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Donation after cardiac death is complex due to significant ethical and scientific issues, and concepts of end-of-life care, personal autonomy, and death.

“What is not forbidden is compulsory.”
W.H. Auden

Organ donation after cardiac death (DCD) differs from the more traditional organ donation after brain death (DBD) insofar that DCD donors are alive and donate organs after discontinuation of life support so that a natural death with cessation of heartbeat and circulation may occur, followed by extraction of organs. This may increase the availability of transplantable organs, leading to improvement in the lives of other humans.  According to the Health Resources and Services Administration, 5896 donations, representing 36% of all donations in 2023, were DCD, representing an increase of 40.7% over the preceding three years. There, however, are significant ethical and scientific issues in the performance of DCD with concepts of end-of-life care, personal autonomy, and concepts of dignity of life and death.

Some reasons for these beliefs are:

Lack of informed consent/authorization: Although DBD is usually authorized by enlisting in a national or state drivers’ licensing database, it is likely that DCD has never been authorized or consented to by any patient. It is unclear why judgement from family members or powers of attorney is ethically an adequate consent in such matters.

Lack of scientific basis for irreversibility: In DBD, there is a distinct line drawn between life and death enabling organ extraction for donation to proceed. DCD operates in a grey area between life and death, wherein medical prognosis may be unclear. I have witnessed at least one patient who survived a DCD attempt, was subsequently admitted to a medical room, and eventually recovered and returned home. This outcome, of course, is uncommon, but illustrates the uncertainty of irreversibility in some patients referred for DCD.

Likelihood of abuse: Under the direction of the attending physician, DCD usually begins by medicating the patient to prevent pain and anxiety, followed by extubation to comfort care. If the patient does not have natural death within a certain time period, the attempt for DCD is stopped and the patient admitted to the hospital. In the face of an entire OR team waiting impatiently to begin organ extraction, the treating physician is likely to face significant pressure to accelerate the process by administering drugs in dosages well beyond those needed to assure comfort, ie. euthanasia. Indeed, a number of physicians known to me have noted exactly this pressure.

Confusion of roles: The attending intensivist is ethically and completely obligated to pursue the treatment and comfort of the patient under his or her care. While organ transplantation is a worthy goal, it does not diffuse the physician’s primary duty to the patient. Participation in DCD may potentially help a prospective organ recipient but does not help and likely harms the afflicted patient, creating a conflict of interest, contrary to ethical standards. Indeed, in my practice, this topic is never discussed with families of patients that are critically ill, unless first broached by family. I always explain to families that ethically I and the ICU care team are responsible only to the patient and family and not to anyone else, even to potential organ recipients.

Dignity and quality of the dying process:  In DCD, the discontinuation of life support against the time demands of securing viable organs is likely to interfere or at least add complexity to the palliative care of the patient during the dying process. This is not a theoretical concern but rather an issue with most, if not all, DCD attempts.

In full disclosure, I do see occasional patients, often younger with diffuse, irreversible brain damage, often having authorized DBD by their drivers’ license, in whom DCD might be reasonable. Medical ethics, of course, is not so much a list of inflexible rules as it is a platform for consideration of difficult issues-often with no universally agreed upon solution.  If DCD is performed, it must be pursued with compassion and respect, to obtain primary emphases on the patient’s dignity and comfort at all times. Suitable reforms in the DCD process would, at least, address many of the concerns previously noted.