Organ and tissue donation is a life-saving gift, and in Australia, the process relies heavily on the expertise and compassion of intensive care unit (ICU) nurses. While most people are familiar with donation following brain death, donation after circulatory death (DCD) is now accounting for nearly 40% of all deceased organ donations in recent years. DCD occurs when organs are retrieved after the heart has stopped beating and death has been declared based on circulatory criteria. It presents unique ethical, emotional and clinical considerations, and requires coordination between critical care staff, organ retrieval teams, and families. ICU nurses are at the heart of this process. From supporting grieving families to ensuring best-practice end-of-life care, their role is essential at every stage.

Donation after circulatory death (DCD) refers to organ donation that takes place after a patient’s heart has irreversibly stopped beating and death is declared based on circulatory criteria. This differs from donation after brain death, where organs are retrieved while circulation is maintained through artificial ventilation.

In DCD cases, life-sustaining treatment is withdrawn, often in an ICU setting, when their doctors do not think they have any chance of survival without ongoing artificial ventilation and/or other life support. Once the heart and circulation stop, a period of 5 minutes must pass to confirm circulation has permanently stopped, and death can be declared.

ICU nurses are integral to the success of organ donation after circulatory death. They live at the bedside, supporting patients and families through some of life’s most emotionally charged moments. Their clinical expertise, emotional intelligence and advocacy are crucial in both preparing for and carrying out the DCD process.

Some of the key responsibilities of ICU nurses in DCD include:

• Providing end-of-life care: Nurses ensure comfort and dignity during the withdrawal of life-sustaining treatment, managing symptoms such as pain and supporting family members throughout.
• Liaising with donation teams: ICU nurses collaborate closely with staff, transplant coordinators, and surgical teams to align timelines.
• Coordinating clinical tasks: This includes managing intravenous access, maintaining documentation, and monitoring physiological changes post-withdrawal, all while ensuring that care remains patient-centred rather than task-driven.
• Advocating for donor and family wishes: Nurses often support discussions around organ donation, helping families understand what DCD involves and ensuring their decisions are respected and honoured throughout the process.
• Maintaining ethical boundaries: ICU nurses play an important role in upholding the principle that treatment withdrawal and the declaration of death must be entirely separate from donation considerations.

Organ donation after circulatory death is highly time-sensitive and involves precise coordination between ICU teams, organ retrieval services, and transplant recipients. ICU nurses play a central role in managing the clinical and logistical steps required to ensure a safe and ethical donation process.

1. Withdrawal of life-sustaining treatment: The DCD process begins with the planned withdrawal of life-sustaining measures. This is usually carried out in a quiet, respectful space, often with the family present. ICU nurses make sure the patient is comfortable, pain-free and treated with dignity throughout.
2. Monitoring the dying process: Once treatment is withdrawn, ICU nurses closely monitor the patient for signs of circulatory arrest. Death is expected within a specific timeframe (usually 90 minutes) to allow for viable organ donation. If death does not occur in that window, donation may not proceed, and the family must be gently guided through this outcome.
3. Confirming death and observing the ‘no touch’ period: Following circulatory arrest, a mandatory observation period, typically five minutes, is required to confirm that circulation has irreversibly ceased. During this time, no interventions are permitted. ICU nurses are responsible for accurate timing, documentation and ensuring compliance with legal standards.
4. Preparing for organ retrieval: Once death is confirmed, ICU nurses assist with preparing the patient and coordinating handover to the retrieval team. This includes appropriate labelling, infection control, and managing any remaining clinical tasks.

Organ donation after circulatory death is governed by national guidelines that set organ and tissue donation and transplantation policy. Their portfolio agency, the Organ and Tissue Authority (OTA) works to improve organ and tissue donation and transplantation outcomes in Australia on behalf of the Government. To achieve this, they work with states and territories, clinicians, the community sector and the general public. Meanwhile, Services Australia hosts and manages the Australian Organ Donor Register – the national register where you can record your organ and tissue donation decision.

ICU nurses must be familiar with these frameworks and receive appropriate training to carry out their responsibilities with confidence and competence.

Donation after circulatory death (DCD) is a complex, time-sensitive, and deeply human process, and ICU nurses are central to making it possible. From providing dignified end-of-life care to coordinating with transplant teams and supporting grieving families, their role is both technically demanding and profoundly compassionate.