Termination of Resuscitation, DNR and POLST Orders, Family Presence, Ethics, and Debriefing Practice Questions

25 multiple-choice questions on Termination of resuscitation, DNR and POLST orders, family presence, ethics, and debriefing for paramedic and EMT students, from Chapter 40 (Responding to the Field Code). Read each question, pick your answer, then tap Show answer to check it and read the explanation.

25 practice questions

1. Your tiered EMS system uses the universal (BLS) termination-of-resuscitation rule. Which finding means the rule does NOT support stopping?

   1. A. ROSC occurred briefly on scene
   2. B. The arrest was not witnessed by anyone
   3. C. The rhythm has been asystole
   4. D. The patient is 84 years old
   Show answer

   Answer: A. ROSC occurred briefly on scene

   The universal TOR rule uses three criteria, all of which must be met: arrest not witnessed by EMS, no shock delivered, and no ROSC before transport; any ROSC, even brief, means the rule does not apply. The 2025 AHA guidelines say it is reasonable to use the universal rule in tiered systems, applied after a period of resuscitation, about 15 to 20 minutes. An unwitnessed arrest is consistent with the rule rather than against it. Asystole means no shock was delivered, which also fits the rule. Age is not part of the rule. (2025 AHA Part 9; Morrison 2006 and 2009.)

2. The ALS termination-of-resuscitation rule adds which criteria to the BLS rule?

   1. A. No IV access and no advanced airway placed
   2. B. Age over 75 and a history of heart failure
   3. C. No bystander witness and no bystander CPR
   4. D. Asystole and an ETCO2 above 20 mmHg
   Show answer

   Answer: C. No bystander witness and no bystander CPR

   The ALS rule requires all five: not witnessed by EMS, not witnessed by a bystander, no bystander CPR, no shock delivered, and no ROSC. Meeting the stricter ALS rule predicts very low survival.

3. A partner suggests running a 'slow code,' with deliberately half-hearted CPR, for a frail 90-year-old who has no DNR order. This practice is:

   1. A. An accepted compromise for families
   2. B. Deceptive and should not be done
   3. C. Required when the outlook is poor
   4. D. Legal if the family is not watching
   Show answer

   Answer: B. Deceptive and should not be done

   A slow code pretends to resuscitate while deliberately withholding effective care, which deceives the family and denies the patient either real resuscitation or an honest decision not to resuscitate; AHA ethics guidance calls it inappropriate. Without a valid DNR, a full attempt is made, and termination is then decided by protocol and medical direction. It is not an accepted compromise. A poor outlook calls for TOR rules or medical control, not sham care. Whether anyone is watching does not change the deception. (AHA 2015 Part 3 ethical issues.)

4. A hospice patient with a valid DNR is awake and alert. He tells you he has changed his mind and wants CPR if his heart stops. You should:

   1. A. Follow the DNR, since it is still signed
   2. B. Ask his family to make the decision
   3. C. Wait for his physician to revoke it
   4. D. Honor his current wish and document it
   Show answer

   Answer: D. Honor his current wish and document it

   A patient with decision-making capacity can revoke a DNR at any time, and his current, clearly stated wish replaces the earlier order; document the conversation and his capacity, and notify medical control and hospice per protocol. The signature on the form does not override what a capable patient says now. The family cannot override a capable patient's own decision. In most states the patient may revoke the order himself without waiting for the physician, although local law and protocol should be followed. (AHA 2015 ethics; state DNR and POLST law, polst.org.)

5. A woman with end-stage heart failure has a POLST marked 'Do not attempt resuscitation' and 'Selective treatment.' She has a pulse and is in severe pulmonary edema. You should:

   1. A. Give CPAP, nitrates, and transport
   2. B. Withhold all treatment per the POLST
   3. C. Intubate her before she tires out
   4. D. Give comfort care only and stay
   Show answer

   Answer: A. Give CPAP, nitrates, and transport

   Selective treatment on a POLST means treating reversible problems with measures such as IV medication and noninvasive ventilation while avoiding intubation and intensive care; the DNR section applies only if she loses her pulse. So CPAP, nitroglycerin, and transport fit her orders. The POLST does not mean withholding all care. Intubation is outside the selective-treatment category. Comfort-only care is a different, more limited choice than the one she made. Forms and wording vary by state. (National POLST; state POLST forms.)

6. Twenty minutes into an unsuccessful resuscitation at home, the best way to prepare the family is to:

   1. A. Tell them honestly it is not going well
   2. B. Say nothing until death is pronounced
   3. C. Promise them that the team will get him back
   4. D. Ask them to decide when the team stops
   Show answer

   Answer: A. Tell them honestly it is not going well

   Giving the family an honest update during the resuscitation, such as 'We are doing everything we can, but his heart has not restarted, and I am worried he may not survive,' prepares them for bad news and supports grieving. Silence until death is pronounced makes the news more of a shock. False promises damage trust. Asking the family to decide when to stop places an unfair burden on them; termination is a medical decision made by protocol or medical control. (AHA 2015 ethics, family presence and communication; NAEMSP TOR resource.)

7. Ten minutes into a resuscitation, the patient's daughter arrives with a valid DNR order. You should:

   1. A. Continue until the ED physician decides
   2. B. Finish the current drug cycle first
   3. C. Stop resuscitation per the order
   4. D. Continue because CPR has begun
   Show answer

   Answer: C. Stop resuscitation per the order

   Once a valid DNR order is produced, it reflects the patient's own decision, so resuscitation stops, with medical control contacted if protocol requires. There is no reason to transport for an ED physician to decide when a valid field order exists. Finishing a drug cycle continues treatment the patient refused. Having already started CPR does not change what the patient wanted. (AHA 2015 ethics; state DNR law.)

8. An adult meets your termination protocol on scene, and medical control agrees. Transporting him with lights, siren, and CPR in progress would mainly:

   1. A. Greatly raise his chance of having ROSC
   2. B. Be needed for an ED physician to call death
   3. C. Give the family the most accurate news
   4. D. Put the crew at risk with almost no benefit
   Show answer

   Answer: D. Put the crew at risk with almost no benefit

   Manual CPR in a moving ambulance is poor in quality and exposes the crew and public to crash and injury risk, while patients who meet validated TOR criteria have almost no chance of survival. Transport does not meaningfully raise the chance of ROSC. Death can be pronounced in the field under protocol with medical direction, so an ED physician is not needed. Transporting a patient who has already died can mislead the family about his chances and delays their grieving. (2025 AHA Part 9 TOR; NAEMSP TOR resource.)

9. The family of a 60-year-old man in cardiac arrest asks to stay in the room during the resuscitation. The best response is to:

   1. A. Refuse, since presence harms the family
   2. B. Allow it, with someone to support them
   3. C. Allow it only after resuscitation ends
   4. D. Refuse, since it raises legal liability
   Show answer

   Answer: B. Allow it, with someone to support them

   Family presence is associated with less anxiety and depression and better grieving, and it does not worsen resuscitation performance, so AHA supports offering it. A designated person should explain events and support the family.

10. After terminating resuscitation, you speak with the patient's wife. The best way to tell her is:

    1. A. 'He has passed on to a better place.'
    2. B. 'I'm very sorry. Your husband has died.'
    3. C. 'We lost him, but we did all we could.'
    4. D. 'He didn't make it through the transport.'
    Show answer

    Answer: B. 'I'm very sorry. Your husband has died.'

    Clear words such as 'died' or 'dead' prevent confusion and help families begin to grieve; euphemisms like 'lost' or 'passed' can be misunderstood. Speak simply, use the patient's name, and allow silence and questions.

11. After resuscitation is terminated in a suspicious death, you should:

    1. A. Remove all tubes before the family enters
    2. B. Clean the body before police arrive
    3. C. Leave tubes and lines in place
    4. D. Move the body to the ambulance
    Show answer

    Answer: C. Leave tubes and lines in place

    In a medical examiner or coroner case, devices placed during resuscitation are left in place and documented so they are not mistaken for injuries. Removing them or cleaning the body can alter evidence.

12. After an unsuccessful resuscitation, a new paramedic asks to practice intubation on the body. The most ethical response is that this:

    1. A. Is not acceptable without consent
    2. B. Is fine because the patient has now died
    3. C. Is acceptable if the medical director agrees
    4. D. Is acceptable if done for one attempt
    Show answer

    Answer: A. Is not acceptable without consent

    Practicing procedures on the newly dead without consent from the family and an approved policy is widely regarded as unethical, as it disregards the dignity of the deceased and the family's rights. Approval from a medical director does not replace family consent, and limiting it to a single attempt does not change the ethical problem. Skills should be learned through simulation or approved programs.

13. Your agency joins a cardiac arrest drug trial in which patients are enrolled without consent because they are unconscious. Under US rules, this is allowed only if:

    1. A. Each family signs consent before the drug
    2. B. The paramedic decides the patient wants it
    3. C. The trial uses only drugs already approved
    4. D. The community is consulted and informed
    Show answer

    Answer: D. The community is consulted and informed

    Federal exception from informed consent rules (21 CFR 50.24) allow emergency research without consent when the condition is life-threatening and consent is impossible, but require community consultation and public disclosure before the study, plus ethics board oversight. Families are informed afterward, and new drugs may be studied.

14. Ethically, stopping resuscitation once it has started, compared with not starting it, is considered:

    1. A. Worse than never starting it
    2. B. Permitted in the hospital, not the field
    3. C. Allowed if the family consents first
    4. D. Equivalent to withholding it
    Show answer

    Answer: D. Equivalent to withholding it

    Ethicists and the AHA consider withholding and withdrawing equivalent, which lets crews begin resuscitation when in doubt and stop when new information appears. Believing that stopping is worse than never starting leads to unnecessary withholding of CPR.

15. Short, structured debriefings after cardiac arrest calls that review CPR data are recommended mainly because they:

    1. A. Assign blame for poor outcomes
    2. B. Improve future CPR quality
    3. C. Replace formal CE requirements
    4. D. Satisfy billing requirements
    Show answer

    Answer: B. Improve future CPR quality

    Data-driven, performance-focused debriefing improves compression quality and may improve ROSC on later calls. Debriefing aims to learn, not to blame, and works best when it is routine and nonpunitive.

16. After an unsuccessful resuscitation of a 2-year-old, a young paramedic on your crew is withdrawn and not sleeping. The best response is to:

    1. A. Encourage peer support or an EAP referral
    2. B. Tell him to stop thinking about the call
    3. C. Assign him to more pediatric calls at once
    4. D. Say nothing and let him handle it alone
    Show answer

    Answer: A. Encourage peer support or an EAP referral

    Pediatric deaths are among the most stressful EMS calls, and peer support, EAP counseling, and mental health resources help prevent long-term harm. Ignoring signs of distress risks burnout, depression, or PTSD.

17. A 6-year-old in unwitnessed cardiac arrest has received no shocks and has had no ROSC after 20 minutes of ALS care. Regarding your adult termination-of-resuscitation rule, it:

    1. A. Applies exactly as for adults
    2. B. Must be applied after 10 minutes
    3. C. Was not validated in children
    4. D. Requires a shock to be given
    Show answer

    Answer: C. Was not validated in children

    The BLS, ALS, and universal TOR rules were derived and validated in adults with nontraumatic arrest, so they are not applied to children; pediatric termination decisions are made with online medical control and pediatric-specific protocols. Applying the adult rule unchanged ignores that it was never tested in this population. No rule sets a 10-minute pediatric limit. A shock is not required; 'no shock delivered' is actually one of the adult rule's criteria for stopping. (2025 AHA Part 9, adult TOR rules; Morrison 2006 validation in adults 18 and older.)

18. Many protocols allow termination of resuscitation in a normothermic adult with a nonshockable rhythm after at least about:

    1. A. 5 minutes of ALS care
    2. B. 10 minutes of BLS care
    3. C. 20 minutes of ALS care
    4. D. 90 minutes of ALS care
    Show answer

    Answer: C. 20 minutes of ALS care

    Most systems require roughly 20 to 30 minutes of high-quality ALS without ROSC before TOR, because most survivors achieve ROSC within that time. Stopping after 5 to 10 minutes would end resuscitation in patients who could still recover; protocols vary.

19. A termination-of-resuscitation rule should generally not be applied to a patient in cardiac arrest from:

    1. A. A prior heart attack
    2. B. Severe hypothermia
    3. C. End-stage COPD
    4. D. Unwitnessed collapse
    Show answer

    Answer: B. Severe hypothermia

    Hypothermic patients can survive prolonged arrest with good outcomes, so TOR rules derived from typical medical arrests do not apply; children, drowning, lightning, and pregnancy are also common exceptions. Unwitnessed collapse is one of the criteria that supports TOR.

20. After resuscitation ends for a man who died at home of an expected illness, his family asks to pray and perform a religious ritual at his side. The death is not suspicious. You should:

    1. A. Refuse until the medical examiner arrives
    2. B. Ask them to wait in another room
    3. C. Limit it to 2 minutes so you can clear
    4. D. Allow it and support them while they do
    Show answer

    Answer: D. Allow it and support them while they do

    When a death is expected and not suspicious, the family's cultural and religious needs come first, and allowing rituals and time with the body helps them grieve; stay to support them and explain next steps. There is no reason to wait for the medical examiner in a non-suspicious death unless protocol requires notification first. Sending the family to another room separates them from the person at a key moment. Cutting their time short so the crew can clear disregards their needs; stay until the next steps are in place. (AHA 2015 ethics; NAEMSP TOR resource on family-centered care.)

21. After you tell a man that his wife has died, he shouts that your crew did not try hard enough. The best response is to:

    1. A. Stay calm, listen, and acknowledge his grief
    2. B. Explain each intervention to prove your case
    3. C. Leave the scene at once to avoid conflict
    4. D. Ask police to remove him from the room
    Show answer

    Answer: A. Stay calm, listen, and acknowledge his grief

    Anger is a common early grief reaction, and a calm, nondefensive response that listens and acknowledges the loss ('I'm so sorry; we did everything we could') usually lets it pass; offer to answer questions later. Arguing through a list of interventions turns grief into a debate. Leaving abruptly abandons a grieving family member. Police are needed only if there is a real threat to safety, not for an expression of grief. (AHA 2015 ethics and family support; death-notification practice.)

22. A hospice patient with a valid DNR falls and has a painful, deformed wrist. She has a pulse and is breathing normally. You should:

    1. A. Splint and treat the injury as usual
    2. B. Withhold care because of the DNR
    3. C. Call hospice and leave her as she is
    4. D. Start CPR only if her pain worsens
    Show answer

    Answer: A. Splint and treat the injury as usual

    A DNR order applies to cardiac or respiratory arrest; it does not limit care for other problems, so a patient with a pulse receives normal splinting, pain relief, and transport or hospice coordination as she wishes. Withholding care misreads the order. Leaving her without treatment ignores pain that can be relieved. CPR is for arrest, not pain, and she has declined it in any case. (National POLST; AHA 2015 ethics.)

23. After 25 minutes of ALS care, your adult patient in cardiac arrest meets your termination-of-resuscitation rule, but his son insists that you keep trying. You should:

    1. A. Stop at once, since the rule overrides him
    2. B. Keep going with CPR for as long as he wishes
    3. C. Explain gently and consult medical control
    4. D. Ask the son to sign a refusal of care form
    Show answer

    Answer: C. Explain gently and consult medical control

    A termination rule is a decision aid, and family wishes are one of the factors protocols ask you to weigh; take time to explain honestly what has been done and why it has not worked, and involve online medical control, who can support the decision or advise continuing. Stopping at once without addressing him adds to his distress and erodes trust. Continuing CPR for as long as he wishes hands the medical decision to the family and prolongs futile care; termination is a medical decision. A refusal of care form is for a competent patient who declines care, not for a family member objecting to termination. (NAEMSP TOR position and resource document; 2025 AHA Part 9 TOR.)

24. After terminating resuscitation at a home, you should:

    1. A. Leave once the time of death is written down
    2. B. Stay with the family until help arrives
    3. C. Have the family move the body to a bed
    4. D. Tell the family to call a funeral home later
    Show answer

    Answer: B. Stay with the family until help arrives

    The family's needs become the focus after TOR; staying until a support person, chaplain, or law enforcement arrives and explaining next steps helps them cope. Leaving abruptly can deepen the family's distress.

25. Minutes after you tell an elderly man that his wife has died, he becomes pale, sweaty, and clutches his chest. You should:

    1. A. Tell him it is only grief and reassure
    2. B. Leave him with neighbors and clear out
    3. C. Wait until the funeral home arrives
    4. D. Assess and treat him as a new patient
    Show answer

    Answer: D. Assess and treat him as a new patient

    Acute grief can trigger real cardiac events (including stress cardiomyopathy and myocardial infarction), so a bereaved family member with chest pain or syncope is a new patient who needs assessment, a 12-lead ECG, and treatment or transport. Dismissing symptoms as grief or leaving the scene risks missing an emergency.