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Circulation. 2025;152(suppl 2):S538–S577. DOI: 10.1161/CIR.0000000000001376 October 21, 2025 S557 Wigginton et al Advanced Life Support: 2025 AHA Guidelines for CPR and ECC TERMINATION OF RESUSCITATIVE MEASURES Recommendations for Termination of Resuscitation COR LOE Recommendations 1 B-NR 1. When TOR is being considered, BLS prehospital professionals should use the BLS TOR rule for adult patients in OHCA, where ALS is not available or may be significantly delayed. 2a B-NR 2. It is reasonable for ALS prehospital professionals to use the ALS TOR rule to terminate resuscitation efforts in the field for adult patients with OHCA. 2a B-NR 3. In a tiered EMS system with both ALS and BLS professionals, it is reasonable to use the Universal TOR rule for adult patients with OHCA. 2b C-LD 4. In intubated adult patients, failure to achieve an end-tidal CO2 of greater than 10 mm Hg by waveform capnography after 20 minutes of ALS resuscitation may be considered as a component of a multimodal approach to decide when to end resuscitative efforts. 3: Harm C-EO 5. In nonintubated adult patients, a specific end-tidal CO2 cutoff value at any time during CPR should not be used as an indication to end resuscitative efforts. Synopsis OHCA is a resource-intensive condition associated with low rates of survival. It is important for EMS professionals to differentiate patients in whom continued resuscitation is futile from patients with a chance of survival who should receive continued resuscitation and transportation to hospital. This will aid in both resource use and optimizing a patient’s chance for survival. Using a validated TOR rule will help ensure accuracy in determining futility in cardiac arrest patients. Though many TOR rules have been proposed,3 TOR rules that have been highly studied in North America include the BLS, ALS, and UTOR rules (Figures 3 and 4). TOR rules are applicable for the specific scope of practice of the EMS agency upon which they were validated. For example, an EMS agency with only BLS-trained professionals (first responders or emergency medical technicians [EMTs]) the BLS TOR rule is appropriate; for an EMS agency with only ALS-trained professionals, the ALS TOR rule is appropriate; and for an agency or system with both BLS- and ALS-trained professionals (commonly referred to as a tiered-response system) the UTOR rule is appropriate. These TOR rules are inappropriate for populations in which they have not been validated, such as for patients with overdose, trauma, or IHCA. Further research is needed to evaluate the appropriate application of existing TOR rules to gain a clearer understanding of the risks and benefits associated with their use. Recommendation-Specific Supportive Text 1 In a meta-analysis of 7 published BLS TOR studies primarily in North America (33 795 patients pooled from retrospective and prospective observational studies), only 0.13% (95% CI, 0.03%–0.58%) of patients who fulfilled the BLS termination criteria survived to hospital discharge.1 A 2024 international meta-analysis2 of 6 reclassified retrospective validation studies from EMS systems primarily in Asia suggests that the specificity of the BLS rule, when generalized outside of North America may be lower than previously reported. The analysis reclassified EMS agencies, included heterogeneous methodologies and response characteristics, and relied heavily on retrospective data. These limitations highlight the importance of further rigorous, prospective research to validate the specificity and applicability of BLS TOR rules by diverse EMS agencies. 2. In a meta-analysis of 2 published retrospective observational studies (10 178 patients) of the ALS TOR rule, only 0.01% (95% CI, 0.00%–0.07%) of patients who fulfilled the ALS termination criteria survived to hospital discharge.1 The same 2024 international meta- analysis described above2 analyzed 17 published studies on ALS TOR patients, finding a pooled specificity of 96% (95% CI, 0.93–0.99). Figure 4. ALS Termination of Resuscitation Rule. ALS indicates advanced life support; and CPR, cardiopulmonary resuscitation. Figure 3. BLS/Universal Termination of Resuscitation Rules. AED indicates automated external defibrillator; and BLS, basic life support. Downloaded from http://ahajournals.org by on October 7, 2026