In Reply: An Analysis of Potential in Germany Based on Retrospective Data From European Countries

Letters to the Editor Cardiac Arrest as an Extended Indication for Organ Donation by Friedrich A. von Samson-Himmelstjerna, Hans de Ferrante, Christoph B. Niehus, Agita Strelniece, Nassim Kakavand, Sarah-Yasmin Thomsen, Rainer Guenther, Steffen Augsberg, Serge Vogelaar, Erwin de Buijzer, Ineke Tieken, Roland Schmitt, Benedikt Kolbrink, and Kevin Schulte in issue 8/2026

The point at issue regarding the reliable determination of death merits closer examination in light of the current medical evidence. Two points are particularly relevant:

• Following the cessation of circulatory function and the corresponding no-touch period, circulatory function does not spontaneously resume. In very rare cases, cardiovascular function may spontaneously resume (autoresuscitation) shortly after the withdrawal of intensive care measures to maintain circulation. This phenomenon has been examined in detail in the literature and occurs—if at all—very soon after the discontinuation of intensive care measures (1). Thus, the published evidence shows that, after a 5-min waiting period, permanent cessation of circulation has occurred.
•  Following permanent cessation of circulation, brain function is necessarily lost. The diagnosis of loss of brain function, as currently defined by the guidelines, is neither possible nor necessary in the context of controlled organ donation following cardiac arrest: permanent circulatory failure and the resulting absence of cerebral perfusion necessarily lead to permanent loss of brain function. It does not logically follow from differences in international practice that this is “not a reliable method for determining death.” The unanswered empirical question is not whether loss of brain function occurs following cardiac arrest—what remains to be definitively established is primarily when brain activity ceases. Evidence to date suggests that a 5-min waiting period is reliable to this end, albeit based on a limited number of cases (2); this waiting period also corresponds to the majority of established international protocols, although some countries provide for longer intervals.

The NeuPaRT study, which is currently in its final stages, was designed as a multicenter, prospective observational study on neurophysiology following treatment withdrawal (3); the data it provides can further inform the development of German guidelines on this issue.

DOI: 10.3238/arztebl.m2026.0101

On behalf of the authors

Dr. med. Friedrich A. von Samson-Himmelstjerna
Medizinische Fakultät, Christian-Albrechts-Universität zu Kiel, Germany

Conflict of interest statement

FAvSH received speaker’s honoraria and reimbursement of congress fees and travel expenses from Chiesi GmbH, von der Lilly Deutschland GmbH, and Astra Zeneca GmbH.

References

1. Zorko DJ, Shemie J, Hornby L, et al.: Autoresuscitation after circulatory arrest: An updated systematic review. Can J Anaesth 2023; 70: 699–712

2. Kolisnyk M, Gofton TE, Norton L, et al.: The relationship between cessation of brain and systemic circulation after withdrawal of life-sustaining measures. Am J Transplant 2025; 25: 2142–50

3. Gofton T, Dhanani S, Meade M, et al.: Neurologic physiology after removal of therapy (NeuPaRT) study: Study protocol of a multicentre, prospective, observational, pilot feasibility study of neurophysiology after withdrawal of life-sustaining measures. BMJ Open 2023; 13: e073643

4. von Samson-Himmelstjerna FA, de Ferrante H, Niehus CB, et al.: Cardiac arrest as an extended indication for organ donation: An analysis of potential in Germany based on retrospective data from European countries. Dtsch Arztebl Int 2026; 123: 207–12