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Traditionally, in many areas EMS crews transported all cardiac arrest victims to the hospital, continuing resuscitative efforts en route. However, there is growing awareness that cardiac arrest patients who are not responding to initial treatment will likely not receive additional benefit from transport to the hospital [91]. Therefore, EMS agencies have adopted protocols for terminating resuscitation efforts in the field.

Several studies have evaluated the prediction of futility by EMS clinicians [92–96]. The Universal Termination of Resuscitation rule developed by Verbeek and Morrison indicates termination of resuscitation in patients who meet three criteria: arrest not witnessed by EMS, no shock delivered, and no ROSC after three periods of CPR and three AED analyses [96, 97]. This applies to BLS and ALS personnel.

Other research also supports that patients who receive appropriate initial ACLS (including airway management and IV access) and who remain in asystole or PEA for greater than 20‐30 minutes of resuscitative efforts without return of pulses are unlikely to be resuscitated [94, 96]. ACLS guidelines support cessation of efforts in these patients without transport to the hospital [1, 91, 93, 95]. Consultation with the direct medical oversight physician may be appropriate in these cases [98].

Nontransport after termination of efforts applies only to patients with sustained pulselessness from suspected cardiac or general medical etiologies. This approach does not apply to patients with special situations such as drug overdoses or severe hypothermia.

The decision to terminate resuscitation or transport to the hospital involves important social and ethical matters. Although some express concern that cessation of resuscitative efforts at the scene may be poorly accepted, two studies suggest that nontransport is well accepted and often preferred if proper counseling and explanation are given to bystanders and family members [99, 100]. Nonetheless, circumstances in which transport to the hospital may be prudent include cardiac arrests occurring in public locations, unexpected death in the very young, and situations with extremely distraught or unaccepting family members. Paramedics are often uncomfortable terminating resuscitation in children [101]. Direct medical oversight physician input may prove helpful in these situations. EMS personnel should receive specific training regarding termination of resuscitation and providing notice of death to loved ones at the scene [102].

As resuscitation strategies and post arrest care continue to improve, the accepted criteria for termination of resuscitation requires continuous reevaluation. A system that looked at using ETCO₂ levels to help guide decisions to terminate found no change in transport rate or survival [103]. However, newly emerging therapies, including strategies for rapid transport and initiation of eCPR, and new diagnostic modalities available in the field, such as capnography and ultrasound, will require reassessment of the decision making and criteria for termination of resuscitation in the prehospital setting.