Futility and Termination of Resuscitation Variation for Pediatric Out-of-Hospital Cardiac Arrest

To evaluate agency-level differences in determinations of futility (defined as withholding resuscitative efforts by emergency medical services [EMS]) and termination of resuscitation (TOR) during prehospital encounters for pediatric out-of-hospital cardiac arrest (OHCA).

We conducted a retrospective cross-sectional study of EMS activations for children (aged <18 years) with nontraumatic OHCA from the 2018-2023 National EMS Information System. Our outcomes of interest were futility and TOR. We constructed mixed-effects models including patient- and agency-level covariables. We quantified the magnitude of agency-level variation using the median odds ratio.

We included 45 045 encounters treated by 6550 EMS agencies. Resuscitation was considered futile in 6.6%; among the remainder, TOR occurred in 25.4%. Futility determinations were less likely in witnessed arrests, events with bystander cardiopulmonary resuscitation (CPR), public locations, and respiratory/asphyxia or drowning etiologies and more likely in rural/wilderness settings and adolescents. TOR was less likely among witnessed arrests and noncardiac etiologies. The median odds ratio for a futility determination was 2.33 (95% CI 2.16-2.47), which exceeded in magnitude the odds ratio for all fixed-effect variables except for arrest witnessed status, etiology of drowning/submersion, bystander CPR status, tribal-type EMS agency, and wilderness events. The median odds ratio for TOR was 3.50 (95% CI 3.32-3.72), which exceeded all fixed-effect variables.

We found substantial agency-level variation in determinations of futility and TOR for pediatric OHCA, underscoring that local EMS practice patterns may shape resuscitation decisions. These findings carry implications for patient care, resource utilization, and clinical outcomes.