DNR Form Missouri: OHDNR vs TPOPP and Which One Paramedics Actually Follow

Missouri Has Two DNR-Type Forms (and the Rules Just Changed)

If you're looking for a DNR form in Missouri, you need to understand that the state has two distinct clinical orders — and a major law change in December 2024 fundamentally shifted which one carries legal weight.

Outside-of-Hospital DNR (OHDNR) — The legacy form. A purple card (exactly 3 7/16 × 4 1/8 inches) that instructs EMS to withhold CPR during cardiac or respiratory arrest. Governed by RSMo 190.600–190.621.

Transportable Physician Orders for Patient Preferences (TPOPP) — Missouri's version of the national POLST form. Covers CPR, medical interventions (comfort care through full treatment), and artificial nutrition. Now valid 24/7 across all settings since December 30, 2024.

The December 2024 Law Change

Before December 30, 2024, Missouri EMS had a serious legal problem. Paramedics arriving at a home were legally required to perform full CPR even if they found a signed TPOPP form — because state law only granted "ambulance indemnity" (legal protection from liability) for following the purple OHDNR card.

The 2024 statutory amendment extended full ambulance indemnity to the TPOPP form. This means Missouri paramedics can now legally honor TPOPP orders in all settings — home, EMS transport, emergency rooms, nursing facilities — without risk of legal liability.

In practice, the TPOPP has replaced the OHDNR as the more comprehensive and practical document. The OHDNR remains legally valid, but it only covers one scenario (cardiac/respiratory arrest) and becomes completely invalid the moment you're admitted to a hospital.

OHDNR vs TPOPP: Key Differences

Scope: The OHDNR addresses only CPR. The TPOPP covers CPR plus medical interventions (antibiotics, IV fluids, hospitalization preferences) plus artificial nutrition decisions.

Setting: The OHDNR works only outside hospitals. Upon inpatient admission, it's void — you default to full code until a physician writes new inpatient orders. The TPOPP follows you through all care transitions without needing re-execution.

Flexibility: The OHDNR is binary — resuscitate or don't. The TPOPP allows "time-limited trials" (try a ventilator for one week, then reassess) and graduated intervention levels between comfort-only and full treatment.

Format: The OHDNR must be printed on purple card stock in exact dimensions. The TPOPP uses standard colored paper, and copies, faxes, and digital scans are all legally valid.

How to Get a DNR/TPOPP in Missouri

Neither form is something you fill out yourself. Both require a licensed physician's signature to be legally valid.

Step 1: Have a conversation with your physician about your goals of care. This isn't a one-minute checkbox exercise — it's a clinical discussion about what "doing everything" actually looks like for your specific medical situation.

Step 2: Your physician completes and signs the TPOPP form based on your expressed preferences. You (or your legally authorized representative — a DPOA-HC agent, guardian, or default surrogate) also sign.

Step 3: The original form stays with you. Copies go to your medical record, any facility where you receive care, and your healthcare agent.

Who Should Have a TPOPP

A TPOPP is appropriate for people with:

• Serious illness where resuscitation would likely be ineffective or contrary to their goals
• Advanced age with frailty and declining health trajectory
• Terminal diagnosis with a preference for comfort-focused care
• Chronic conditions requiring frequent hospitalization

A TPOPP is generally not appropriate for healthy adults doing standard advance care planning. For those situations, a DPOA-HC and Health Care Choices Directive provide the right level of planning without the clinical specificity of physician orders.

How a DNR Relates to Your Advance Directive

A common misconception: your advance directive (DPOA-HC + Health Care Choices Directive) and a TPOPP/DNR are not the same thing and don't replace each other.

Your advance directive documents your wishes and names your decision-maker. It's a planning document.

A TPOPP/OHDNR is a physician's medical order — an actionable clinical instruction that paramedics and nurses follow immediately without interpretation.

Think of it this way: your advance directive is the input. The TPOPP is the output. Your physician uses your documented wishes (and a clinical conversation) to translate your preferences into specific medical orders that first responders can execute in seconds.

The Missouri Advance Directive & Living Will Kit covers the full planning sequence: executing your DPOA-HC and Directive first, then having the TPOPP conversation with your physician from a position of documented clarity rather than improvising under pressure.

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