marking the first successful deceased-donor kidney transplant.¹¹ This was followed in 1963 with the first successful lung transplant, done by Dr. James Hardy at the University of Mississippi Medical Center.¹² In 1966 came the first pancreas transplant (performed by Dr. Richard Lillehei and Dr. William Kelly at the University of Minnesota)¹³, followed a year later by the first liver transplant performed by Dr. Thomas Starzl at the University of Colorado in Denver.¹⁴ Dr. Christiaan Bernard of the Groote Schuur Hospital in South Africa performed the first successful heart transplant in 1967.¹⁵

What these “firsts” had in common was that all the transplanted organs were from donors who had died following cessation of circulation, now known as Donation after Circulatory Death (DCD). Original recipient survival rates were poor due to organ rejection and poor organ quality caused by WIT.

Right image: Richard (recipient), front left, and his twin brother Ron (donor), front, pose with doctors, from top left, Murray, John Merrill and J. Hartwell Harrison

In 1968, the Harvard Ad Hoc Committee defined the concept of “coma depasse” (state beyond death), which was first described in French literature¹⁶ as “le coma passe.” The Committee called this finding: “Brain Death (BD)” or “Death by Neurologic Criteria (DNC).” It was not until 1981 that BD/DNC was recognized as an acceptable form of death and incorporated into United States law through the Uniform Determination of Death Act (UDDA)⁸, which recognizes both brain death (BD/DNC) and death based on circulatory and respiratory criteria as legal definitions of death. From that time forward, BD/DNC donors began to replace DCD as the predominant pathway for organ transplantation due to improved recipient outcomes — though a small percentage of donations continued to occur via the DCD pathway in some areas of the United States.

National Initiatives to Increase Recovery of Deceased Donor Organs

The expanding role for lifesaving organ transplantation in the treatment of end-stage organ failure has become well accepted by the medical community. Recipient and graft survival rates have significantly increased due to innovations in organ recovery, transplantation techniques, and advancements in immunosuppressive agents. With this success, the donation and transplantation community began to explore opportunities to increase the number of organs available for transplant. The number of people declared dead by neurologic criteria is rare in comparison to circulatory criteria. Therefore, the pool of potential BD/DNC donors alone would never be able to meet the actual need for organ transplants. Another donation potential had to be identified.

Between 2003 – 2006, the Health Resources and Services Administration (HRSA) funded and led a national Organ Donation Breakthrough Collaborative.¹⁷ At these series of national meetings, which included members of the donation and transplantation community, various methods for increasing donation and transplantation were discussed. Ideas included increasing the number of brain dead donors through improving deceased donor management through “Best Practice Sharing” of successful OPO processes, use of expanded criteria donors (older donors and donors with more complex medical histories), and the re-introduction and standardization of process which led to an increase in DCD donors (Figure Intro – 3).

Figure Intro-3. Donation After Circulatory Death (DCD) process
In DCD cases, organs are recovered after death determined by respiratory and circulatory criteria; in the United States, this typically follows a planned withdrawal of life-sustaining treatment (WLST).

Attributable to the initiatives of the Organ Donation Breakthrough Collaborative, there was a 22.5% expansion in the aggregate number of organ donors in the United States. This represents a fourfold increase from the 5.5% growth recorded during an identical duration immediately before the Collaborative’s inception.¹⁷

Figure Intro-4.  Year-over-year comparison of number of brain dead to DCD donors in the U.S.²

Since the Collaborative, the medical criteria for deceased organ donation have continued to broaden based on favorable clinical experience, with increasing proportions of donors and organs coming from less traditional eligibility categories. In 2024, the total number of deceased organ donors was 16,988; of that, there were 7,283 people who donated organs after circulatory death (DCD donors) representing an increase of nearly 24% over the 2023 total and the highest number of annual DCD donors in history.² (See Figure Intro-4.)

In 2021, the Organ Procurement Transplantation Network (OPTN) launched a DCD Procurement Collaborative project. The primary aim of the project was to further increase the number of DCD donors recovered by OPOs. It was an “all teach, all share, all learn” engagement effort to align with OPTN strategic goals, recognize the community needs and desire to improve, identify gaps in practice, and share effective practices. Three key drivers for change were identified: (1) optimizing clinical practices and staffing structures; (2) strengthening relationships between OPOs, hospitals, and transplant programs; and (3) enhancing the process for obtaining authorizations.¹⁸

In February 2022, the National Academy of Science, Engineering, and Medicine (NASEM) issued a report¹⁹ outlining recommendations to improve fairness and equity, reduce nonuse of donated organs, and improve the United State’s Organ Transplant System’s overall performance.

• Recommendations for DCD included:²⁰
• Reduce or eliminate the existing variations among donor hospitals, OPOs, and transplant centers in DCD procurement and transplantation;
• Utilize the proven capabilities of the highest performing OPOs, hospitals, and transplant centers to establish bold national goals and drive national progress toward greater equity and higher rates of donation, procurement, and transplantation from DCD donors; and
• Increase the percentage of DCD donors to at least 45%, ensuring there is no reduction in the number of organs retrieved from donors with neurological determination of death.

Deceased organ donation follows one of two pathways: BD/DNC or DCD. Figure Intro-5 depicts the alignment between the potential donor and family, the hospital, and the OPO during the deceased organ donation process.

The majority of BD/DNC organ donations occur at a relatively small number of hospitals in the United States, primarily trauma centers and tertiary/quaternary hospitals. The increase in DCD organ donation has led to more community hospitals and non-trauma centers participating in deceased organ donation. Whether BD/DNC or DCD, the organ donation process is initiated when the hospital patient care team recognizes clinical triggers for notification to the OPO to evaluate for the potential of donation. The donation process relies on mechanical ventilation to allow sufficient time for donor potential evaluation and donor management. Access to critical care (point “i” in Figure Intro-5) is therefore essential; for patients who do not die in the critical care unit, tissue and eye donation may still be a possibility if they are deemed medically suitable by the OPO, tissue bank, or eye bank.

Following the BD/DNC donation pathway in Figure Intro-5, death is declared after the determination of permanent cessation of function of the entire brain including the brainstem. Following the declaration of death (point “ii”), the donation conversation is initiated with the legal next of kin/legal authorizing party (LNOK/LAP, point “iii”) through collaboration with the OPO and the hospital patient care team. Authorization for donation may be provided by the donor prior to their death (First Person Authorization [FPA]), or may be provided by a LNOK/LAP listed in a predetermined order of decision makers according to each state’s Uniform Anatomical Gift Act (UAGA). For minors, including those who may have registered their intent or assent to donate, the donation conversation will include a decision by the parents (or in some states a guardian) whether or not to authorize donation. Once authorization is obtained (“P” on Figure Intro-5) the OPO continues medical management of the donor in the ICU setting with the support of the hospital patient care team. Organs are allocated to transplant centers via the donor-recipient match list (Point “Q”).  Once organs have been accepted by transplant centers, the donor is taken to the operating room for organ recovery (“R”).

For patients who are not BD/DNC, but the LNOK/LAP, along with the hospital patient care team, have determined a plan to withdraw life-sustaining treatment (WLST) (“iv”), the opportunity for organ donation can be presented. It is important to acknowledge that the practice of DCD is an integral part of the continuum of quality end-of-life care for patients and their families, when life-sustaining treatments are no longer beneficial to the patient.²¹ Once the patient is declared dead by cessation of circulation, organ donation may then proceed by the DCD pathway (“vi”). The OPO coordinates with the hospital patient care team to continue medical management while organs are allocated to and accepted by transplant centers (“viii, Q, and ix”). WLST is coordinated between the OPO, the hospital patient care team, and the donor’s family (“v”). Following WLST, circulatory death (point “vi”) must be declared prior to proceeding with organ recovery (“R”). The length of time that passes between WLST and declaration of death is a primary factor in whether viable organs can be recovered (“R”) or the donation would not proceed (“vii”). New technologies and techniques are positively impacting this process through lengthening this time and increasing donation potential. Essential 8 outlines more details.

Figure Intro-4.  Year-over-year comparison of number of brain dead vs. DCD donors in the U.S.²

Classifications of Donation after Circulatory Death

The practice of DCD has been extensively reviewed by physicians, ethicists, and scientists. The authoritative National Academy of Medicine (previously called the Institute of Medicine [IOM]), held two national consensus conferences on the topic of DCD, one in 1997 and another in 2000.^{22, 23} They concluded that DCD adhered to the principle of “causing no harm” to the donor, and acknowledged that DCD saves lives and has benefited donor families who reported that DCD gave meaning to a family member’s death. The practice of DCD has also been carefully reviewed by the Department of Health and Human Services (DHHS), the World Health Organization (WHO), and multiple international medical organizations. All came to a similar conclusion and support this practice pathway to organ donation. There has been an intense effort by all involved organizations to ensure that potential conflicts of interest that could complicate organ donation are eliminated and to optimize the recovery and preservation of organs for transplantation.

The waitlist and the need for more organs for transplant grew as medical criteria for deceased organ donation continued to broaden based on more favorable clinical experiences. Both trends spurred greater efforts to identify DCD potentials, resulting in an increased number of DCD donors. As indicated in Figure Intro-4, the number of DCD donors has significantly increased over the years.

The ongoing advances in technology and recovery procedures have created the ability to transplant more DCD organs than ever; they have also required hospitals and OPOs to improve their potential DCD donor identification and management processes.

BD/DNC occurs most often in the ICU setting and there is a well-defined hospital-specific policy for this determination. Quite different from BD/DNC, circulatory death may occur in or outside of the hospital, e.g., in an ambulance, the emergency room, the ICU, the general floor of a hospital, nursing home, etc. This growing experience in the potential for DCD donors led to the need to distinguish several categories of DCD for these different end-of-life situations.

Figure Intro-6. Maastricht classification of DCD

These categories, known as the Maastricht Classification of DCD,²⁴ have been used worldwide over the last 20 years and facilitate the characterization of the different types of DCD potentials, which may impact technical and medical aspects (organ viability, preservation modalities, graft survival) and ethical considerations. An advantage to this classification system is its simplicity and usefulness. Attempts to improve the Maastricht classification have focused on adding more categories, with the objective of distinguishing the different ischemic insults to the organ and consequently different outcomes (see Figure Intro-6).

Currently, in the United States, the practice of controlled DCD (Figure Intro-6, Maastricht category III) is most common. The term ‘controlled’ indicates that the DCD process is planned and not unexpected. As families initiate the decision to WLST, the timing of WLST can be coordinated, allowing for a more controlled process.

In some cases in the United States, uncontrolled DCD (Figure Intro-6, Maastricht category IV) is practiced. In these situations, the patient has been declared BD/DNC. Sudden cardiac arrest occurs during donor management but prior to planned organ recovery, necessitating the rapid recovery of organs in the operating room. Because of the sudden cardiac arrest, the timing of organ recovery is uncontrolled.

In many parts of the world, uDCD (Cat I or II) is a common pathway to deceased organ donation. Donation occurs following cessation of circulation (cardiac arrest). In Cat I, the individual is found without circulation and no attempts at resuscitation occur prior to recovery of organs for donation. In Cat II, the circulatory arrest is witnessed and resuscitative measures are initiated and continued with no successful return of spontaneous circulation (ROSC). The family is informed that resuscitative measures are unsuccessful and with family consent for donation, CPR continues, while the deceased donor is taken to the operating room where CPR is ceased and organ recovery may occur.

Currently in the United States, uDCD cat I and II is only practiced in a few locations, but might become more common in the future. Accordingly, this guide will focus primarily on the process of controlled DCD (category III).