Summary
Most organ donations in the United States once came from people declared brain-dead, but a growing share now come from donors whose hearts stop first. In research published in the medical journal JAMA, NYU Langone Health investigators said donation after circulatory death—DCD—accounted for 49% of deceased donors in the U.S. last year, up from 2% in 2000.
The change is occurring alongside a national push to expand the supply of transplant organs, as the U.S. continues to face a severe shortage. The researchers said technology has helped overcome some barriers to using organs after circulation slows, supporting the rise of DCD donation even as more than 100,000 people remain on the transplant waiting list and thousands die while waiting.
In the JAMA study, the NYU Langone team analyzed data from the nation’s Organ Procurement and Transplantation Network and from 55 organ procurement organizations, known as OPOs, that recover organs in assigned regions. The analysis found that circulatory death accounted for more than half the donors at 24 organ donation agencies last year, but the share differed substantially, with some agencies reporting as little as 11% of donors coming from circulatory death.
The investigators also pointed to factors that could help explain that variation, including how familiar hospitals are with the additional steps of DCD. They said the ability to adopt newer technologies can matter as well: after death is declared, a tool called normothermic regional perfusion can temporarily restore blood flow to organs in the chest or abdomen, avoiding the brain, while surgeons do the delicate retrieval work.
The DCD approach remains controversial in some quarters because it includes decisions around timing and the ethics of restoring blood flow temporarily after death is declared. Even so, NYU Langone said the policy and clinical challenge is to ensure the process works correctly and safely while maintaining public confidence, particularly after rare but frightening reports have shaken trust in the transplant system.
Federal officials with the Health Resources and Services Administration are preparing new national policies aimed at improving safeguards for DCD. One proposal described by the researchers would allow people involved with a potential donor who questions whether their condition meets requirements for withdrawing life support to call for a pause in the preparation process. Other proposals would require OPOs to document that hospitals perform appropriate neurological exams and to educate families of potential DCD donors about the steps required.
The Association of Organ Procurement Organizations has also issued guidance and, the report said, some OPOs have already created checklists to help hospitals. The group’s president, Jeff Trageser, said the association urges withdrawal of life support in the critical care unit rather than in an operating room to help avoid public confusion about when death occurs and when organ teams step in.
Dr. Babak Orandi, an NYU transplant surgeon and study co-author, said the country needs to build understanding and execute DCD carefully. “Donation after circulatory death ‘requires a lot of buy-in from the community, including the local hospitals, to make this happen,’” Orandi said, adding that “A couple of cases out of many, many cases has led to a loss of trust.” He also said, “we need to make sure we are doing it well,” and that if DCD were stopped or severely restricted, “there would be pretty significant repercussions for patients.”