Missouri Do Not Resuscitate (DNR) Order Form
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I, _____________________________, authorize emergency medical services personnel to
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 permis