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Historically, EMS clinicians may have been indoctrinated to be weary of withholding resuscitative efforts. In some cases, appropriate input from family members might have been disregarded. The concern rested on the notion that deciding not to attempt resuscitation is an irreversible decision. On the other hand, attempts can always be abandoned later. However, patient autonomy is an important consideration, and there are times when initiating resuscitative efforts are inappropriate given the clinical circumstances or known patient directives.

The primary EMS situations involving noninitiation of resuscitation efforts include:

 The patient has a do not resuscitate (DNR) order (usually a state‐recognized document such as a Physician Orders for Life‐Sustaining Treatment (POLST form); see Chapter 65).

 The patient has clear signs of irreversible death (such as rigor mortis).

EMS agencies should have protocols and policies reflecting these situations. Personnel should receive education in the ethical principle of patient autonomy and the local regulations regarding patient directives. In each situation, consultation with the direct medical oversight physician is appropriate. CPR should be initiated whenever the situation is unclear until decision made by the oversight physician.

Bystanders or caregivers may call 9‐1‐1 despite the presence of a DNR order. This may occur because of the lack of knowledge of the patient’s status, uncertainty about the patient’s condition, panic, or simply the caregiver’s wish to have an independent person confirm death. EMS personnel should not be surprised by these situations. Prompt consultation with the direct medical oversight physician may be appropriate in these situations.

Physician Orders for Life‐Sustaining Treatment (POLST), is an effort to provide a standardized order sheet to indicate the specific wishes of the patient in a detailed manner. It signed by the patient and physician. A number of states have enacted legislation for this program. The specific operational details must be implemented prospectively to avoid confusion and misunderstanding at the patient’s side (see Chapter 65).