Futility and Termination of Resuscitation in Pediatric Out-of-Hospital Cardiac Arrest

Per the American Heart Association, there are approximately 7,000 pediatric out-of-hospital cardiac arrests (OHCA) each year, with an estimated survival rate of 7.8%.¹ When emergency medical service (EMS) practitioners are called to a pediatric cardiac arrest, they need to determine whether resuscitative measures would be futile as well as when to perform termination of resuscitation (TOR) when these measures are unsuccessful in achieving return of spontaneous circulation. However, there is little research in this population of patients to provide guidance. In fact, guidelines regarding futility and TOR that the National Association of State EMS Officials provide do not apply to patients younger than 18 years of age.² In addition, there is a paucity of research in this field, possibly because of differences in etiologies of cardiac arrest in children compared with adults, as well as the heightened emotions of EMS providers and families when resuscitative efforts are stopped in children. A study by Ramgopal et al³ suggested that there may be significant differences in oversight and education within EMS agencies, with subsequently highly subjective factors being used to make these decisions about resuscitation. The authors sought to determine the patient and EMS-agency level factors associated with the determination of futility and TOR and to characterize differences between agencies.³

For this study, the authors used data from the National EMS Information System (NEMSIS) which is a national repository that collects, stores, and disseminates EMS data, including cardiac arrest characteristics, disposition patterns, and details of the responding EMS team.³ The authors looked at data from 2018–2023 in patients younger than 18 years of age with OHCA. Exclusion criteria included patients needing water or air transports, those needing interfacility transports, those with traumas, and those with active do-not-resuscitate orders. Some of the data examined included demographics (race and ethnicity were not used as variables because of a lack of data in NEMSIS); Neighborhood Opportunity Index; urbanicity; and event-level characteristics, such as EMS response time, bystander cardiopulmonary resuscitation (CPR), EMS level of service (basic life support [BLS] vs advanced life support [ALS]), etiology of the arrest, and cardiac rhythms witnessed. For each outcome, the authors used advanced univariable and multivariable regression methods to create models that analyzed how different factors relate to the specific questions of futility and TOR. Results were reported as odd ratios with a 95% confidence interval for each model. Additionally, the authors developed intraclass correlation coefficients (ICC) to determine how much variation in practice determined differences between agencies. Finally, the authors did an exploratory analysis of adult OHCA data using the same exclusion criteria to assess frequency of futility designations and TOR in this cohort.³

For this study, the authors looked at over 250,000 encounters, ultimately coming up with 45,045 encounters that fit all criteria: 51.6% were infants (<1 year of age), 19% were adolescents (12-17 years old), and 29.4% were split between toddlers and childhood (1-11 years old). Futility was determined in 6.6% of cases. Situational factors associated with lower odds of futility determination included witnessed events, bystander CPR, public location of the arrest, respiratory/asphyxia or drowning as the cause of the arrest, BLS use by EMS (compared to ALS), and female sex. Futility determinations were more common in rural/wilderness settings and in adolescents (compared to infants). Some of the agency characteristics associated with lower odds of futility determination included private nonhospital and for-profit statuses. Futility determination was more commonly seen with mixed agency types (volunteer and nonvolunteer) and tribal agencies. The odds ratio for futility determination was 2.33, demonstrating that clinically similar arrests could be more than twice as likely to be deemed futile, depending on the agency involved. The ICC was 0.19, which suggests that 19% of the variability in futility designation was attributable to agency differences. Futility was determined more often in daytime than in the evening or night.

After removing the number of events deemed futile, the authors examined TOR seen in 25.4% of the cohort. Reasons to TOR included protocol completion (50.5%), orders from medical control (31.3%), obvious signs of death (17.6%), and the inability to perform resuscitation (0.6%). TOR occurred more commonly in rural/wilderness settings, at a prolonged scene time (>7 minutes), after bystander CPR was performed, and when mixed EMS agencies were present. TOR occurred less commonly in noninfant patients, witnessed arrests, respiratory arrests and drug overdoses, events with shockable rhythms, cases when BLS only was used, and cardiac arrests that occurred in public. Relative to other agencies, TOR occurred less frequently in for-profit agencies. The odds ratio between agencies for TOR was 3.5, and the ICC was 0.34. Scene time over 35 minutes was also associated with TOR.

When looking at the agency specifics, the authors found that 21% of the agencies had made at least one determination of futility and 47.5% made at least one TOR determination. Among adults, agencies made futility determinations in 16.3% and TOR in 32%.

In this work, the authors found that agency-level variability was significant in the determination of futility and TOR in pediatric OHCA.³ This phenomenon has also been described in the literature on adult patients. Because of the paucity of guidelines and the practice patterns being determined by local leadership, this data suggest that the decisions to not resuscitate or to terminate resuscitative efforts may be influenced by the personal beliefs of EMS caregivers, which can bring up ethical concerns. Some of the limitations mentioned by the authors include the retrospective nature of the work, the lack of some clinical and physiologic data that would help explain the rationale for clinical decisions, and the lack of geographic data.


References

1. Virani SS, Alonso A, Benjamin EJ, et al. Heart Disease and Stroke Statistics—2020 Update: A Report From the American Heart Association. Circulation. 2020;141(9):e139-e596.
2. NASEMSO Medical Directors Council. National Model EMS Clinical Guidelines Version 3.0. Accessed October 6, 2026. https://nasemso.org/docs.ashx?id=1444322
3. Ramgopal S, Loftus K, Amagasa S, et al. Futility and Termination of Resuscitation Variation for Pediatric Out-of-Hospital Cardiac Arrest. Pediatrics. 2026;158(3):e2026076981.