MISSOURI OUTSIDE-HOSPITAL DO-NOT-RESUSCITATE DIRECTIVE
(“DNR Directive”)
[// GUIDANCE: This template is drafted to comply with the Missouri “Outside the Hospital Do-Not-Resuscitate Act,” Mo. Rev. Stat. §§ 190.600 – 190.621, and current Department of Health & Senior Services (“DHSS”) regulations. Customize bracketed fields, obtain all required signatures, and attach any DHSS-issued standardized form or medical bracelet/necklace order confirmation.]
DOCUMENT HEADER
1. Parties & Identification
1.1 Declarant: [PLACEHOLDER – Full Legal Name of Patient] (“Declarant”)
1.2 Attending Physician/APRN: [PLACEHOLDER – Name & Missouri License No.] (“Physician”)
1.3 Health-Care Facility (if any): [PLACEHOLDER]
1.4 Emergency Medical Services (“EMS”) Agencies: Any licensed Missouri EMS personnel responding to Declarant.
2. Effective Date & Jurisdiction
This DNR Directive becomes effective on the later of (i) the date executed by the Declarant and Physician, or (ii) the date indicated in Section X below, and is governed exclusively by Missouri state health-care law, including Mo. Rev. Stat. §§ 190.600 – 190.621.
3. Recitals
A. Declarant is a competent adult (or legally authorized representative) who desires to direct that no cardiopulmonary resuscitation (“CPR”) be attempted in the event of cardiac or respiratory arrest occurring outside a hospital.
B. Physician has explained the nature, consequences, and alternatives to a DNR order and concurs with Declarant’s decision.
C. This Directive is executed to ensure EMS and all Health-Care Providers may rely on Declarant’s wishes in good faith and without liability.
TABLE OF CONTENTS
I. Definitions
II. Operative Provisions
III. Representations & Warranties
IV. Covenants & Restrictions
V. Revocation & Amendment
VI. Risk Allocation
VII. General Provisions
VIII. Execution Block
I. DEFINITIONS
“Act” – The Missouri Outside the Hospital Do-Not-Resuscitate Act, Mo. Rev. Stat. §§ 190.600 – 190.621.
“Cardiopulmonary Resuscitation” or “CPR” – Chest compressions, manual or mechanical ventilation, defibrillation, endotracheal intubation, administration of advanced cardiac life support medications, or other related interventions intended to restore cardiopulmonary function.
“DNR Order” – A medical order, signed by a Physician, directing that CPR not be initiated.
“Declarant” – The individual identified in Section 1.1 or that individual’s court-appointed guardian, attorney-in-fact for health care, or other legally authorized representative acting under Mo. Rev. Stat. § 404.820.
“EMS Personnel” – Licensed first responders, emergency medical technicians, paramedics, or ambulance services operating under Chapter 190, RSMo.
“Good Faith” – Honesty in fact and the reasonable belief that the action is in accordance with applicable professional standards.
“Health-Care Provider” – Any person licensed, certified, or otherwise authorized to administer health-care services in Missouri.
II. OPERATIVE PROVISIONS
2.1 DNR DIRECTIVE
(a) Upon the occurrence of cardiac or respiratory arrest outside a hospital, EMS Personnel and all Health-Care Providers shall not initiate CPR on the Declarant.
(b) Permissible comfort-care measures (e.g., airway suctioning, oxygen delivery, pain medication) may be provided.
2.2 SCOPE & EMS RECOGNITION
(a) This Directive is valid in all non-hospital settings within Missouri and must be honored by EMS Personnel when:
(i) Presented with (1) this signed Directive or (2) a DHSS-approved DNR identification (bracelet/necklace); and
(ii) The Declarant is found in cardiopulmonary arrest.
(b) If uncertainty exists regarding validity, EMS Personnel shall provide standard life-support until confirmation is obtained, consistent with § 190.608.
2.3 LIMITATIONS
(a) This Directive does not affect:
(i) The provision of non-CPR medical interventions;
(ii) Obligations of hospital personnel once the Declarant is admitted;
(iii) Organ-donation measures consented to separately.
(b) Nothing herein authorizes euthanasia or assisted suicide.
III. REPRESENTATIONS & WARRANTIES
3.1 Declarant represents and warrants that:
(a) They are at least 18 years of age and of sound mind, or the signatory is otherwise legally authorized.
(b) Execution of this Directive is voluntary and not the result of duress or undue influence.
(c) They have discussed the medical consequences with the Physician and had the opportunity to ask questions.
3.2 Physician represents and warrants that:
(a) They hold an active Missouri medical license;
(b) In their professional judgment, the Declarant understands the nature and consequences of the Directive;
(c) They will duly enter a corresponding DNR Order in the Declarant’s medical record in accordance with § 190.603.
[// GUIDANCE: Include any facility-specific policy acknowledgments here if executed within a long-term care center.]
IV. COVENANTS & RESTRICTIONS
4.1 Declarant covenants to:
(a) Maintain the original executed Directive in an accessible location;
(b) Inform close family members, legal guardians, and any health-care proxy of its existence;
(c) Present, or cause to be presented, the Directive or DNR identification to EMS Personnel when reasonably possible.
4.2 Physician covenants to:
(a) Provide copies of the executed Directive to the Declarant and facility (if any);
(b) Review the Directive’s continued suitability at each significant change in Declarant’s condition.
V. REVOCATION & AMENDMENT
5.1 REVOCATION BY DECLARANT
(a) The Declarant may revoke this Directive at any time by:
(i) A written revocation signed and dated by the Declarant;
(ii) An oral statement to EMS Personnel or a Health-Care Provider in the presence of at least two (2) witnesses; or
(iii) Destruction of the original Directive and any DNR identification.
(b) Upon revocation, Declarant shall promptly notify the Physician and, if applicable, return any DHSS-issued bracelet/necklace.
5.2 AMENDMENT
Amendments must:
(a) Comply with all execution formalities herein; and
(b) Expressly state that the prior Directive is superseded.
VI. RISK ALLOCATION
6.1 INDEMNIFICATION – PROVIDER PROTECTION
Declarant (or Declarant’s estate) shall indemnify and hold harmless EMS Personnel and Health-Care Providers from any civil or criminal liability arising from honoring this Directive in good faith pursuant to § 190.606.
6.2 LIABILITY CAP – GOOD FAITH STANDARD
No party shall be liable for damages under this Directive beyond those resulting from gross negligence or willful misconduct.
6.3 FORCE MAJEURE
Performance is excused to the extent compliance is prevented by circumstances beyond the reasonable control of EMS Personnel (e.g., disaster triage protocols).
VII. GENERAL PROVISIONS
7.1 Governing Law. This Directive is governed by Missouri law.
7.2 Severability. If any provision is held invalid, the remaining provisions shall remain in full force and effect.
7.3 Integration. This document, together with any attached DHSS standardized form, constitutes the entire DNR agreement between the parties.
7.4 Counterparts & Electronic Signatures. This Directive may be executed in counterparts and by electronic signature, each of which is deemed an original.
VIII. EXECUTION BLOCK
[// GUIDANCE: Missouri permits either two (2) adult witnesses OR a notary. If a legal representative signs, provide documentation of authority.]
A. DECLARANT
Signature: _______
Printed Name: _____
Date: ___
B. WITNESSES (must be 18 + and not related by blood, marriage, or adoption; may not be the Physician or a health-care provider directly involved in care)
-
Witness #1 Signature: _____ Date: _
Printed Name & Address: ____ -
Witness #2 Signature: _____ Date: _
Printed Name & Address: ____
— OR —
NOTARY PUBLIC
State of Missouri )
County of ___) ss.
On this _ day of _, 20__, before me, the undersigned Notary Public, personally appeared [PLACEHOLDER – Declarant Name], known to me (or satisfactorily proven) to be the person whose name is subscribed to the foregoing instrument and acknowledged that they executed the same for the purposes therein contained.
Notary Public Signature: _____
My Commission Expires: _________
C. PHYSICIAN / ADVANCED PRACTICE REGISTERED NURSE
I, the undersigned Missouri-licensed [Physician / APRN], hereby issue a Do-Not-Resuscitate Order consistent with this Directive.
Signature: ______
Printed Name & Credentials: _____
Missouri License No.: ______
Date: ____
OPTIONAL ATTACHMENTS
A. Copy of DHSS Standardized “Outside Hospital DNR” Form
B. Proof of DNR Bracelet/Necklace Order
C. Documentation of Health-Care Power of Attorney or Guardianship
[// GUIDANCE: 1) File copies with primary care providers; 2) Upload to any available electronic registry; 3) Place on refrigerator or other EMS-visible location at Declarant’s residence.]