The American Society of Transplantation (AST) and the American Society of Transplant Surgeons (ASTS) reaffirm their commitment to expanding access to organ transplantation while preserving the safety, dignity, and trust of donors, families, and the public. Amid growing public concern, particularly following Congressional hearings and media coverage, AST and ASTS emphasize the importance of medical accuracy, ethical clarity, and public education in Donation after Circulatory Death (DCD) and the use of Normothermic Regional Perfusion (NRP). In addition, AST and ASTS applaud the recent unified actions of the U.S. government and federal agencies with transplantation oversight within the U.S. Department of Health and Human Services (HHS), including the Health Resources and Services Administration (HRSA), the Centers for Medicare & Medicaid Services (CMS) and the Food and Drug Administration (FDA), in their dedicated efforts to support and advance the U.S. organ transplant system.
The September 2025 decision by HRSA to decertify a poorly performing organ procurement organization (OPO) is a powerful act that will strengthen the organ transplant system going forward. AST and ASTS are committed to partnering with federal agencies to support the organ transplant network and foster public trust to increase life-saving transplants.
Due to the recent discourse surrounding the determination of death and the performance of several OPOs, AST and ASTS have co-authored this statement which aims to clarify standards, address misconceptions, and reinforce the integrity of the transplant system.
I. Addressing Misunderstandings of the Declaration of Death Process
Recent media reports and congressional hearings have contributed to public confusion by implying that organs are retrieved from donors before death is legally confirmed. These portrayals often fail to distinguish between withdrawal of life-sustaining treatment (WLST), the declaration of death, and organ procurement. In DCD, WLST is a clinical decision made independently of donation considerations and managed by patient care teams that are completely separate from organ procurement teams. Only after the permanent cessation of circulation—confirmed by a standardized, mandatory 5-minute no-touch observation period—can organ recovery proceed.
In the rare occurrence of a misapplication or deviation from protocol, it is imperative that the isolated cases do not obscure the rigorously structured, ethically-sound process practiced nationally and globally. Misconceptions of the declaration of death process can only be combatted through education, which is why AST and ASTS have outlined below the pathways that lead to declaration of death.
Death by neurologic criteria (DNC), commonly referred to as brain death, is determined through a rigorous, standardized clinical process that includes:
Confirmation of irreversible, catastrophic brain injury of known cause.
Exclusion of reversible confounding factors (e.g., drug effects, hypothermia).
Neurological assessment confirming coma and absence of brainstem reflexes.
An apnea test to confirm absence of spontaneous breathing.
Ancillary testing when parts of the exam cannot be completed.
Repeat evaluation as required, especially in pediatric cases.
This process ensures ethical, accurate, and irreversible determination of death prior to donation.
DCD applies to patients who do not meet brain death criteria but for whom the family and clinical team have agreed to the withdrawal of life-sustaining treatment (WLST). This pathway follows strict ethical and clinical protocols:
WLST is a clinical decision made independently of donation.
After circulatory arrest, a mandatory 5-minute no-touch observation period confirms the permanence of death and ensures autoresuscitation does not occur.
Only after this observation period can death be officially declared, and organ recovery permitted.
The transplant team is NOT involved in ANY step of end-of-life care or the declaration of death. This separation safeguards the autonomy and dignity of the patient and their family.
AST and ASTS oppose calls to redefine death to include irreversible coma, a move that would blur critical ethical boundaries and erode public trust. Instead, AST and ASTS advocate for reinforcing the existing safeguards that currently uphold the integrity of the process.
II. Ethical Safeguards: The 5-Minute Observation Period
A cornerstone of the DCD process is the mandatory observation period following cessation of circulation, designed to ensure that autoresuscitation does not occur. Based on a multicenter prospective study published in the New England Journal of Medicine,(1) the longest recorded instance of autoresuscitation was 4 minutes and 20 seconds.
To uphold both ethical and scientific standards, AST and ASTS recommend a standardized 5-minute waiting period after the cessation of circulation and before the declaration of death. This no-touch period is critical to confirm death beyond doubt and to protect the donor, their family, and the public’s confidence in organ donation.
III. Normothermic Regional Perfusion (NRP) and Cerebral Isolation
Normothermic Regional Perfusion (NRP), particularly Thoracoabdominal NRP (TA-NRP), is used to restore circulation selectively to the organs after death to preserve organ viability and improve transplant outcomes. It is not used to restore life or resuscitate the deceased in any fashion.
AST and ASTS emphasize that cerebral reperfusion must be actively prevented to uphold the dead donor rule. Robust clinical studies have shown no evidence of brain perfusion when proper measures are taken—such as occlusion and venting of the aortic arch vessels during TA-NRP and occlusion and venting of the aorta for abdominal-NRP. These safeguards are essential to maintain the ethical boundary between organ recovery and the confirmation of death.
Accordingly, AST and ASTS recommend continued use of both occlusion and venting of the aortic arch vessels during TA-NRP and occlusion and venting of the aorta for abdominal-NRP until further definitive evidence becomes available.
To read the consensus statements on NRP, see, and
Transplantation 108(2):p 312-318, February 2024 | Read more
Transplantation 108(8):p 1655-1659, August 2024 | Read more
Transplantation 108(8):p 1660-1668, August 2024. | Read more
Conclusion
Donation after Circulatory Death (DCD) and Death by Neurologic Criteria (DNC) are critical, ethically robust practices of modern transplantation that saves lives. However, recent media narratives and misinformation have risked undermining public trust by misrepresenting how death is determined, and organs are recovered.
AST and ASTS caution against the call to redefine death and instead advocate for continued adherence to proven safeguards, including the 5-minute observation period and cerebral isolation during NRP. The Societies also urge increased investment in clinician education and public communication, drawing on successful international models like that of Spain (2).
Only by maintaining clear boundaries, reinforcing transparency, and honoring donor dignity can we preserve the trust of the public and continue to save lives through organ donation.
References
1. Dhanani S, et al. Resumption of Cardiac Activity after Withdrawal of Life-Sustaining Measures. N Engl J Med. 2021;384(4):345-352.
2. Streit S, et al. Ten Lessons from the Spanish Model of Organ Donation and Transplantation. Transpl Int. 2023 May 25:36:11009.doi: 10.3389/ti.2023.11009. eCollection 2023.
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