Termination of Resuscitation
Objective: Follow your service's written termination-of-resuscitation rule and medical control. Know when that rule says you must keep going.
Why this matters
Keep working the arrest in front of you until a written rule says you may stop. The family is watching and the strip has been asystole. Do not keep going forever only out of habit, and do not stop because you are tired. TOR means termination of resuscitation. The criteria are your service’s written rule plus medical control. They are not a personal guess. Do not stop because one end-tidal carbon dioxide number is low. That number is not a reason to stop by itself.
- Know your medical and trauma termination protocols before the call.
- A shockable rhythm, hypothermia, or pregnancy usually means you do not use a basic life support (BLS) termination rule.
- If you stop, write the times, the rhythm, who authorized it, and what you told the family.
Clinical sequence
- Work the arrest in front of you. Do high-quality CPR, shock if the rhythm is shockable, and look for reversible causes.
- Stopping is a written-rule decision, not a feeling. Know whether you are using a basic life support rule, an advanced life support (ALS) rule, or a universal rule, and who has to be on the phone.
- Do not stop resuscitation on end-tidal carbon dioxide (EtCO2) alone. Do not stop a hypothermia or poisoning arrest that your protocol says to transport.
- If you stop, write the rule you used, the times, and the family conversation. If you are unsure, keep working and transport.
- Say aloud / radio script. The rule we are using is ___.
- We do not stop on EtCO2 alone.
- If we are unsure, we keep working and we transport.
Teaching points
- Basic life support and the universal rule use the same three items, and all three have to be true before transport. EMS did not witness the arrest, no shock was delivered, and there is no return of spontaneous circulation. A bystander may still have seen the collapse. That does not by itself fail the rule. AHA 2025 says a basic life support crew uses this rule when advanced life support is not available or will be very late. A system with both basic and advanced crews may use the same three items as the universal rule. The rule is more reliable after about 15 minutes of resuscitation than after a few minutes. Your protocol and medical control still have to allow the stop.
- The advanced life support rule is stricter. All of these are true: nobody witnessed the arrest, nobody started bystander CPR, there is no return of circulation after advanced care, and no shock was delivered. Use that rule only if your service is an advanced life support service and the protocol names it.
- End-tidal carbon dioxide does not stop the resuscitation by itself. In a patient with a tracheal tube, a value that stays at or below 10 mm Hg after 20 minutes of advanced life support can be one piece of a written decision. Without a tube, do not use any end-tidal carbon dioxide cutoff to stop.
- Do not stop resuscitation for recurring ventricular fibrillation, obvious hypothermia, pregnancy past viability, or a poisoning or airway problem you have not treated.
- Trauma termination is a different protocol. See traumatic arrest.
Common errors
- Stopping on fine ventricular fibrillation you never confirmed.
- Transporting asystole for 40 minutes with no reason other than habit.
- Failing to write down who authorized termination.
Practice
One-minute check
Partner: an 80-year-old found in asystole. The crew did not witness the collapse. You have done 20 minutes of ALS, and the family is present. Say what you need from protocol or medical control 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 — basic, advanced, and universal termination rules match the crew’s scope. End-tidal carbon dioxide is not used alone to stop
- NAEMSP / ACEP / ACS-COT traumatic OHCA 2025 — trauma TOR is a different rule set
- Your medical director’s termination protocol and the online medical control script own the decision.
Education only. Apply learning within your protocols and medical direction. This is not clinical care guidance.
Check Your Understanding
Questions drawn only from this lesson. After you check, the key is highlighted. Education practice — not a certification exam.