Abstract
Donation after circulatory death (DCD) has become a key avenue for expanding the organ donor pool. Many DCD protocols include premortem intravenous heparin to reduce microthrombus formation and preserve graft viability. This presents the plausible risk of premortem bleeding from an intervention that offers no direct therapeutic benefit to the donor. Ethical concerns and moral distress can arise when potential donors have a catastrophic intracranial hemorrhage with ongoing physiological concern for bleeding risk that is not survivable, but do not currently meet brain death criteria. While prior analyses describe premortem interventions in DCD in conceptual or protocol-driven terms, this case report considers the ethical concerns inherent in premortem heparin administration and illustrates how multidisciplinary teams can operationalize ethical safeguards, including transparent communication, attention to surrogate understanding, and separation of end-of-life decisions from donation-related interventions, to mitigate concerns and minimize moral distress. These issues are directly relevant to palliative care clinicians, who frequently support families during end-of-life crises and when there is consideration for organ donation. Through a multidisciplinary and ethically guided approach, this case illustrates how collaborative decision-making and transparent communication can uphold both donor dignity and transplant integrity.
Keywords
Introduction
Donation after circulatory death (DCD), the process of organ donation that occurs after death is declared based on irreversible cessation of circulatory and respiratory function rather than neurological (brain) death criteria, has become a key avenue for expanding the organ donor pool. In DCD, organs are recovered after a period of observed absence of pulse, blood pressure, and ventilation following planned withdrawal of life-sustaining therapy (controlled DCD) or unsuccessful resuscitation after unexpected cardiac arrest (uncontrolled DCD). 1 In contrast, donation after brain death (DBD), also called donation after neurological determination of death, occurs when death is declared based on irreversible loss of all brain function, including to the brainstem following stringent clinical criteria. 2 In DBD, circulation is maintained with mechanical ventilation until organ procurement. 2
A cornerstone of successful organ procurement in DCD is the administration of intravenous heparin prior to withdrawal of life support. Heparin, a potent anticoagulant, reduces the risk of intra-arrest microthrombi formation that can impair graft perfusion and reduce organ viability. Following cessation of circulation, stagnant blood flow and hypoxia promote intravascular coagulation, which can compromise organ perfusion and increase the risk of graft thrombosis and ischemic complications. In a multicenter study, premortem use of anticoagulation was not associated with outcomes of procured kidneys. 3 However, failure to administer premortem heparin did negatively impact liver transplant graft survival. 4 Animal models have also shown cytoprotective effects beyond anticoagulation, including improved perfusion and reduced ischemic injury. 5
The American Heart Association notes that while heparinization is common in organ procurement policies, it should be avoided in cases where there is a high risk of hemorrhage or where it is specifically contraindicated. This creates a unique discussion in the setting of donors with intracranial hemorrhage (ICrH). 6 ICrH is defined as any bleeding within the cranial vault, and its major subtypes are classified by the anatomical location of the bleeding: within the brain parenchyma (intracerebral hemorrhage), within the subarachnoid space (subarachnoid hemorrhage), and between the dura and arachnoid membranes (subdural hemorrhage). 7
Multiple meta-analysis and guidelines statements indicate that prophylactic-dose unfractionated heparin or low-molecular-weight heparin, started after ICrH stability is confirmed (typically >24–48 hours post-ICH) has not been shown to worsen ICrH.8–10 However, therapeutic-dose heparin or early initiation (<24 hours) is generally contraindicated due to a higher bleeding risk.8,9 While heparinization is a standard organ preservation intervention, the timing and dose remain areas of practice variation, with the most common dose being 30,000–50,000 units given premortem by IV bolus, which is significantly higher than therapeutic doses administered in other settings.3,6
As heparinization presents the plausible risk of premortem bleeding from an intervention that offers no direct therapeutic benefit to the organ donor, some clinicians express ethical concerns, conflicts of conscience, and moral distress when potential organ donors have catastrophic ICrH with ongoing physiological concern for bleeding risk that is not survivable, but do not currently meet brain death criteria. It is important to note that the work-up and evaluation for organ donation require time, meaning the likelihood that heparin is administered in less than 24 hours after ICH is relatively low. However, palliative care physicians and others engaged in end-of-life and organ donation discussions may find themselves considering the tension between preserving organ viability for recipients and ensuring that any medical interventions at the end of life do not hasten or cause the donor’s death.
While prior analyses describe premortem interventions (PMIs) in DCD in conceptual or protocol-driven terms, this case report considers the ethical concerns inherent in premortem heparin administration and illustrates how multidisciplinary teams can operationalize ethical safeguards, including transparent communication, attention to surrogate understanding, and separation of end-of-life decisions from donation-related interventions, to mitigate concerns and minimize moral distress. These issues are directly relevant to palliative care clinicians, who frequently support families during end-of-life crises and when there is consideration for organ donation. Through a multidisciplinary and ethically guided approach, this case illustrates how collaborative decision-making and transparent communication can uphold both donor dignity and transplant integrity.
Case Description
A previously healthy man in his early 50s was brought to the emergency department at a United States-based academic medical center with established neurology, neurosurgery, intensive care, palliative care, and clinical ethics services after being found unresponsive by family members. His past medical history was notable only for well-controlled hypertension and a remote history of mild alcohol use. On arrival, he had a Glasgow Coma Scale (GCS, a standardized scale which assesses the severity of impaired consciousness and coma in the acutely ill) score of 4/15, fixed and dilated pupils, and absent brainstem reflexes except for spontaneous breathing efforts. Vital signs demonstrated hypertension (BP 180/95 mmHg), bradycardia (HR 48 bpm), and irregular respirations consistent with impending brain herniation.
Computed tomography (CT) of the head revealed a large, acute left-sided subdural hematoma (SDH) measuring approximately 20 mm in thickness, with severe midline shift exceeding 12 mm, uncal herniation, and signs of transtentorial herniation. There was no evidence of vascular malformations or aneurysms on CT angiography. Laboratory studies showed normal coagulation parameters (INR 1.1, platelet count 230,000/μL), and no evidence of anticoagulant or antiplatelet use. The patient had no prior known bleeding disorders.
Neurosurgical evaluation concluded that the SDH was catastrophic and nonsurvivable given the degree of mass effect and uncal herniation. Surgical evacuation was deemed futile. The patient was admitted to the intensive care unit (ICU) for neurocritical care, including mechanical ventilation, sedation, and medical management aimed at intracranial pressure control. Despite maximal supportive measures, the patient showed no neurological improvement over 48 hours and failed repeated brainstem reflex testing. Repeat neuroimaging was obtained during the ICU stay and continued to demonstrate large-volume SDH with severe mass effect and herniation physiology. He did not meet the criteria for brain death due to preserved spontaneous respiratory efforts and lack of apnea upon testing.
Prognostication was grave, and care goals were discussed extensively with the patient’s family through multiple family meetings with the neurology, neurosurgery, critical care, and palliative care teams. The palliative care team supported the family through prognostic communication and helped clarify the patient’s values. The family elected to withdraw life-sustaining therapy in accordance with the patient’s previously expressed wishes and expressed his desire to be an organ donor. The palliative care team reinforced the separation between the decision to withdraw life-sustaining therapy and subsequent donation-related planning. The organ procurement organization (OPO) was consulted, and the patient was evaluated and listed as a candidate for DCD.
Prior to organ retrieval, the interdisciplinary medical team deliberated extensively on the appropriateness of premortem anticoagulation. Although no interval SDH expansion was documented, radiographical “stability” in the sense typically used to justify initiation of anticoagulation had not been established through serial imaging demonstrating stability over a longer period. Given the catastrophic hemorrhage, ongoing herniation physiology, and absence of confirmed stability, the clinical team considered the ICrH “clinically active” for purposes of weighing the plausible anticoagulation-related risk of premortem bleeding. Some expressed ethical concerns and moral distress about the administration of heparin in a patient with the potential for bleeding risk with a condition that is not survivable but does not currently meet brain death criteria.
Given these concerns, the team discussed timing and justification for heparin administration in a multidisciplinary forum including critical care, neurology, neurosurgery, palliative care, clinical ethics, and the OPO. To mitigate theoretical risk while aligning with organ preservation goals, heparin was deferred until physiological decline during the agonal phase, consistent with institutional practice. Per protocol, the patient was taken to the operating room, and life-sustaining therapies, including mechanical ventilation, were discontinued. Heparin was administered once the patient’s systolic blood pressure fell below 80 mmHg or oxygen saturation dropped below 80% to minimize the risk of thrombosis during the agonal phase. Circulatory death was declared 19 minutes post-extubation, consistent with DCD protocols requiring a 5-minute no-touch period following pulselessness. 3 Organ recovery proceeded without complications.
Discussion
Premortem heparin administration has become a widely accepted standard in many DCD protocols; however, this practice is not without clinical and ethical complexities, especially in donors with active ICrH.
The justification for heparin
In the context of DCD, no drug other than heparin is currently established as providing equivalent anticoagulation benefits for organ procurement. 3 There is noted variability in timing and dosing of unfractionated heparin administration with limited impact on kidney donation outcomes While lower doses (<300 K units) have been studied in the setting of renal donation outcomes, minimal information exists on lower doses for procurement of other organs (Heissheimer, 2018). Experimental use of tissue plasminogen activator (tPA) has been studied in animal models, but tPA does not provide equivalent anticoagulation and has no demonstrated benefit in DCD outcomes. 5
Heparin is routinely used in other clinical settings, including for prophylaxis against venous thromboembolism in hospitalized and postoperative patients; however, the dosing is significantly lower than that used in organ procurement procedures, with the most common dose being 5000 units of unfractionated heparin given three times per day. 10 Of importance, VTE prophylaxis doses have not shown risk for ICrH expansion or rebleeding when started after there has been established ICrH stability on neuroimaging. 10
Outside of the context of organ donation, therapeutic or treatment doses of heparin are provided when a VTE has occurred; however, they are generally avoided in the early period after an ICrH, with limited retrospective data suggesting that therapeutic anticoagulation may be considered only in select cases of symptomatic VTE, and typically not until 1–2 weeks after hemorrhage onset, when the risk of rebleeding is lower. 11 The guideline consensus for treatment doses of unfractionated heparin is an intravenous bolus of 80 units/kg body weight followed by a continuous infusion of 18 units/kg/h, titrated to achieve a target activated partial thromboplastin time of 1.5–2.5 times control. 11 Thus, the treatment loading dose bolus remains less than the dose required for organ preservation. Of importance to note is that if bleeding were to recur or worsen after the administration of heparin in a patient with ICrH, the adverse event would be expected to occur within the first several hours to days after heparin initiation, with the highest risk in the initial 24–48 hours.
Informed consent and first-person authorization
Informed consent in the context of DCD is obtained by trained designated requestors, typically after a decision to withdraw life-sustaining therapy has been made. The standard informed consent procedure thus requires explanation of the DCD process including the timing and nature of death determination as well as interventions that may be performed before and after death. 12 Because nearly all potential DCD donors are unable to participate in decision-making due to neurological function, surrogate decision-makers are relied upon for informed consent. Surrogates must understand detailed information regarding the intervention’s purpose, expected benefits, and possible risks to make informed decisions. Achieving truly informed consent in this context can be challenging when surrogates are also navigating end-of-life decisions for the patient, the combination of which can easily become overwhelming. This decision is often made under conditions of acute stress, grief, and uncertainty about patient preferences.
The informed consent process in DCD is also shaped by first-person authorization (FPA) or the legal documentation of an individual’s decision to donate organs after death. When FPA is present, the Uniform Anatomical Gift Act (UAGA) in the United States recognizes the donor’s wishes as legally binding. 13 Under the UAGA, FPA allows OPOs to proceed with organ preservation measures providing these interventions do not hasten death nor violate the dead donor role. 13 However, first person authorization for organ donation does not necessarily include consent for PMIs and the UAGA does not explicitly address PMI, resulting in variability in practice. 13
In this case, premortem heparin was explicitly addressed by the OPO during discussions with the patient’s surrogates as part of DCD planning. The OPO explained the purpose of heparin for organ preservation, its lack of direct benefit to the patient, and the theoretical risk of worsening intracranial bleeding. Surrogates affirmed that donation aligned with the patient’s values and expressed understanding of the role and timing of PMIs.
Risk of harm and the dead donor rule
Current literature provides guidance that administration of heparin in patients with ICrH that leads to hematoma expansion or rebleeding is strongly associated with worse functional outcomes and increased mortality. 14 The dead donor rule, a foundational principle in transplantation ethics, requires that organ procurement must not cause a donor’s death and that death must be declared prior to organ recovery. Current medical literature recognizes the utility of heparin utilization, yet emphasizes that its administration is ethically acceptable only if it does not contribute to the donor’s death or cause harm that would otherwise not occur. 13 Thus, in the setting of ICrH, it is important to consider whether utilization of an anticoagulant could potentially impact application of the dead donor rule, given the theoretical risk of worsening bleeding that, if it were to occur, could be perceived as hastening death.
DuBois and colleagues emphasize that PMIs like heparin administration demand heightened ethical scrutiny and should be accompanied by robust institutional safeguards to preserve public trust in transplantation systems. Without clear protocols and transparency, there is a risk of eroding confidence in the altruistic and ethical basis of organ donation. 15 This case highlights this tension and the impact it can have on clinical teams confronted with balancing the obligations to an individual patient and the societal benefit of transplantation in the setting of organ scarcity. From a principled ethics perspective, respect for autonomy supports honoring first-person authorization and surrogate affirmation of the patient’s donation preferences. However, nonmaleficence and the clinician’s fiduciary duty to the patient can weigh heavily when interventions, such as premortem heparinization, can potentially cause or worsen harm in the absence of patient benefit. An ethics-of-care lens emphasizes relational responsibilities to the patient and family, including transparency, trust, and minimizing additional burden while supporting end-of-life decision-making.12,13 While organ donation advances an important common good, this case underscores that public trust in the transplantation system depends on ethical safeguards that prioritize both the dying patient’s moral status and the integrity of end-of-life care.
Future efforts should focus on developing consensus guidance that integrates clinical evidence, ethical principles, and stakeholder perspectives regarding PMIs in DCD, as recent scholarship has emphasized the importance of transparency and procedural safeguards in maintaining public trust.12,13 Key reflection points for clinicians include (1) explicitly separating the decision to withdraw life-sustaining therapy from donation-related planning; (2) disclosing PMIs—including their purpose, lack of direct patient benefit, and plausible risks—while respecting the extent to which surrogate decision-makers wish to engage with or receive this information; (3) ensuring that surrogate decision-makers have time and support to understand donation processes amid grief; and (4) involving palliative care and ethics consultation early when there is concern that an intervention could be perceived as hastening death or undermining the dead donor rule. Longitudinal studies comparing outcomes when heparin is withheld versus administered in high-bleeding-risk contexts would also help inform practice.
Conclusion
The use of premortem heparin in DCD may present a significant ethical dilemma when the donor has active ICrH. While heparin enhances transplant outcomes by preserving organ viability, it may carry a plausible risk of hastening death, potentially conflicting with the dead donor rule and principles of nonmaleficence. This case underscores the need for thoughtful, multidisciplinary approaches that prioritize transparent communication, informed surrogate consent, and ethical integrity. Institutional safeguards, ethics consultations, and continued research are essential to navigating the complex intersection of end-of-life care and organ donation. As DCD becomes more common, developing clearer guidelines for PMIs, especially in vulnerable populations, will be critical for maintaining public trust and ethical consistency in organ transplantation.
Informed Consent Statement
Written informed consent was obtained from the patient (or the patient’s next of kin) for the publication of this case report and any accompanying images. All identifying information has been removed to protect anonymity.
Footnotes
Author Disclosure Statement
All authors have read and approved the article and have no conflicts of interest to disclose.
Funding Information
There are no financial disclosures.