Do not resuscitate (DNR) emergency medical services (EMS) protocol variation in the United States

Document Type

Article

Publication Date

7-16-2025

Publication Title

The American journal of emergency medicine

Abstract

BACKGROUND: Do Not Resuscitate (DNR) orders are essential for ensuring that critically ill patients receive care from Emergency Medical Service (EMS) aligned with their preferences. However, significant variations exist in EMS protocols regarding acceptable DNR documentation leading to discordant care, moral distress, and ethical dilemmas.

OBJECTIVE: To characterize the variation of DNR documentation in EMS protocols.

METHODS: We performed a structured review of available statewide EMS protocols and of the 50 most populous U.S. cities to identify DNR protocols. We categorized the most common forms of DNR documentation: advance directives, living wills, jewelry/bracelets, portable medical orders (e.g. POLST), and verbal DNRs. Each type of DNR documentation was classified according to whether it is accepted, not mentioned, explicitly disallowed or required direct medical oversight (DMO) contact.

RESULTS: A total of 63 EMS protocols were included in this review; 31/51 (61 %) were statewide and 33/50 (67 %) were citywide protocols. Of available protocols 86 % (54/63) had a specific DNR protocol. Of available reviewed EMS DNR protocols, 50.0 % (27/54) permitted use of Advanced Directives, 13.0 % (7/54) Living Wills, 61.1 % (33/54) DNR Jewelry and 76.0 % (41/54) Portable Medical Orders. Notably, 38.5 % (21/52) of EMS protocols did not specify or disallowed verbal DNRs while 11.5 % (6/52) required DMO contact. Verbal DNRs were accepted from healthcare providers in 18.5 % (10/54) and from non-healthcare providers 26.6 % (16/54) of EMS protocols.

CONCLUSIONS: Although most EMS protocols have dedicated DNR protocols, this is not universal and there is significant variability in types of documentation recognized as valid. Documentation that is concise, portable, and designed for EMS use, such as the POLST is preferred. Future research should assess the effectiveness of these different documentation types and consider the expanding the use of verbal DNRs to ensure goal-concordant care in the out of hospital setting.

PubMed ID

40714438

Volume

97

First Page

123

Last Page

128

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