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

Amelia M Breyre; E Jane Merkle-Scotland; David H Yang; Kenneth Hanson; Sameer Jagani; Abe Tolkoff; Satheesh Gunaga

doi:10.1016/j.ajem.2025.07.035

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

Am J Emerg Med. 2025 Nov:97:123-128. doi: 10.1016/j.ajem.2025.07.035. Epub 2025 Jul 16.

Authors

Amelia M Breyre¹, E Jane Merkle-Scotland², David H Yang³, Kenneth Hanson⁴, Sameer Jagani⁵, Abe Tolkoff³, Satheesh Gunaga⁶

Affiliations

¹ University of California San Francisco, San Francisco, CA, USA. Electronic address: amelia.breyre@gmail.com.
² Montana State University, MT, USA.
³ Department of Emergency Medicine, Yale University School of Medicine, New Haven, CT, USA.
⁴ Central Michigan University, College of Medicine-East Campus, Saginaw, MI, USA.
⁵ Department of Osteopathic Medical Specialties, Michigan State University College of Osteopathic Medicine, East Lansing, MI, USA.
⁶ Department of Osteopathic Medical Specialties, Michigan State University College of Osteopathic Medicine, East Lansing, MI, USA; Department of Emergency Medicine, Henry Ford Health, Wyandotte Hospital, Wyandotte, MI, USA; Envision Healthcare, Ann Arbor, MI, USA.

PMID: 40714438
DOI: 10.1016/j.ajem.2025.07.035

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.

Keywords: Advance care planning; Do not resuscitate; EMS protocols; Emergency medical services; End of life care; Hospice; Prehospital.

MeSH terms

Advance Directives
Clinical Protocols*
Documentation
Emergency Medical Services* / standards
Emergency Medical Services* / statistics & numerical data
Humans
Resuscitation Orders*
United States