Introduction: cDCDD has immense potential to expand deceased organ donation and transplantation worldwide.  Barriers to its uptake include a lack of consensus on ethical, legal and clinical practices. In 2024, the European Society of Organ Transplantation (ESOT) led an international project to address uncertainties in cDCDD and make recommendations for adult and paediatric donor management, use of NRP, and the unified concept of death. We report here the work of the subgroup dedicated to adult cDCDD.
Methods: A modified Delphi process was conducted by independent company Adelphi Targis comprising two survey rounds administered online in English. An international multidisciplinary committee of experts in deceased donation developed the questionnaire and identified expert panelists to participate in the study. Panelists indicated their level of agreement with statements relating to patient suitability for cDCDD, family communication, end-of-life care and decision-making about cDCDD, and use ante mortem interventions. The questionnaire was revised following review of the first survey round results at a meeting in Bucharest, Romania on 12-10-2024.
Results: 37 international expert panelists from 15 countries completed the survey; 65% were male. Consensus was reached on 33 major recommendations. These highlighted the importance of:
- mechanisms for the routine identification of patients potentially suitable for cDCDD;
- maintenance of life-support measures until there has ocurred evaluation of suitability for cDCDD and, where appropriate, discussion with family to offer donation;
- the cDCDD suitability evaluation being multidisciplinary and involving donation personnel;
family communication about cDCDD being initiated by trained donation professionals and only after family understand that death will occur;
- the approach to end-of-life care being consistent with routine end-of-life care in the absence of cDCDD, including the provision of sedatives and analgesics for comfort care, and family being offered the option of being present during withdrawal of life sustaining measures until death; and,
- the use of ante-mortem interventions being considered if their potential benefits outweigh their potential burdens or risks.
There was also consensus that when cDCDD programs are introduced, opportunities for donation after neurological determination of death (DNDD) should be prioritised and that careful introduction of cDCDD programs may result in additional DNDD, as a proportion of patients who are evaluated as potential donors via cDCDD will proceed to DNDD.
Conclusion: This international initiative achieved consensus addressing ethical, legal and clinical practice uncertainties or controversies with recommendations to optimise opportunities for successful recovery and transplantation of organs via cDCDD.