Table 4 Increased concerns with the practice of uncontrolled donation after cardiocirculatory death.

The decision to withdraw life support is independent of the DCD decision.

The decision to stop CPR is not independent of organ donation. As soon as CPR is stopped, it is clear that organ donation procedures will start. The decision to stop CPR is therefore a decision whether to attempt to save the life versus identify the patient as a donor.

Informed consent is obtained for DCD.

Consent is not truly informed. First, a signed donor card is a legally binding and irrevocable decision, but unlikely informed [78, 160]. Second, organ preservation is started based on an "opting-out" system, prior to determination of donor status and prior to contacting the family [79]. This "protects rather than infringes the family's prerogative to make decisions [about organ donation]" and "enhances autonomy", allows the family the "opportunity to donate", "preserves family choice", and is an "expression of respect" for the family's choice [75–77]. This assumes that the surgical steps taken to preserve organs are "modest", "minimally invasive", and "only slight" [75–79]. These are at best arguable claims.

Absent circulation for 2-10 minutes is permanent, and therefore is diagnostic of death.

The IOM claims that a "hands off period could be very brief and may even be unnecessary" [75], apparently ignoring the cases of Lazarus phenomenon after stopping failed CPR. In addition, re-starting CPR and/or ECMO clearly reverse the absent circulation, and often allow resumed brain activity, and in the context of ECMO, often allow survival with good neurological outcome [64–74].

Death declaration conforms with accepted medical standards and with the intent of the law.

The accepted medical standard when using ECMO to rescue a patient during failed CPR is to cool the patient for 24 hours, then slowly re-warm, and then assess prognosis cautiously.