Hearts Stopped Beating Before Donation Now Account for Half of U.S. Organ Donors

Half of the organs transplanted in the United States now come from donors whose hearts had stopped beating before procurement. That proportion, near zero a generation ago, marks a fundamental shift in how American medicine approaches the scarcity of transplantable organs - one driven by technology, ethical deliberation, and the relentless pressure of a waiting list that holds more than 100,000 names.

A new analysis published February 26 in the Journal of the American Medical Association traces this transformation over 25 years, documenting how donation after circulatory death (DCD) climbed from 2 percent of all deceased donors in 2000 to 49 percent in 2025. The research, led by investigators at NYU Langone Health, draws on data from the Organ Procurement and Transplantation Network, which tracks every organ recovered in the United States.

Two Types of Deceased Donation

The mechanics of deceased organ donation divide into two pathways defined by what causes death. The traditional pathway - donation after brain death (DBD) - involves donors who have sustained fatal brain injuries but whose hearts continue beating, sustained by mechanical ventilation. Because blood continues to circulate, organs receive oxygen and remain viable during the process of consent, evaluation, and surgical preparation.

Donation after circulatory death involves a different situation. DCD donors do not meet brain death criteria but cannot survive without life-sustaining treatment. When families decide to withdraw that treatment, organs begin to lose blood flow. If the patient dies within a defined time window after support is removed - typically 60 to 90 minutes - organs can be recovered for transplantation. The ethical framework for DCD is carefully structured to ensure that the decision to withdraw treatment is entirely separate from and prior to any discussion of donation.

For much of the late 20th century, DCD organs were considered inferior. The period without oxygenated circulation - called warm ischemic time - was thought to cause damage that made recovered livers, kidneys, and especially hearts and lungs unsuitable for transplantation. That perception shaped practice: DCD remained rare even as the waiting list grew.

Technology Changed the Calculus

Two technological developments shifted the field. Normothermic regional perfusion temporarily restores blood flow to organs in the donor's body after the heart stops, using a machine circuit that circulates oxygenated blood through the abdominal or thoracic organs before they are recovered. This effectively limits the warm ischemic damage that made DCD organs problematic and allows assessment of organ function before commitment to transplantation.

Machine perfusion devices - which pump nutrient- and oxygen-rich solution through organs after removal - extend the preservation window and have been shown to improve outcomes for DCD kidneys and livers in randomized trials. Together, these two technologies have allowed transplant teams to use organs that would previously have been discarded and to accept donors who would have been excluded on grounds of organ viability.

The data reflect this expansion. The study found that today's DCD donors are older, have higher body mass indices, and are more likely to have conditions such as diabetes or hypertension than comparable donors from earlier eras - a direct consequence of relaxed eligibility criteria made possible by better organ preservation technology.

Geographic Variation Remains Substantial

The national 49 percent figure conceals striking regional variation. Across the 55 organ procurement organizations in the United States, the proportion of donors who were DCD ranged from a high of 73 percent to a low of 11 percent. At 44 percent of procurement organizations, DCD already constitutes the majority of donors.

This variation likely reflects a mix of factors: institutional culture and expertise with DCD surgical techniques, regional differences in brain injury rates and ICU management practices, and differences in how DCD is discussed and offered to families. Whether the variation represents genuine differences in appropriate utilization or differences in institutional practice quality is an open question that the study highlights as worthy of further investigation.

"Our results highlight the opportunity to further grow donation after circulatory death and save even more lives," said Dorry Segev, professor and vice chair in the Department of Surgery at NYU Grossman School of Medicine and co-senior author on the paper.

The Public Trust Question

As DCD becomes the modal form of deceased donation rather than an exception, the ethical and communication frameworks surrounding it become more consequential. The separation between treatment decisions and donation decisions - which the DCD protocol is designed to protect - must be clearly understood by families, clinicians, and the public to maintain the trust that organ donation requires.

"Clear, consistent standards for donation after circulatory death are important so patients are protected and the public is assured that the process is safe," said Babak Orandi, associate professor of Surgery and Medicine at NYU Grossman School of Medicine and co-senior author.

"As donation after circulatory death becomes more common, expanded education and dialogue with patients, families, and clinicians will be essential to maintaining that trust," added co-author Macey Levan, associate professor of Surgery and Population Health at NYU Grossman School of Medicine.

Next Steps for Research

The study's authors plan to examine how organs from DCD donors perform over time compared with those from brain-dead donors - a comparison that has become more clinically meaningful now that DCD organs, with improved preservation, are being used for a wider range of recipients. They also aim to explore ways to improve donor identification and recovery practices at organizations where DCD utilization remains low.

The 100,000-person waiting list frames the urgency. Each percentage point increase in DCD utilization represents hundreds of additional transplants per year. The 25-year trajectory documented in this study suggests that the field has found a path to expanding the donor pool - and that continued investment in preservation technology and ethical infrastructure can extend it further.