Donation after brain death (DBD)

Donation after brain death (DBD) is deceased organ donation in which the donor's death is determined by neurologic criteria, the irreversible cessation of all functions of the entire brain, including the brainstem, before the organs are recovered. Because death is declared while the heart is still beating and the body is supported by mechanical ventilation, the organs remain perfused with oxygenated blood until the moment they are removed.[1][2] DBD was historically the predominant deceased-donor pathway and remains a major source of transplantable organs, though donation after circulatory death has grown rapidly and now approaches an equal share in the United States.[3]

Brain death (death by neurologic criteria, or BD/DNC) is legal death in all U.S. states. Because the donor is already dead at the time of recovery, DBD satisfies the dead donor rule, the longstanding ethical norm that vital-organ recovery must not cause the donor's death.[1][2] DBD is distinct from withdrawal of life support in a patient who is not brain dead, which is the setting for DCD.[4]

Determination of death by neurologic criteria

Brain death is the permanent loss of all brain function as a whole, including the capacity for consciousness and all brainstem functions such as spontaneous breathing. In the United States the clinical determination is governed by professional consensus guidance, most recently the 2023 AAN/AAP/CNS/SCCM Pediatric and Adult Brain Death/Death by Neurologic Criteria Consensus Practice Guideline (Greer et al.), which integrated and updated the prior 2010 adult and 2011 pediatric guidelines.[5]

Determination follows a structured sequence:[1][5]

• Prerequisites. A known, irreversible, catastrophic brain injury must be established, and confounders must be excluded, including severe electrolyte, acid-base, or endocrine derangements, drug intoxication or neuromuscular blockade, and hypothermia. Core temperature and blood pressure must be within specified ranges before testing.
• Clinical examination. Demonstration of coma with no responsiveness, and absence of all brainstem reflexes (for example, pupillary, corneal, oculocephalic, oculovestibular, and gag/cough responses).
• Apnea test. A controlled test showing no spontaneous respiratory effort despite a rise in carbon dioxide to a defined threshold, confirming loss of the brainstem respiratory drive.
• Ancillary testing. Studies such as electroencephalography or tests of cerebral blood flow are used when the full clinical examination or apnea test cannot be completed safely or interpreted reliably; they are not required when the clinical examination and apnea test are conclusive.[6]

Legal framework

In the United States the legal standard derives from the Uniform Determination of Death Act (UDDA) of 1981, which provides that an individual is dead who has sustained either irreversible cessation of circulatory and respiratory functions or irreversible cessation of all functions of the entire brain, including the brainstem; the determination must be made in accordance with accepted medical standards.[7] This is the "whole-brain" standard, and a determination of brain death is a determination of legal death. The relationship between the statute and the clinical guidelines is discussed further in Uniform Determination of Death Act and brain death.[7]

Because brain death is legal death, organ recovery from a DBD donor does not cause death and so is consistent with the dead donor rule.[1][2]

The DBD donation process

The DBD pathway proceeds through a defined sequence: hospital referral of a patient with a devastating, potentially imminent-death neurologic injury to an organ procurement organization; declaration of brain death by the treating clinicians according to accepted standards; authorization for donation (through first-person registration or next-of-kin authorization); donor management to maintain organ function while circulation is intact; allocation through the national match; and controlled surgical recovery, in which the organs are removed and the aorta is cross-clamped to begin cold preservation.[1][8][9] Donor management in DBD, including hemodynamic, ventilatory, and hormonal support of the brain-dead donor, is covered in Donor management and optimization.[8]

Advantages

The principal physiologic advantage of DBD is that the organs remain perfused with oxygenated blood up to the moment of cross-clamp, so they are not exposed to the agonal warm-ischemia interval that characterizes donation after circulatory death.[1][4] This generally yields lower warm-ischemia time and has historically been associated with favorable graft outcomes, and it permits a more controlled, fully planned recovery and broader organ yield per donor.[4] Preservation after recovery then follows standard methods described in Organ preservation and machine perfusion.

Controversies and balance of views

Although brain death is legally settled in the United States, its conceptual basis remains debated in the bioethics and medical literature, and reliable sources present a range of positions that this article summarizes without endorsement.[10][11]

• Coherence of the whole-brain criterion. Some scholars argue that the whole-brain standard is internally inconsistent, noting that some brain-dead patients retain isolated, regulated functions (for example, hypothalamic-pituitary hormonal activity), which they say is in tension with the statutory language "all functions of the entire brain." Defenders respond that BD/DNC, properly performed, reliably identifies the permanent loss of the organism's integrated function and that the criterion remains medically and ethically sound.[10][11]
• Statutory revision effort. Partly in response to such concerns, the Uniform Law Commission convened a committee in 2021 to consider revising the UDDA, including whether to retain "all functions of the entire brain", but paused the drafting effort in 2023 amid deep disagreement among medical, legal, religious, and patient-advocacy stakeholders, leaving the original 1981 text in force.[11][12]
• Family and religious objections; accommodation. Some families and faith traditions reject neurologic criteria for death. A small number of states have reasonable-accommodation provisions: New Jersey uniquely bars declaring brain death over a documented religious objection, and states such as New York, California, and Illinois require hospitals to provide more limited accommodation.[1][13]

These debates are interconnected with the broader contested terrain around the dead donor rule and the determination of death, treated in their own articles.

Epidemiology

In 2024 there were 16,989 deceased donors in the United States, of whom roughly 9,700 were donation-after-brain-death donors and roughly 7,280 were DCD donors.[3] DBD donation declined modestly in 2024, the first decrease in DBD donors after a steady rise beginning around 2013, while DCD donation rose by about 23 percent, continuing a long-term shift; DCD has grown from roughly 2 percent of deceased donors around 2000 to nearly half by the mid-2020s.[3] DBD nonetheless remains the larger of the two pathways by donor count and typically yields more organs per donor (figures as of OPTN/SRTR 2024 data).[3]

See also

• Donation after circulatory death (DCD)
• The dead donor rule
• Uniform Determination of Death Act and brain death
• Deceased donation
• Donor management and optimization

References

• Goila AK, Pawar M. Brain death. StatPearls. NBK538159. Updated 2024. https://www.ncbi.nlm.nih.gov/books/NBK538159/
• Health Resources and Services Administration / OPTN. Deceased donation (death by neurologic and by circulatory criteria). https://www.hrsa.gov/optn/patients/organ-donation/deceased-donation
• Lentine KL, et al. OPTN/SRTR 2024 Annual Data Report: Overview of US Solid Organ Transplantation; and HRSA, "Organ Transplants Exceeded 48,000 in 2024." Of 16,989 deceased donors, ~9,700 DBD and ~7,280 DCD (as of OPTN/SRTR 2024 data). https://srtr.hrsa.gov/adr/2024/Overview/ ; https://www.hrsa.gov/optn/news-events/news/organ-transplants-exceeded-48000-2024-33-percent-increase-transplants-performed-2023
• Manara AR, Murphy PG, O'Callaghan G. Donation after circulatory death versus donation after brain death (comparison of warm ischemia and pathway). Br J Anaesth. 2012;108(suppl 1):i108-i121. doi:10.1093/bja/aer357. https://pubmed.ncbi.nlm.nih.gov/22194426/
• Greer DM, Kirschen MP, Lewis A, et al. Pediatric and adult brain death/death by neurologic criteria consensus practice guideline. Neurology. 2023;101(24):1112-1132. doi:10.1212/WNL.0000000000207740. PMID:37821233. https://www.neurology.org/doi/10.1212/WNL.0000000000207740
• American Academy of Neurology. 2023 BD/DNC guideline summary, role of clinical examination, apnea testing, and ancillary studies. https://www.aan.com/PressRoom/Home/PressRelease/5119
• Uniform Determination of Death Act (1981), National Conference of Commissioners on Uniform State Laws / Uniform Law Commission. Text and overview. https://www.uniformlaws.org/committees/community-home?CommunityKey=155faf5d-03c2-4027-99ba-ee4c99019d6c ; summary at https://en.wikipedia.org/wiki/Uniform_Determination_of_Death_Act
• Meyfroidt G, Gunst J, Martin-Loeches I, et al. Management of the brain-dead donor in the ICU: general and specific therapy to improve transplantable organ quality. Intensive Care Med. 2019;45(3):343-353. doi:10.1007/s00134-019-05551-y. https://pubmed.ncbi.nlm.nih.gov/30741327/
• OPTN. The basic path of donation. https://optn.transplant.hrsa.gov/learn/about-donation/the-basic-path-of-donation
• Lewis A, Bonnie RJ, Pope T, et al. Determination of death by neurologic criteria in the United States: the case for revising the UDDA (overview of the coherence debate). J Law Med Ethics. 2019;47(4 suppl):9-24. doi:10.1177/1073110519898039. https://pubmed.ncbi.nlm.nih.gov/31955710/
• Lewis A. The Uniform Determination of Death Act is being revised. Neurocrit Care. 2022;36(2):335-338. doi:10.1007/s12028-021-01439-2. PMID:35102538. https://pubmed.ncbi.nlm.nih.gov/35102538/
• Lewis A. The Uniform Determination of Death Act is not changing, the Uniform Law Commission paused its UDDA revision effort in September 2023. Am J Bioeth. 2024;24(1). doi:10.1080/15265161.2024.2371129. https://www.tandfonline.com/doi/full/10.1080/15265161.2024.2371129
• Olick RS, Braun EA, Potash J. Brain death, religious freedom, and public policy: New Jersey's landmark legislative initiative; and Son RG, Setta SM. Frequency of use of the religious exemption in New Jersey cases of brain-death determination. https://pubmed.ncbi.nlm.nih.gov/10115859/ ; https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6092846/