Understanding Organ Donation
After Cardiac Death (DCD)
A Resource Guide for Healthcare Professionals
Organ and tissue donation offers families a glimmer of hope
and comfort at a time when all seems lost. It also provides
families the opportunity to honour a loved one’s wish to donate.
Organ transplantation has evolved from an experimental
treatment to the treatment of choice for thousands of Ontarians
who await the gift of life. Transplantation offers recipients
whose lives were severely restricted by their illness, or next
to death, a dramatic improvement in health and well-being.
Unfortunately the supply of solid organs for transplantation has
not met the demand and has, despite best efforts, remained
relatively unchanged over the past decade. Historically organ
donation has only occurred after brain death and only a small
percentage of all hospital deaths result from a determination of
neurological death (brain death). Some estimates are as small as
1.5-3%. Reliance on organ donation after brain death severely
limits the availability of organs for transplant. The numbers tell
A Historical Overview of Donation and Transplantation Activity
Actual Donors Transplants Waiting List
1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004
UNDERSTANDING ORGAN DONATION AFTER CARDIAC DEATH (DCD) A Resource Guide for Healthcare Professionals 3
DCD: A Short History
Formerly called Non-Heart-Beating Organ Donation (NHBD),
organ donation after cardiac death (DCD) has been an end-of-
life option for patients and families for more than thirty years in
the USA and Europe. Prior to the introduction of the concept of
brain death and its ensuing laws, DCD was the way in which all
organs were recovered.
Initially DCD had its limitations such as poor organ function
for recipients. Donation after brain death (deceased donation)
offered better outcomes. As a result DCD fell by the wayside
and donation after brain death became the preferred method
of organ recovery.
The ongoing shortage of organs for transplantation has
created a renewed interest in organ donation after cardiac
death. Improved medications and surgical techniques have
dramatically improved the outcomes for recipients of DCD
donated organs. These advances combined with the severe
shortage of organs for transplant make organ donation
after cardiac death another option for patients and families
interested in giving the gift of life.
DCD: A Short Description
Organ donation after cardiac death is an option for families
of patients who have decided to withdraw life support after a
physician has determined that there is no long- term prognosis
for recovery, and for those patients who do not meet the
criteria for neurological death. After the decision has been
made that the patient has no chance of survival and the family
has decided to withdraw life support, the family is offered the
option of organ donation after cardiac death. The option of
donating organs after cardiac death should be offered prior to
the withdrawal of life support but only after the decision to
withdraw life support has been made.
UNDERSTANDING ORGAN DONATION AFTER CARDIAC DEATH (DCD) A Resource Guide for Healthcare Professionals 5
Hospital Staff – Your Role in DCD
Trillium Gift of Life Network (TGLN) will assist hospitals in
providing the option of DCD to families while ensuring the
process works for all those involved.
• Makes major decisions about patient care
• Works to preserve life before decision made to withdraw care
• Serves as family advocate and may offer the option of DCD
• Declares patient’s death by cardio-circulatory criteria
• Provides on-going care to families throughout the patient’s
• Coordinates clinical management of patients and provides
support for family
• May make the referral call to Trillium Gift Of Life Network
about potential DCD donor
• May initiate DCD conversation after discussion with the
healthcare team and Trillium Gift Of Life Network
Pastoral Care and Social Worker:
• Meets spiritual, religious and other non-clinical needs of
patient and family
• Serves as family advocate in collaboration with medical and
• May provide DCD information in response to family requests
The DCD Process: Ten Steps To Saving Lives
The DCD process is no more difficult or complex than organ
donation after brain death. The wishes and needs of the
family are paramount and always the focus of the team
during this emotionally charged time. Families make the
decision to help others at a time of great personal loss.
Sensitivity, openness and the ability to actively listen can
all help in making the DCD process as positive as possible
under the circumstances.
Step One: End-of-Life Decision
For the patient on life support, the family is informed about
the serious nature of their loved one’s injury and their poor
prognosis. After all medical options have been exhausted,
families are consulted regarding the withdrawal of life sustaining
treatment. The decision to withdraw life support is made by
the family and the medical team. Participants may include the
attending physician, bedside nurse, clergy, a representative
from social work and extended family members. The option
of organ donation after cardiac death poses no difference
in the decision to withdraw life support than cases where
support is withdrawn and donation was not an option.
Step Two: Offering The Option
After TGLN has been contacted, a decision will be made to
determine if the patient is a potential DCD donor. Once this
decision has been made, a designated person (either an Organ
& Tissue Donation Coordinator, their designate, or a hospital
assigned person) will offer the family the option of donation.
The person providing the option will have specific training
on how to sensitively conduct a donation conversation. This
conversation will take place in a quiet area away from the
patient’s bedside where the family will not be distracted
by external stimuli. The family is given full and complete
information regarding the option of DCD so that they can
make a decision that is right for them and their loved one.
UNDERSTANDING ORGAN DONATION AFTER CARDIAC DEATH (DCD) A Resource Guide for Healthcare Professionals 7
The DCD Process: Ten Steps (continued)
Step Three: Consent
If the family consents to organ donation the next of kin or
legal substitute completes the organ donor consent form
in compliance with the Trillium Gift Of Life Network Act.
In addition, TGLN staff, or designated hospital staff, obtain
written consent for several specific actions:
• Organ donation after cardiac death
• Pre-mortem treatment for the purpose of organ donation
after cardiac death
This may include medication and preparation for the insertion
of cannulas to ensure optimal organ outcome.
To ensure timely surgical recovery of consented organs and
optimal graft function, it may be necessary to insert a small
cannula in the groin where organ flush solutions will be
administered after death has been pronounced and the
five minute waiting time post asystole has been observed.
Anticoagulants may be administered prior to death while
the heart continues to beat to avoid clotting and ensure
circulation and perfusion to all organs.
Step Four: Evaluation
The TGLN coordinator, in collaboration with the healthcare
team, will coordinate the donation process. This will include
a respiratory drive assessment, organ function assessment,
and a complete and thorough medical and social history to
ensure transplant suitability. Further suitability testing may
ensue as a result of the social/medical questionnaire. The
TGLN representative will schedule the OR time and arrange
the arrival of the necessary surgical recovery teams.
The TGLN representative will discuss with the family the
possibility that their loved one will not expire within the
timeframe needed for donation to ensure optimum outcomes
for transplant recipients. If this situation occurs the patient
will be returned to an appropriate area of the hospital where
comfort measures can be provided and family members can
Step Five: Coordination and Decision Making
TGLN staff and the medical staff at your hospital will consult
with the family regarding timing of withdrawal. This decision
will be made prior to the arrival of the surgical team.
Withdrawal of life support may occur in the ICU, the OR or
another area close to the OR.
Withdrawal of life support is usually done by the physician who
has been in charge of the patient’s care, but may be done by
other physicians depending on your specific hospital policy.
Step Six: Preparing for Surgery
When the surgical recovery team arrives at the hospital they
will consult with the healthcare team. The recovery team will
be available to answer any questions or address any concerns
the staff may have. They will get an update on the status of the
patient and review the consent form and confirm blood type.
Step Seven: Final Good-Byes
Trillium Gift of Life Network recognizes that this is an
emotionally charged time for family members. Family members
will be afforded every opportunity to have their last moments
with their loved one be as memorable and personal as possible.
The TGLN representative will be available at this time to offer
support and tend to the needs and final wishes of family
UNDERSTANDING ORGAN DONATION AFTER CARDIAC DEATH (DCD) A Resource Guide for Healthcare Professionals 9
The DCD Process: Ten Steps (continued)
Step Eight: Withdrawal of Life Support
If withdrawal of life support is to take place in the operating
room the patient will now be transferred, supported on a
ventilator and monitored by medical staff. If support is to be
withdrawn in the ICU, the medical team will withdraw life
support. A physician not involved with the transplantation
process will pronounce death. A second physician is required
by the TGLN Act to confirm death for donation to occur. In
addition, a physician will confirm the absence of spontaneous
respiration and absence of a pulse pressure for a period of five
It is important to note that in all settings where life support is
withdrawn, patient comfort measures are of utmost concern.
The attending physician may administer analgesia based on
clinical judgment. The same end-of-life care is given to the
patient regardless of whether support is withdrawn in the
ICU or OR and if organ donation had not been an option. In
some instances the family may be present in the OR for the
withdrawal of life support depending on individual hospital
Step Nine: Organ Recovery
After the declaration of death and the five-minute absence
of spontaneous respiration and absence of pulse pressure is
documented, surgical recovery of organs begins. (Research has
shown that a patient’s heart will not resume beating beyond
two minutes after declaration of cardiac death.)
If the patient does not expire within the timeframe needed for
organ recovery (120 minutes), the patient will be transferred
to a designated area as outlined in step four.
Step Ten: Saving More Lives
The organs that are recovered are allocated according to an
agreed upon provincial algorithm which gives waiting recipients
a second chance at life.
Benefits of Organ Donation After Cardiac Death
Organ donation after cardiac death provides the family
of patients who do not meet the criteria for donation after
neurological death (deceased donation) the option of
honouring a loved one’s wish.
Recipients are not the only ones that benefit from organ
donation. Because of the recipient’s second chance at life
their family is able to enjoy more quality time together.
Organs from DCD donors are proven to have similar
outcomes as those from deceased donors.
UNDERSTANDING ORGAN DONATION AFTER CARDIAC DEATH (DCD) A Resource Guide for Healthcare Professionals 11
Frequently Asked Questions
Organ donation can raise a variety of question and concerns
not only for families of potential donors but also for those
who care for them. Research has shown that organ donation
after cardiac death raises some specific concerns, such as:
1. Who are the two physicians that pronounce death?
The attending physicians such as a neurologist, neurosurgeon,
anesthetist or intensivist are all able to declare death. The
physicians that declare death will have no affiliation with a
2. Will the family be able to be with their loved one at
the end of life?
Depending upon the hospital protocol this may be an option
for families. If withdrawal of life support occurs in the ICU the
family may be present to witness asystole. In some institutions
it may even be possible for family members to be in the OR
when death is declared. It is important to note that family
members will be informed of the need to leave their loved
one’s side once death has been declared so that the recovery
surgery may proceed.
3. Is the patient really dead when organ recovery occurs?
Organs are never recovered from a patient until they have had
two (2) confirmations of death by two different physicians who
have no association with a transplant program. TGLN will then
wait an additional five minutes prior to the start of surgical
recovery of organs to ensure auto resuscitation does not occur.
4. Does the patient feel pain during organ recovery?
No. After someone dies they no longer feel pain. Organ
donation after cardiac death only occurs after a patient
is declared dead.
5. Are medical professionals doing harm?
Patients considered for DCD have suffered an injury or illness
that has rendered them dependent on life support with no
hope of recovery. DCD is not offered as an option to families
until a decision to withdraw life support has been made in
consultation with the medical team. DCD is an option for
families at end-of-life where their loved one does not meet
the criteria for deceased donation but who are interested in
donating the gift of life.
6. Is there a conflict of interest for the Organ Procurement
TGLN will only be contacted when death is imminent or after
the decision to withdraw life support has been made by the
family and physician. The role of TGLN is to educate and
support hospital staff, ensure every family is offered the option
of donation according to the Trillium Gift of Life Network Act,
and to honor the wishes of patients and their families.
UNDERSTANDING ORGAN DONATION AFTER CARDIAC DEATH (DCD) A Resource Guide for Healthcare Professionals 13
Trillium Gift of Life Network gratefully acknowledges the
work of the University of Wisconsin Hospitals and Clinics
Organ Procurement Organization, and for their sharing of
both expertise and resources.
Organ Donation After Cardiac Death: Saving More Lives.
The University of Wisconsin Hospitals and Clinics Organ
Procurement Organization, 600 Highland Avenue, Madison, WI
UNDERSTANDING ORGAN DONATION AFTER CARDIAC DEATH (DCD) A Resource Guide for Healthcare Professionals 15
For more information:
Trillium Gift of Life Network
155 University Avenue, Suite 1440
Toronto, Ontario M5H 3B7
Toronto Region: 416-363-4438
Toll Free: 1-877-363-8456
Printed in Canada, 2005