Ethical tensions and professional attitudes toward circulatory death organ donation in the ICU: a systematic review.

Abstract

PURPOSE Donation after circulatory death (DCD) represents a valuable opportunity to expand the organ donor pool. However, its implementation in intensive care units (ICUs) remains ethically and emotionally complex. ICU healthcare professionals (HCPs) play a pivotal role in this process, yet their attitudes, knowledge, and perceived challenges are not fully understood. This systematic review aimed to explore ICU HCPs' attitudes (as defined by Rosenberg and Hovland) toward controlled DCD (cDCD). METHODS We conducted a systematic review of studies published until March 2025 in four databases. Eligible studies included original research reporting ICU-specific data on HCPs' attitudes toward DCD. Study quality was assessed using the Mixed Methods Appraisal Tool. A structured narrative synthesis was performed. RESULTS Twenty-five studies involving 3,878 HCPs were included. Overall, support for DCD was evident though it remained lower than for donation after brain death. Ethical concerns focused on potential conflicts of interest between the withdrawal of life-sustaining treatment and the pursuit of organ donation, the timing of withdrawal, the urgency of organ retrieval, and the challenge of balancing compassionate end-of-life care with procedural imperatives. Common barriers included the lack of standardized protocols, insufficient training, and uncertainty surrounding death determination. CONCLUSIONS While ICU HCPs generally support DCD, significant ethical tensions and systemic barriers persist. Institutional efforts should focus on implementing clear protocols, promoting interprofessional education, and providing emotional support to ensure ethical integrity and staff well-being. Future research should explore differences in attitudes between uDCD and cDCD and work toward the development of validated tools to assess professional attitudes.