Donation After Circulatory Death: How Death Is Determined for Organ Donation

Organ donation depends on a clear answer to a hard question: when is a person dead? For one growing kind of donation, that answer is being debated, and federal regulators have taken action. This article explains how it works and what is disputed. It is a fast-changing topic, and its most recent source is from August 2026.

What are the two ways death is determined for donation?

By brain criteria or by circulatory criteria. In donation after brain death, a patient who has lost all brain function is kept on life support so the organs stay healthy. See Brain Death vs. Coma. In donation after circulatory death (DCD), the patient has usually suffered a severe brain injury that doctors expect to be fatal, but the brain still has some function, so the patient does not meet brain death criteria. U.S. law, as a physician quoted in The Hospitalist described it, defines death as the irreversible stopping of either brain function or circulatory function.

How does DCD work?

The family first decides to withdraw life support, and consent to donation is obtained. According to a Hall Render summary, the patient is then moved to the operating room, life support is withdrawn, and death is declared after the heart stops and a required waiting period passes. Only then does recovery of organs begin. The Hospitalist reports that this “stand-off” time is normally five minutes in the United States. A transplant rule called the “dead donor rule” says surgeons may not take vital organs before death, or cause death by taking them.

Why five minutes?

To make sure the heart does not restart on its own. A Czech medical review notes that an early international workshop recommended waiting 10 minutes, and that this was shortened to 5 minutes after recommendations from the Institute of Medicine. Practices still vary. The Hospitalist reports they range from 10 minutes in some European countries to 75 seconds for infant heart donors at one Colorado hospital.

What does research say about the wait?

A 2021 study in the New England Journal of Medicine, led by Sonny Dhanani, monitored 631 patients in 20 intensive care units in three countries after life support was withdrawn. Bedside staff noticed the heart or breathing resume in 5 patients (1%). A later review of recorded heartbeat and blood pressure data from 480 patients found 67 cases (14%) in which the heart briefly resumed after a pause. The longest pause before this happened was 4 minutes 20 seconds. The authors said the results support the five-minute observation period. A limitation is that patients without arterial pressure monitors were left out, and some data were incomplete.

How common has DCD become?

Much more common. The Organ Procurement and Transplantation Network (OPTN) reported 7,280 DCD donors in 2024, up 23.5% from 2023. A July 2025 letter from U.S. senators to HHS, citing a federal review, said DCD use had nearly doubled in four years.

What is normothermic regional perfusion, and why is it debated?

It is a technique in which, after death is declared by circulatory criteria, a heart-lung machine restores blood flow inside the body so the organs are healthier when removed. The Hospitalist reports it was developed by a group at Royal Papworth Hospital in the United Kingdom. Critics, including the American College of Physicians, argue that restarting circulation conflicts with the idea that circulatory death must be irreversible, and so may break the dead donor rule. Others, including an author writing on an American Philosophical Association blog, argue the technique does not cause death even if the patient were alive when declared dead. The question is not settled.

What did federal reviews find?

In 2025, the U.S. Health Resources and Services Administration (HRSA) reviewed a Kentucky organ procurement organization, now called Network for Hope. It examined 351 cases from 2021 to 2024 in which donation was authorized but not completed. It found 103 cases with “concerning features,” including 73 patients who showed neurological signs, such as pain or discomfort, that were not consistent with proceeding. The Denver Gazette reported that at least 28 patients had no recorded time of cardiac death. HHS said some potential donors may not have been dead when recovery began.

HHS announced a reform initiative in July 2025. In September 2025 it announced the decertification of a Miami organ procurement organization, the first in U.S. history. On August 5, 2026, HHS began decertifying Network for Hope. Network for Hope said it strongly disagrees and will appeal. This article does not cover developments after the August 2026 announcement.

What is the other side of the story?

That organ donation saves many lives, and that the federal actions so far involve specific organizations. The Association of Organ Procurement Organizations said that in 2025 more than 46,000 deceased-donor organs were transplanted, saving over 40,000 lives. It asked HHS to publicly explain the evidence behind its decision and to avoid disrupting donor families and patients waiting for transplants. More than 100,000 people in the U.S. are waiting for an organ. The reviews do not measure how often problems occur across the country, and the cases HRSA examined were ones where donation was authorized but not completed.

What can families do?

Ask questions. Families considering DCD can ask how death will be determined, how long the team will wait before declaring it, and how comfort care will be handled while life support is withdrawn. These are suggestions, not requirements. HHS has directed new policies to give families more information about DCD. For faith perspectives and general information, see Organ and Tissue Donation After Death, Can Catholics Donate Their Organs?, and Can a Muslim Be an Organ Donor?.