Bucharest Consensus: Ethical Standards for Controlled DCDD: Transplant International | June 2026

• Controlled donation after circulatory determination of death is becoming an increasingly important pathway to expand deceased organ donation worldwide.

• This ESOT Bucharest international consensus provides practical, ethical, and operational standards for adult controlled DCDD programs.

• The recommendations were developed using a Delphi process involving 37 experts from 15 countries, covering intensive care, transplant surgery, donation coordination, ethics, and law.

• The central principle is that decisions about withdrawal of life-sustaining measures must remain completely separate from decisions about organ donation.

• A robust legal framework is essential before starting or expanding controlled DCDD programs, including clear rules for death determination, consent, donation authorization, and ante-mortem interventions.

• Public and professional education is necessary because controlled DCDD differs from donation after neurological determination of death and may be poorly understood.

• Potential donors should be identified early as part of routine end-of-life care, and referral triggers should be built into ICU and emergency care pathways.

• Treating clinicians should not unilaterally exclude patients from donation; suitability assessment should involve donation professionals and transplant teams when needed.

• Prediction of time to death after withdrawal of life support is imprecise, so suitability should not rely on a single scoring tool or individual clinician judgement alone.

• Communication with families should be sensitive, staged, and preferably led by trained donation professionals who are not directly responsible for the patient’s clinical care.

• Families should first understand that death is expected and that withdrawal of life-sustaining measures has been decided before donation is discussed.

• Patient comfort, dignity, sedation, analgesia, and family presence during withdrawal of life support must remain central and should never be compromised for donation success.

• The withdrawal process and comfort care should be managed by the treating clinical team, not by donation or transplant personnel.

• Ante-mortem interventions may be considered when legally permitted, clinically justified, and aligned with the patient’s values or donation goals.

• The benefits of ante-mortem interventions should be balanced against their invasiveness, discomfort, risk, and potential impact on the end-of-life experience.

• The consensus emphasizes that donation can serve the patient’s values when donation was known or likely to be important to them, but this must never override comfort and dignity.

• Programs should collect data on missed opportunities, failed donation attempts, and logistical barriers to improve future controlled DCDD pathways.

• The report highlights the need for research into ante-mortem interventions, prediction of time to death after withdrawal, and best models for family communication.

• Controlled DCDD should be developed through national protocols adapted to local legal, cultural, clinical, and logistical realities.

Bottom line: The Bucharest ESOT consensus establishes controlled DCDD as an ethically acceptable and clinically important donation pathway, provided that end-of-life care remains patient-centered, donation decisions are clearly separated from withdrawal decisions, and ante-mortem interventions are carefully justified and transparently discussed.