Implementation gap in prehospital termination-of-resuscitation policies for out-of-hospital cardiac arrest with do-not-attempt-cardiopulmonary-resuscitation wishes in Japan: a nationwide survey.

Aim: We evaluated the nationwide availability of prehospital termination-of-resuscitation (TOR) policies for out-of-hospital cardiac arrest (OHCA) with do-not-attempt-cardiopulmonary-resuscitation (DNACPR) wishes in Japan, and quantified the implementation gap between policy adoption and operational use. Methods: We conducted a nationwide cross-sectional survey of all prefecture-level and regional medical control councils and fire departments in Japan. The primary outcome was the fire-department-level crude operational application rate among departments with a policy in place. Results: Responses were obtained from 46 of 47 prefecture-level medical control councils (98%), 129 of 250 regional medical control councils (52%), and 561 of 791 fire departments (71%). A prehospital TOR policy for OHCA patients with DNACPR wishes was available in 265 of 561 fire departments (47%). Among 391 fire departments reporting at least one OHCA with DNACPR wishes in 2024, 156 had a policy in place. Among 151 with evaluable data, 78 (52%) did not apply the policy to any such case during the study year; 35 of these departments reported three or more DNACPR cases. Departments with a policy reported fewer transports with ongoing cardiopulmonary resuscitation than departments without a policy (46% vs. 82%, adjusted OR, 0.17; 95% CI, 0.09-0.30). Conclusion: Although prehospital TOR policies for OHCA patients with DNACPR wishes were available in nearly half of fire departments, implementation was highly heterogeneous: more than half of departments with a policy reported a crude operational application rate of 0% during the study year, despite encountering relevant cases. Efforts to improve operational uptake may be as important as policy development itself.