Termination of Resuscitation
Objective: Use your service TOR / medical-control rule as a rule, not a vibe — and know when you must keep going.
Why This Is Hard
The family is watching and the strip has been asystole. Crews either never stop or stop because they are tired. NAEMSP and AHA: TOR criteria are system rules. They are not your personal threshold.
- Know your medical and traumatic TOR protocols before the call.
- Shockable rhythm, hypothermia, and pregnancy usually mean you do not apply a basic BLS TOR rule.
- If you stop, document times, rhythm, who authorized, and what the family was told.
Field Rules (Education)
- BLS TOR themes (example, not your protocol): unwitnessed, no shock advised, no ROSC after a period of BLS — many systems still require OLMC.
- ALS TOR is stricter and local. Persistent asystole despite ALS is a common theme — still follow the card.
- Do not TOR: recurring VF, obvious hypothermia, pregnant beyond viability themes, toxic/airway issues you have not treated.
- Trauma TOR is a different paper (NAEMSP/ACS/ACEP traumatic arrest). See traumatic arrest.
Field Pitfalls
- Quitting on fine VF you never confirmed.
- Transporting a 40-minute asystole without a reason other than habit.
- No documentation of who authorized TOR.
Practice
60-second drill
Partner: 80-year-old, unwitnessed asystole, 20 minutes ALS, family present. What you need from protocol/OLMC before you stop.
Related: Traumatic arrest, Asystole vs fine VF.
Sources & Further Study
Named guidelines for further study. They are not clinical orders and do not replace your protocol or medical direction.
- NASEMSO National Model EMS Clinical Guidelines (2022) — U.S. EMS model language; protocol still wins
- AHA 2025 Part 9: Adult ALS — TOR recommendations when resuscitation has been unsuccessful — system-specific
- NAEMSP / ACEP / ACS-COT traumatic OHCA 2025 — trauma TOR is a different rule set
- Your medical director’s TOR protocol and OLMC script own the decision.
Education only. Apply learning within your protocols and medical direction. This is not clinical care guidance.
Check Your Understanding
Street decisions from this lesson only. After you check, the key is highlighted. Education practice — not a certification exam.