Official Virginia Do Not Resuscitate Order Document

Official Virginia Do Not Resuscitate Order Document

A Virginia Do Not Resuscitate (DNR) Order is a legal document that allows individuals to express their wishes regarding medical treatment in the event of a life-threatening situation. This form ensures that if a person's heart stops beating or they stop breathing, healthcare providers will not perform cardiopulmonary resuscitation (CPR) or other life-saving measures. Understanding how to properly complete and implement this form is crucial for anyone considering their end-of-life care options.

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In the realm of healthcare decision-making, the Virginia Do Not Resuscitate (DNR) Order form serves as a critical tool for individuals wishing to express their preferences regarding life-sustaining treatments. This legally binding document allows patients to communicate their desire not to receive cardiopulmonary resuscitation (CPR) in the event of a cardiac or respiratory arrest. The DNR form is designed to ensure that a person's wishes are respected, particularly during emergencies when they may be unable to voice their decisions. Key aspects of the form include the requirement for it to be signed by a physician, the necessity for it to be prominently displayed or easily accessible, and the importance of discussing its implications with family members and healthcare providers. Additionally, the DNR Order is part of a broader conversation about advance care planning, which encourages individuals to consider their values and preferences regarding medical treatment as they face serious health conditions. Understanding the nuances of the Virginia DNR Order form can empower individuals to take charge of their healthcare choices and ensure their wishes are honored in critical moments.

Preview - Virginia Do Not Resuscitate Order Form

Virginia Do Not Resuscitate Order Template

This document serves as a Do Not Resuscitate Order in accordance with the laws of the Commonwealth of Virginia. It reflects the wishes of the individual named below regarding the withholding of cardiopulmonary resuscitation (CPR) in the event of cardiac or respiratory arrest.

Please complete all sections of this form.

Patient Information:

  • Name: _______________________________
  • Birth Date: __________________________
  • Address: _____________________________
  • City: _______________________________
  • State: Virginia
  • Zip Code: ____________________________

Medical Information:

  • Primary Physician: ________________________
  • Physician Phone Number: __________________
  • Medical Condition: ________________________

In recognition of the patient's right to make decisions concerning their own health, including the right to accept or refuse medical treatment, the undersigned hereby requests and directs that in the event of cardiac or respiratory arrest, no resuscitative measures be initiated or continued.

Authorized Signature:

  • Patient (or legal guardian): _________________________
  • Signature Date: _________________________

Physician Acknowledgment:

I, the undersigned physician, certify that I have discussed the implications of this Do Not Resuscitate Order with the patient and/or their legal guardian. I have explained that this order will direct health care providers to withhold cardiopulmonary resuscitation in the case of cardiac or respiratory arrest.

  • Physician's Name: _________________________
  • License Number: __________________________
  • Signature: ________________________________
  • Date: ____________________________________

This order is based upon the patient's known desires, condition, and the medical judgment of the attending physician. This order is to remain in full force and effect until revoked by the patient or their legal guardian.

Note: It is the responsibility of the patient or their legal representative to notify and provide a copy of this Do Not Resuscitate Order to current and future health care providers.

File Specifics

Fact Name Details
Definition A Do Not Resuscitate (DNR) Order is a legal document that indicates a person's wish not to receive cardiopulmonary resuscitation (CPR) in the event of cardiac arrest.
Governing Law The Virginia Do Not Resuscitate Order is governed by the Code of Virginia ยง 54.1-2980.
Eligibility Any adult with decision-making capacity can create a DNR order. Parents or guardians may create one for minors.
Signature Requirement The form must be signed by the patient or the patient's legal representative, along with a licensed physician.
Form Availability The DNR order form is available through healthcare providers, hospitals, and the Virginia Department of Health website.
Revocation A DNR order can be revoked at any time by the patient or their legal representative, verbally or in writing.
Healthcare Provider Obligations Healthcare providers must honor a valid DNR order and cannot perform CPR if the order is present.
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