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Objectives The study aims to define the prevalence of Do-Not-Resuscitate (DNR) orders among patients with shock in the emergency department (ED) and explore their impact on clinical management and mortality outcomes.Design A retrospective observational cohort study was conducted involving patients presenting to the ED with shock.Setting An ED in a tertiary hospital in western China.Participants 2001 patients (aged ≥18 years) presenting to the ED with shock from 1 January 2022 to 31 December 2023.Methods The enrolled patients were divided into DNR (order issued within 24 hours of ED admission)/non-DNR groups. Demographics, vitals, comorbidities, laboratory values, medications and prognoses were obtained from electronic healthcare records. DNR prevalence and its associations with mortality, ICU admission, vasopressor administration and antibiotic administration were assessed via logistic regression.Results Compared with patients without DNR orders, patients with DNR orders (n=399 (19.9%)) were older (p<0.001) and more likely to have comorbidities. DNR status was associated with higher in-hospital (17.8% vs 6.5%, p<0.001) and 30-day (32% vs 12%, p<0.001) mortality. However, there were no significant differences in intensive care unit (ICU) admission (64.2% vs 58.8%, p=0.148), ICU length of stay (41.0 hours vs 45.4 hours, p=0.834) or vasopressor use (29.8% vs 25.5%, p=0.082). Logistic regression analysis revealed that ICU admission was associated with the number of antibiotics (p=0.010), vasopressor use (p<0.001) and initial lactate level (p=0.026) but not DNR status (p=0.650). Furthermore, DNR status neither affected vasopressor administration (OR=0.888, 95% CI: 0.671 to 1.174, p=0.405) nor antibiotic administration (OR=1.484, 95% CI: 1.052 to 2.092, p=0.024).Conclusions Compared with patients with shock in the ED who did not have DNR status, those with DNR status (prevalence ~20%) had higher in-hospital and 30-day mortality (but most survived) and similar ICU admission and intervention treatments.