Setting the National Standard for DCD & NRP:
AOPO’s New Guidelines Reinforce Ethical & Clinical Safeguards in Organ Donation

Donation after Circulatory Death (DCD) has become a cornerstone of modern transplantation and now accounts for approximately half of all organ donors nationwide. As DCD, normothermic regional perfusion (NRP), and normothermic machine perfusion (NMP) continue to evolve, it is essential that core ethical, clinical, and legal standards are consistently upheld to preserve patient dignity, protect families, ensure compliance with hospital policy, and maintain public trust in the donation and transplant system.

To support these goals, the Association of Organ Procurement Organizations (AOPO) released new DCD Guidelines and NRP Safeguards developed through the work of the AOPO DCD and NRP Task Forces. These guidelines help ensure consistency and transparency across the donation process while supporting collaboration among organ procurement organizations (OPOs), healthcare teams, and families.

The guidelines align with recommendations from the American Society of Transplantation (AST), the American Society of Transplant Surgeons (ASTS), and the American Hospital Association (AHA) and reflect the direction of policies currently under development within the Organ Procurement and Transplantation Network (OPTN).

Protecting Patients and Families

At the center of the guidelines is a clear principle: patient safety remains the top priority throughout the DCD evaluation and donation process.

Several foundational safeguards guide these practices:

• • • Withdrawal of life-sustaining therapies (WLST) is determined solely by the healthcare team and the patient’s family, independent of the OPO and the donation decision.
    • End-of-life care remains focused on the patient and family, with comfort and dignity as the primary goals.
    • The determination of death is fully independent of the OPO, transplant teams, and perfusion teams.
    • Clear communication and collaboration between the healthcare team, the family, and the OPO support transparency and goal-concordant care.

Family communication is a critical component of the process. Legal next of kin or a patient’s agent must understand that organ donation occurs only after WLST and after death is determined according to hospital policy and accepted medical standards.

Highly skilled OPO professionals speak with families about the opportunity for organ donation, providing clear information about the process and what to expect. These conversations are approached with compassion and respect, recognizing the profound loss families are experiencing.

These conversations typically include:

• • • An overview of how the donation process works
    • Where withdrawal of life-sustaining therapy will occur
    • The possibility that death may not occur within the timeframe required for donation
    • The potential impact of warm ischemic time on organ transplantability

End-of-life care during DCD remains comfort-focused and patient-centered. All medications and interventions related to comfort care are ordered and managed exclusively by the patient’s healthcare team. The OPO and transplant teams do not direct or participate in comfort-care decision-making.

Location of Withdrawal of Life-Sustaining Therapy

The guidelines emphasize that the location of WLST should prioritize the comfort and dignity of the patient and the presence of loved ones.

In most circumstances, the preferred setting is the critical care unit, reflecting the patient’s typical care environment. However, flexibility may be appropriate depending on clinical circumstances and logistical considerations.

WLST may occur in several settings, including:

• • • The critical care unit, which remains the preferred location for most patients
    • A nearby clinical space such as a pre-operative holding area or post-anesthesia care unit, allowing family members to remain present during extubation
    • The operating room, when patient presentation, organ type, or logistical considerations support that approach

Regardless of location, the healthcare team maintains full and independent control over the withdrawal process, ensuring that clinical decisions remain centered on the patient and their family.

Safeguards in Determination of Death

The guidelines reinforce long-standing medical standards surrounding the determination of circulatory death. Death must be determined by the attending physician or designated provider based on the permanent cessation of circulation and respiration.

Following circulatory arrest, a mandatory five-minute observation period occurs before organ recovery begins. This period confirms the permanence of arrest and the absence of autoresuscitation.

No organ recovery or perfusion activity may begin until:

• • • Death has been formally pronounced
    • The five-minute observation period has been completed

The guidelines also establish a mechanism to address clinical or ethical concerns that may arise during the process. The healthcare team may call for a pause at any time if concerns arise about whether it remains appropriate to proceed with WLST or donation activities. When a pause is implemented, the process stops while the clinical situation is reviewed and the concern is addressed.

These safeguards reinforce the ethical foundation of organ donation and ensure adherence to the dead donor rule, which requires that organ recovery occur only after death has been determined.

NRP Safeguards and Cerebral Protection

As technologies such as Normothermic Regional Perfusion (NRP) expand opportunities for transplantation, the guidelines outline safeguards to ensure these innovations are implemented responsibly.

NRP techniques — including thoraco-abdominal NRP (TA-NRP) and abdominal NRP (A-NRP) — may be used after death to perfuse targeted organs and improve transplant outcomes. To maintain compliance with ethical standards and national recommendations, protective measures must prevent any return of circulation to the brain.

These safeguards include:

• • • Confirmation of clamping and venting of the aortic arch vessels during TA-NRP
    • Confirmation of clamping and venting of the aorta during A-NRP
    • Documentation of the method and timing of these protective strategies

Advancing Donation While Preserving Trust

Many OPOs already incorporate similar safeguards into their practices. AOPO’s guidelines provide a unified framework to ensure these protections are clearly defined and consistently applied nationwide.

At every stage of the donation process, end-of-life care must remain centered on the patient and their family, grounded in comfort, dignity, and trust.

The AOPO DCD Task Force recommends that organizations review their policies and practices to ensure alignment with these standards. Clear alignment across the system will strengthen national consistency, reduce uncertainty for healthcare teams, OPO staff, and families, and reinforce the ethical integrity of the donation process.

Readers can explore the full guidance for additional detail on the clinical and operational safeguards supporting ethical, transparent, and consistent DCD donation nationwide. The DCD Guidelines and NRP Safeguards Report is maintained as an evolving framework that will continue to adapt as new evidence and clinical advancements emerge.

Thank you,