Study objective: Prior research has established the futility of continued resuscitation efforts for patients in cardiac arrest who fail to respond to out-of-hospital advanced cardiac life support. Determination of both medical and nonmedical factors resulting in the transport of patients in continuing cardiac arrest to the hospital may encourage the development of new systems or strategies to increase the appropriateness of these transports. Methods: The attending paramedic completed a prospective survey after unsuccessful resuscitation efforts in our urban, hospital-based, two- tier emergency medical services (EMS) system. All nontraumatic adult arrests were included unless they were clearly noncardiac in nature. Results: Paramedics responded to 259 cardiac arrests between September 12, 1996, and April 31, 1997. Seventy-nine patients were pronounced dead without resuscitation efforts. Of the remaining 180 patients, 44 had return of spontaneous circulation and were transported to the hospital, 68 were pronounced dead in the field, and 68 were transported to the hospital in continuing cardiac arrest. The 68 patients transported while in cardiac arrest are the focus of this study. Rare problems with field termination were identified. Reasons for transport of the 68 patients in continuing cardiac arrest included arrest in ambulance or going to ambulance (n=6), arrest in a public place (n=17), environmental factors (n=6), road hazard to paramedics (n=l), possible reversible cause (n=4), persistent ventricular dysrhythmia (n=5), no intravenous access (n=5), airway difficulties (n=5), family unable to accept field termination (n=3), cultural or language barrier (n=1), EMS physician ordered transport (n=1), and obesity (n=1). A protocol allowing pronouncement of death in the ambulance and transport of the body to a designated area could have prevented lights-and-siren transport to the emergency department in 24 of the 68 cases. Conclusion: Factors other than medical ones often influence the decision to transport patients in continuing cardiac arrest. In our urban system, physician, medical examiner, and paramedic education and protocols were needed to aid decisionmaking in this situation.