Managing death in the prehospital setting presents unique challenges compared to the hospital context. A recent article in Prehospital Emergency Care proposes recontextualizing "Termination of Resuscitation" as "Withdrawal of Life Support," applying intensive care best practices to prehospital emergency care. Literature analysis and field practice observation suggest the need to formalize existing but uncodified approaches.
The problem: a gap between theory and practice
Peter Antevy, emergency physician and medical officer at Handtevy, recently posed on LinkedIn a question that many EMS providers face daily: "Your patient is in cardiac arrest and the chances of survival are not promising. The family is crying outside. Do you keep them there or let them in?"
The question is not rhetorical. It highlights a gap in prehospital literature and protocols: while in hospital settings, particularly in intensive care units, end-of-life management and family presence during care are extensively studied and protocolized aspects, in the prehospital context standardized guidelines are lacking.
The epidemiological data are significant: approximately 10 deaths per 1,000 emergency interventions occur in the field. In Italy, we're talking about approximately 60,000 out-of-hospital cardiac arrests per year, most with unfavorable outcomes. These events are often sudden, traumatic, and occur in the presence of family members or bystanders who witness the rescue team's intervention.
The literature documents that prehospital emergency service providers experience high rates of post-traumatic stress disorder (PTSD) and moral distress, particularly when they perceive a misalignment between the care provided and the patient's and family's values.
The study: from TOR to WOLS
In the article "Reframing Prehospital Termination of Resuscitation as Withdrawal of Life Support: Applying Lessons from the ICU in the Prehospital Setting," published in Prehospital Emergency Care in October 2025, Braude and colleagues from the University of New Mexico propose a conceptual and operational paradigm shift.
The terminological proposal
The authors suggest replacing the term "Termination of Resuscitation" (TOR) with "Withdrawal of Life Support" (WOLS). The difference is not merely semantic: it reflects a different conceptual framework for interpreting the moment when the decision is made to cease resuscitative efforts.
TOR, in current practice, is perceived as an abrupt cessation, often experienced as a "failure" of the intervention. WOLS, instead, recontextualizes the moment as a deliberate clinical decision to suspend artificial life support, analogous to what routinely occurs in intensive care units when proceeding with withdrawal of life-sustaining treatment.
This recontextualization has implications that are not only linguistic but also psychological and operational. As Antevy emphasizes in his comment: "Reframing 'termination of resuscitation' as 'withdrawal of life support' isn't just semantics—it's about making death less traumatic, humanizing the final moments, and providing emotional support for both families and EMS clinicians."
Operational elements of the WOLS model
The study identifies four key components for implementing the WOLS approach in the prehospital setting:
1. Family Witnessed Resuscitation (FWR) When scene safety conditions permit and the family desires it, the opportunity to observe resuscitative efforts is offered. Hospital literature documents that FWR is associated with reduced anxiety, depression, and intrusive thoughts post-event in family members, without negative impact on resuscitation duration or mortality.
A 2015 systematic review and subsequent meta-analyses showed that offering FWR causes no differences in resuscitation duration or prehospital mortality. Furthermore, family members present during resuscitation showed less post-event anxiety, depression, and intrusive thoughts according to assessments months after the event.
2. Pre-cessation contact Before interrupting resuscitative maneuvers, family members are given a moment to touch and communicate with the patient. In some cases documented in the study, CPR was prolonged by a few minutes specifically to allow a close family member to arrive.
The authors report an emblematic case: a crew continued chest compressions long enough for a mother to arrive. Once the mother touched her son and spoke to him, the maneuvers were suspended. The family expressed immense gratitude and the team reported finding the experience more meaningful compared to "standard" TOR.
3. Recontextualization of the decision-making process Cessation of maneuvers is communicated and documented not as "failure" but as a deliberate clinical decision to withdraw futile treatment, maintaining focus on patient dignity and respect for family values.
4. Ritualization of the moment Brief recognition rituals (moment of silence, pause before leaving the scene) that formalize the transition and acknowledge the person's death, not just the end of a technical intervention.
Supporting evidence from the hospital context
The authors cite extensive literature from the hospital context documenting:
- Significant reduction in post-traumatic stress disorder in family members who witness resuscitation (up to 50% reduction in some studies)
- Greater satisfaction and understanding of efforts made by the medical team
- No increase in medical-legal disputes (contrary to common fears)
- Better grief processing with reduced complicated grief
- No negative impact on team performance or duration of maneuvers
The evidence comes primarily from emergency department and intensive care settings. Braude's study proposes transferring these validated principles to the prehospital context, which presents specific challenges but also unique opportunities for early intervention on psychological trauma.
Observations from the Italian context: existing but uncodified practices
Analysis of the Italian situation reveals an interesting phenomenon: many of the practices proposed in Braude's study are already implemented in the field, but in the absence of formal protocols or theoretical reference frameworks.
The regulatory and cultural context
The Italian Resuscitation Council, in its guidelines, recommends "offering family members of patients in cardiac arrest the opportunity to be present during CPR maneuvers, in cases where this opportunity can be offered." The wording, however, remains generic and does not provide specific operational guidance for the prehospital context.
This lack of specificity leaves broad discretion to providers, resulting in heterogeneous applications across different EMS systems and even within the same system, depending on individual professionals' sensitivity.
A study published in the Italian Journal of Emergency Medicine found that 57% of Italian providers are favorable to family presence during resuscitation, a percentage significantly higher than the international average (20-35% in Anglo-Saxon countries). This data suggests a favorable cultural predisposition that has not yet translated into standardized protocols.
The literature identifies as the main critical issue the "poor preparation of prehospital emergency personnel in managing these types of events, particularly the relational aspect with families, especially in case of patient death." This training gap creates a paradox: providers culturally predisposed to family inclusion but lacking the technical tools to manage it effectively.
The case study: Valle d'Aosta
A particular observation emerges from analyzing the established practice in the system where I work, the Valle d'Aosta EMS, where there is a habitual but unstructured application of principles largely consistent with the WOLS approach.
Observed elements:
Family inclusion: When scene safety conditions permit and family members express the desire to be present, access during resuscitative maneuvers is facilitated. The decision is made case-by-case by the team leader, typically the team physician.
Emergency psychologist intervention: A distinctive element of the Valle d'Aosta model, this figure intervenes to support families in case of death, both on-scene and in the hours/days following the event.
This latter element represents an evolution of the WOLS model proposed by Braude: the presence of a professional figure dedicated to immediate psychological support constitutes an integration of the framework that could represent an original Italian contribution to international literature.
Facilitation of contact: On this element, suggested by Braude, I must admit we still need to work more; we should push to ensure that, before cessation of maneuvers, when clinically appropriate, family members are given a brief moment of physical contact with the patient.
The gap between practice and theory: the need for a scientific framework
Observation of these practices highlights a recurring pattern in Italian emergency medicine: practical competence acquired through experience and cultural sensitivity, but lack of scientific codification and operational standardization.
Limitations of the unstructured approach
"Case-by-case" management based on individual provider sensitivity presents several critical issues:
Intra and inter-system variability: Application depends on the individual provider's training, experience, and personal predisposition, generating inconsistency in approach even within the same EMS system.
Absence of medical-legal support: Providers who choose to include the family operate in a regulatory vacuum, potentially exposed to challenges in case of adverse outcomes or problematic family reactions.
Lack of outcome data: Without formal protocols and data collection systems, it is not possible to evaluate the effectiveness of these approaches, identify best practices, or areas for improvement.
Training gap: The literature identifies as the main critical issue the poor preparation of prehospital providers in managing the relational aspect with families, particularly in communicating death. The absence of structured training perpetuates reliance on personal abilities alone.
Perspectives and future directions
Braude and colleagues' article opens an important discussion on death management in the prehospital setting, proposing a conceptual framework (WOLS) that redefines TOR as a deliberate withdrawal process rather than an abrupt cessation.
Observation of already existing practices in the Italian context, particularly the Valle d'Aosta experience with the integration of the emergency psychologist, suggests that these principles can be successfully implemented. However, the lack of formalization and scientific validation represents a missed opportunity.
Research needs
Several areas require scientific investigation:
Family outcomes: Prospective studies evaluating the incidence of PTSD, anxiety disorders, depression, and complicated grief in family members who witnessed vs did not witness resuscitation in the prehospital context.
Provider outcomes: Analysis of the impact of the WOLS approach on burnout, moral distress, and professional satisfaction of EMS providers.
Emergency psychologist effectiveness: Quantitative evaluation of outcomes of the Valle d'Aosta model, with particular focus on cost-effectiveness and sustainability.
Implementation barriers: Identification of practical, organizational, and cultural obstacles to implementing FWR and WOLS protocols in different Italian EMS systems.
Conclusions
Braude's proposal to recontextualize TOR as WOLS finds confirmation in already existing but unformalized practices in the Italian context. The challenge is not to import an external model, but to recognize, codify, and scientifically validate approaches that emerge from clinical practice.
The integration of the emergency psychologist observed in Valle d'Aosta represents a potentially significant evolution of the WOLS model that requires systematic evaluation.
The transition from "acquired culture" to "scientific method" requires investment in research, training, and protocol development, but offers the opportunity to improve both outcomes for patients and families and the well-being of EMS providers.
References:
- Braude D, DeFilippo M, George N, LaPrise R, Pruett K. Reframing Prehospital Termination of Resuscitation as Withdrawal of Life Support: Applying Lessons from the ICU in the Prehospital Setting. Prehospital Emergency Care. 2025. DOI: 10.1080/10903127.2025.2554914
- Italian Resuscitation Council (2021). European Resuscitation Council Guidelines 2021: Ethics of Resuscitation and End-of-Life Decisions (Chapter 12). Italian translation by IRC.
- Monti M, Prati G, Caligari S. Family members during emergencies: hindrance or resource? What do healthcare providers think? Field research. Italian Journal of Emergency Medicine. 2014;10(1):11-22.
- PTEP (Psychological Trauma in EMS Patients) - National Association of Emergency Medical Technicians
- Emergency Resilience Course - Alexandra Jabr, Ph.D., EMT-P
