OBJECTIVES: Many emergency medical services (EMS) 9-1-1 activations result in patients declining evaluation, treatment, or transport to the emergency department (ED). Assessment of a patient's decision-making capacity to refuse and taking appropriate actions based on that are critical elements of EMS practice. However, EMS clinician approaches in this area are under-studied, and variation may exist. As EMS practice is highly protocolized, our goal was to examine all publicly available United States (U.S.) state protocols and describe their guidance around refusals. METHODS: We used a structured, multi-step content analysis and published expert recommendations on managing refusal of care in health care settings to identify 35 specific elements within five domains of prehospital refusal management: decision-making capacity assessment, risk assessment, persuasion, escalation to medical oversight, and documentation. We systematically and comprehensively reviewed 34 state protocols and a U.S. national protocol for the presence of these elements. RESULTS: Among 34 state protocols examined, 24% (8) had no guidance on refusal, with 18% (6) including at least some guidance in all domains. Among states with any guidance on refusal, we found a median of 15, a mean of 15, and a range of 5-25 elements included. Three states (9%) discussed all four components of decision-making capacity. Seven (21%) emphasized assessing risk of a severe medical emergency when considering refusal. Guidance on persuasion for high-risk patients was included in 13 (38%). Escalation to direct medical oversight was present in 20 (59%). Only 21 (62%) of protocols provided specific documentation guidelines. Notably, guidance was identified in state protocols that is inconsistent with expert recommendations for management of refusal in the ED. Checklists were included in 4 (12%). CONCLUSIONS: Substantial variability exists among state protocols regarding patient refusal guidance. Few protocols address high-risk patients, provide strategies for persuasion, or include checklists for proper management. Standardizing and expanding protocols may enhance EMS care.