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Missouri Do Not Resuscitate Form

The Missouri do not resuscitate form is provided by Missouri Department of Health.

Missouri Do Not Resuscitate Form
Missouri Do Not Resuscitate Form
OUTSIDE THE HOSPITAL DO-NOT-RESUSCITATE (OHDNR) ORDER
I, _____________________________, authorize emergency medical services personnel to
(name)
withhold or withdraw cardiopulmonary resuscitation from me in the event I suffer cardiac or respiratory
arrest. Cardiac arrest means my heart stops beating and respiratory arrest means I stop breathing.
I understand that in the event that I suffer cardiac or respiratory arrest, this OHDNR order will take effect
and no medical procedure to restart breathing or heart functioning will be instituted.
I understand this decision will not prevent me from obtaining other emergency medical care and medical
interventions, such as intravenous fluids, oxygen or therapies other than cardiopulmonary resuscitation
such as those deemed necessary to provide comfort care or to alleviate pain by any health care provider
(e.g. paramedics) and/or medical care directed by a physician prior to my death.
I understand I may revoke this order at any time.
I give permission for this OHDNR order to be given to outside the hospital care providers (e.g.
paramedics), doctors, nurses, or other health care personnel as necessary to implement this order.
I hereby agree to the “Outside The Hospital Do-Not-Resuscitate” (OHDNR) Order.
PatientPrinted or Typed Name
Date
Patient’s Signature or Patient Representative’s Signature
Date
REVOCATION PROVISION
I hereby revoke the above declaration.
Patient’s Signature or Patient Representative’s Signature Date
I AUTHORIZE EMERGENCY MEDICAL SERVICES PERSONNEL TO WITHHOLD OR WITHDRAW
CARDIOPULMONARY RESUSCITATION FROM THE PATIENT IN THE EVENT OF CARDIAC OR
RESPIRATORY ARREST.
I affirm this order is the expressed wish of the patient/patient’s representative, medically appropriate and
documented in the patient’s permanent medical record.
Attending Physician’s Signature (Mandatory)
Date
Attending Physician Printed or Typed Name Attending Physician’s
License No.
Attending Physician’s
Telephone No.
AddressPrinted or Typed
Facility or Agency Name
THIS OHDNR ORDER SHALL REMAIN WITH THE PATIENT WHEN TRANSFERRED OUTSIDE THE
HEALTH CARE FACILITY.
Emergency Medical Services personnel shall not comply with an outside the hospital do-not-resuscitate order when
the patient or the patient’s representative expresses to such personnel in any manner, before or after the onset of a
cardiac or respiratory arrest, the desire to be resuscitated or if the patient is or is believed to be pregnant.
Statutory citation 190.600-190.621 RSMo
9/07
Missouri Do Not Resuscitate Form