The Debate over Death Determination in DCD

Organ donation after the circulatory determination of death has become a standard medical practice in the developed world. Despite its widespread acceptance, though, the question of whether the donor is actually dead at the moment of donation persists. In this issue, Don Marquis concludes that DCD donors are indeed not dead at the moment of donation because the cessation of their cardiac function is not irreversible.

I believe DCD survives Marquis’s criticisms, although careful attention to the details is necessary to see why. One source of confusion is terminology. The abbreviation “DCD” originally meant “donation after cardiac death,” but this is a misnomer. The “C” in DCD should refer to circulatory function. The Uniform Determination of Death Act identifies cessation of circulation as the test for death, and in keeping with the death statutes based on the UDDA, physicians commonly declare patients dead once their circulation permanently stops, despite residual electrocardiographic activity. The misplaced focus on the heart instead of circulation is understandable because the heart is usually the organ responsible for circulation, but what counts is absence of circulation.

Marquis distinguishes permanent from irreversible cessation of circulation. Cessation of circulation can be said to be permanent if, once it stops, it will neither restart spontaneously—“autoresuscitate”—nor will be restarted by medical resuscitation. Marquis rightly notes that the probability of autoresuscitation is an empirical issue. In a recent analysis of all published cases of autoresuscitation in patients whose heart stopped beating after life-sustaining therapy was discontinued, not a single case was reported of autoresuscitation to circulation, despite a few cases of autoresuscitation to cardiac electrical activity.¹

Once a donor has been without circulation long enough that autoresuscitation cannot occur, and since DCD donors have do-not-resuscitate orders and medical resuscitation will not occur, the permanent cessation of circulation inevitably and rapidly evolves into irreversible cessation. Given these conditions, permanent cessation of circulation is a valid surrogate indicator for irreversible cessation.

Marquis approvingly cites Robert Veatch’s critique of a study of infant heart donation following a DCD protocol. Veatch claimed that restarting the hearts in recipient infants retroactively invalidated the death determination in the donor infants by showing that the donors’ loss of cardiac function was not irreversible. This analysis errs, however, in focusing on cardiac function. The donor infants were declared dead because they had been without a heartbeat beyond the period in which autoresuscitation has been observed and because medical resuscitation was prohibited. At that moment, they were declared dead on the grounds that their circulation had ceased permanently. Nothing that happened thereafter altered this circumstance. For the dead donor infants, it did not matter if their nonbeating hearts were left in place, removed and sent for postmortem examination, or removed and given to other infants. Restarting the hearts elsewhere does not alter the fact that the donor infants had lost circulation permanently. ²

Physicians declare death in DCD donors in the same way as in non-DCD patients. When called to declare death on any patient whose death was expected and who had a DNR order, physicians determine only that the cessation of circulation is permanent. They know that autoresuscitation does not occur in this situation and that medical resuscitation will not be performed. They make no effort to prove that cessation of circulation is irreversible because doing so is unnecessary.

Declaring death in a DCD donor highlights a distinction between the ontology of death, as we might call it, and medical practice. From a purely ontological perspective, Marquis is right that these patients are not unequivocally dead until their cessation of circulation is irreversible. But from a medical practice standpoint, physicians routinely and rightly declare patients dead at the moment their cessation of circulation is permanent. Because this practice is encompassed in a UDDA provision requiring death determination to be “in accordance with accepted medical standards,” declaring death on DCD donors does not violate the dead donor rule.