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Wilderness travelers, outdoor instructors, guides, and Wilderness EMS personnel benefit from clear guidelines or protocols that address the unique circumstances encountered in the wilderness and remote settings regarding starting, withholding, and terminating resuscitation efforts for people in cardiac arrest. Because the chance of return of spontaneous circulation (ROSC) and survival with intact neurological function decreases exponentially with any delay or break in the AHA chain of survival, overall outcomes, universally poor in an urban context, are even worse in the wilderness. On-scene personnel may not have the medical, rescue, or outdoor training and experience to make an accurate risk-benefit analysis. For example, If a physician is present, they may not have the training or expertise to assess the hazards associated with a technical rescue or evacuation or know how to mitigate any environmental risks; the same holds for EMS professionals. Conversely, while many outdoor instructors and guides have the training and technical experience to assess and mitigate any risks associated with a rescue or technical evacuation, or adverse environmental conditions, they may not have the required medical training or experience to evaluate the patient’s likelihood of survival with neurological functioning intact. In addition, many outdoor programs and most recreationalists do not have timely or reliable communication with outside agencies that may be able to offer assistance. The following algorithm provides a data-driven template for a termination of resuscitation (TOR) protocol for recreationalists, outdoor trip leaders, guides, and wilderness EMS personnel; medical directors can modify the algorithm to align with regional laws and response times.  Click image to download a pdf file copy. Want to learn more about wilderness medicine? Take one of our courses. Guides and expedition leaders should consider taking our Wilderness First Responder course. Looking for a reliable field reference? Consider consider purchasing one of our print or digital handbooks; our digital handbook apps are available in English, Spanish, and Japanese. Updates are free for life. A digital SOAP note app is also available. Supplemental Reading 
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