Emergency Medical Services and Do Not Attempt Resuscitation Directives among Patients with Out-of-Hospital Cardiac Arrest

Abstract Background Emergency Medical Services (EMS) are often involved in end-of-life circumstances, yet little is known about how EMS interfaces with advance directives to forego unwanted resuscitation (Do Not Attempt Resuscitation (DNAR. We evaluated the frequency of these directives involved in out-of-hospital cardiac arrest (OHCA) and how they impact care. Methods We conducted a cohort investigation of adult, EMS-attended OHCA from January 1–December 31, 2018 in King County, WA. DNAR status was ascertained from dispatch, EMS, and hospital records. Resuscitation was classified according to DNAR status: not initiated, initiated but ceased due to the DNAR, or full efforts. Results Of 3,152 EMS-attended OHCA, 314 (9.9%) had a DNAR directive. DNAR was present more often among those for whom EMS did not attempt resuscitation compared to when EMS provided some resuscitation (13.2% [212/1611] vs 6.6% [101/1541], (p  Of those receiving resuscitation with a DNAR directive (n = 101), the DNAR was presented on average 6 minutes following EMS arrival. A total of 82% (n = 83) had EMS efforts ceased as a consequence of the DNAR while 18% (n = 18) received full efforts. Full-efforts compared to ceased-efforts were more likely to have a witnessed arrest (67% vs. 36%), present with shockable rhythm (22% vs. 6%), achieve spontaneous circulation by time of DNAR presentation (50% vs 4%), and have family contradict the DNAR (33% vs 0%) (P  Conclusions Approximately 10% of EMS-attended OHCA involvedDNAR. EMS typically fulfilled this end-of-life preference, though wishes were challenged by delayed directive presentation or contradictory family wishes.