Navigating ethical challenges in donation after circulatory death: Nurses' perspectives

BackgroundControlled Donation after Circulatory Death (cDCD) offers new opportunities but also new, demanding ethical challenges in the field of organ donation. The process requires navigating boundaries due to the transition from intensive care and life-sustaining treatment to the end-of-life care and a possible cDCD process. Previous research has mainly focused on medical aspects, leaving a gap regarding intensive care nurses' and their reflections of possible, ethical challenges during the cDCD process.AimTo explore ethical challenges intensive care nurses encounter when navigating life-sustaining treatment, its withdrawal, and potential organ donation in cDCD.Research designA qualitative design with an inductive approach was applied using Critical Incident Technique.Participants and research contextThe study was conducted at two Swedish ICUs and included multiple scenarios when cDCD was managed after withdrawal of life-sustaining treatment. Five experienced intensive care nurses were interviewed, yielding 142 critical incidents for analysis.Ethical considerationsThe study followed the Declaration of Helsinki and Swedish law on ethical vetting. Approval was obtained from the Swedish Ethical Review Authority (ref. 2017/1722-31-1).ResultsFive themes were identified: (1) Navigating Ethical Boundaries in End-of-Life Care and cDCD, (2) Safeguarding Autonomy in cDCD Decisions, (3) Balancing Emotional Presence and Ethical Practice, (4) Managing Ethical Uncertainty Through Knowledge and Team Support, and (5) Ensuring Ethical Responsibility Through Interprofessional Communication. Ethical challenges were linked to unclear procedures, limited training, and fragmented communication, while structured guidelines and collegial support enabled ethical coherence.ConclusionscDCD requires continuous negotiation between ethical-, professional-, and emotional dimensions. To ensure ethically sustainable practice, organisations need to strengthen ethical awareness, structured training, and interprofessional communication. Integrating both biomedical principles and caring ethics is crucial to safeguard patient autonomy, support relatives, and enabling healthcare professionals to act with confidence during end-of-life care and organ donation.