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A Virginia DNR form is a written Do Not Resuscitate order that tells health care personnel not to start cardiopulmonary resuscitation (CPR) for the patient named on it. Virginia calls its form a Durable Do Not Resuscitate (DDNR) Order. It needs a physician's signature and the signature of the patient or of the person authorized to consent for the patient.[1] Fill it out online or download it as a PDF.
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A Virginia Durable DNR Order is the state form that records a patient's decision to forgo resuscitation. The printed order directs qualified health care personnel to withhold cardiopulmonary resuscitation if the patient's heart or breathing stops. The form lists these procedures:
The same order directs personnel to still provide other medical interventions, such as intravenous fluids, oxygen, or other therapies needed for comfort care or to relieve pain.
Virginia sets the contents of the Durable DNR Order Form in 12VAC5-66-40 of the Virginia Administrative Code. The form must contain a do not resuscitate determination, plus a signature and the date of issue, from a physician who has a bona fide physician-patient relationship with the patient. It must also carry the signature of the patient or, if applicable, the person authorized to consent on the patient's behalf.[1]
A Durable DNR Order Form shall contain, from a physician with whom the patient has a bona fide physician-patient relationship, a do not resuscitate determination, signature and the date of issue, the signature of the patient, or, if applicable, the person authorized to consent on the patient's behalf.
A complete Virginia DNR order therefore has three parts:
Three identical Durable DNR Order Forms must be filled out and distributed as the rule directs. An original or a legible photocopy of the Durable DNR Order Form, POST form, or POLST form must be readily available to health care personnel at the patient's current location.[1]
A durable DNR order stays in effect until it is revoked under § 54.1-2987.1 of the Code of Virginia. It also ends if the provider who issued it rescinds it, following accepted medical practice.[1]
Under § 54.1-2987.1 of the Code of Virginia, a physician may issue a Durable Do Not Resuscitate Order for a patient with whom the physician has a bona fide physician-patient relationship, and only with the patient's consent. If the patient is a minor or is otherwise incapable of making an informed decision about consent, the order needs the request and consent of the person authorized to consent on the patient's behalf.[2]
The form's Applicability section says any qualified health care personnel may honor it. That term covers qualified emergency medical services personnel. It also covers any licensed health care provider or practitioner working in a facility, program or organization that the State Board of Health or another state agency operates, licenses or owns. A licensed practitioner at a continuing care retirement community is covered too.
The form's Instructions add two points about where it applies:
The Signature of the Patient section also warns that personnel who have doubts about whether the order applies or is valid will begin CPR.
The form's Revocation section says the patient, or an authorized decision maker who initiated the order, may revoke a Durable DNR Order at any time. There are two ways to do it:
If an Other DNR Order also exists and is revoked, the form says health care personnel should make sure the revocation is honored by updating or destroying that order. Under Virginia's rule, an order also ends when the provider who issued it rescinds it.
The Virginia DNR Order Form is a five-page document. The first two pages contain general information about the DNR form. The order itself starts on page 3 and repeats in identical form on pages 4 and 5.
The general information pages have these sections:
The form labels each of the three order pages with a copy number:
The form's title is Durable Do Not Resuscitate Order. Its instructions shorten that name to DDNR.
Copy 3 is the copy used to order DDNR jewelry, a necklace or bracelet. The form says it must show the words Do Not Resuscitate, the patient's full legal name, the physician's name and phone number, and the Virginia Durable DNR issuance date.
A patient and a physician fill out the Virginia DNR form together. You complete page 3 first, then repeat the same entries on pages 4 and 5, which duplicate page 3 as Copy 2 and Copy 3. The six steps below follow the form from top to bottom.
Step 1: Patient's Full Legal Name and Date
At the top of page 3, write the patient's full legal name and the date on the lines marked Patient's Full Legal Name and Date.
Step 2: Check Box 1 or 2 for the Patient's Capacity
Below the printed Physician's Order, the physician must check 1 or 2. Check 1 if the patient is capable of making an informed decision about medical treatment. The form says the patient's signature is required with 1. Check 2 if the patient is incapable of making that decision.
Step 3: If You Checked 2, Check A, B, or C
Only when 2 is checked, the physician also checks one of three boxes:
The form describes a written advance directive as a living will or a durable power of attorney for health care. FormsPal has a Virginia living will and a Virginia power of attorney. You can also read what a living will is and see the medical power of attorney form.
Step 4: Physician's Printed Name, Signature, and Emergency Phone Number
The physician prints their name, signs on the Physician's Signature line, and writes a phone number on the Emergency Phone Number line.
Step 5: Patient's Signature or Signature of Person Authorized to Consent
The patient signs on the Patient's Signature line. When box 2 is checked, the person authorized to consent signs on the line marked Signature of Person Authorized to Consent on the Patient's Behalf.
Step 6: Complete Copy 2 and Copy 3
Pages 4 and 5 repeat page 3. Fill out Copy 2 (page 4) and Copy 3 (page 5) with the same entries and signatures. Virginia's rule calls for three identical forms.[1]
Most problems come from a missing check mark or a missing signature. The items below come from the printed wording of the Virginia form and from the state rule on signatures.[1]
Once the form is complete, keep it where health care personnel can reach it. For other Virginia paperwork, see FormsPal's Virginia forms page.
A physician with whom you have a bona fide physician-patient relationship completes the Durable DNR Order Form. The form carries the physician's do not resuscitate determination, signature and date of issue. It also carries the signature of the patient or the person authorized to consent on the patient's behalf. Three identical forms must be filled out and distributed.[1]
In Virginia, a Durable DNR Order Form needs the physician's determination, signature and date of issue, and the signature of the patient or the person authorized to consent. An original or a legible photocopy must be readily available to health care personnel at the patient's current location.[1]
No. The Virginia rule says a Durable DNR Order Form must contain a physician's do not resuscitate determination, signature and the date of issue. A form without the physician's signature lacks what the rule requires.[1]
General information, not legal or tax advice.