Virginia Do Not Resuscitate Order (DNR) Form

DNR stands for Do-Not-Resuscitate. This document shows a patient’s will to exercise their right to reject resuscitation and die a natural death due to an accident, illness, or old age. When a person chooses to reject such medical help, they need a legal document to make that possible. In the United States, this document is called a DNR Order.

Each state has its form of DNR order. The forms differ in structures and sign requirements. However, the core of such documents is always the same: they provide patients with the right to reject resuscitation treatment, including the following set of procedures:

  • Indirect heart massage
  • Mouth-to-mouth breathing
  • Defibrillation
  • Breathing assistance
  • Administering medications

In each state, DNR programs are regulated by different administrative rules and laws. In Virginia, the DNR program is subject to regulation by § 54.1-2987.1 of the Code of Virginia. To sign a DNR form in Virginia, you will need a patient and a physician.

The Structure of the Virginia DNR Order Form

The Virginia DNR Order Form is a five-page document. The first two pages contain general information about the DNR form.

The sections include:

  • Purpose. Describes what the DNR form is used for.
  • Applicability. Explains that the form serves as a legal document and is honored by any medical personnel throughout the state.
  • Instructions. A vast section with five subchapters that delve deeper into the use of the document.
  • Revocation. This section explains how a patient can revoke (cancel) the activated DNR order.
  • Signature of the patient. This section explains the aftermath of signing the document. It reminds the patient that they can revoke the order at any time and deals with several related issues.

The form itself starts on page 3—that’s where a patient and their physician should go to fill out the form. The two must fill out two subsequent pages that contain identical information.

It is necessary because each page—starting with page 3—has its purpose:

  • Page 3 should be kept by the patient
  • Page 4 should be kept by the physician
  • Page 5 should be used to order DNR jewelry—a DNR ID device that the patient can wear as a bracelet or a necklace. Such ID jewelry is also honored to identify that its owner has the DNR order to reject CPR procedures.
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Download your fillable Virginia DNR form in PDF format.

How to Fill Out the Virginia DNR Order Form?

A patient and a physician fill out the pages of the Virginia DNR form.

1. Provide the Patient’s Personal Information

step 1 to filling out the virginia dnr form - provide the patients personal information

First, the patient writes down their full name and puts down the date of signing.

2. Have a Physician Specify the Patient’s Health Status

step 2.1 to filling out the virginia dnr form - have a physician specify the patients health status

Then, the physician must check one of the two boxes to specify if the patient can make decisions or is not capable of doing so.

step 2.2 to filling out the virginia dnr form - have a physician specify the patients health status

Suppose the patient is not capable of making decisions regarding their health and life. In that case, the physician must check one of three boxes in the next section to specify if the patient—while being capable of making decisions—has either executed an advanced directive to reject CPR or has appointed a legal representative to act on their behalf, or has never done any of that. If they have not, the DNR form should be signed by a person authorized to act on the patient’s behalf.

3. Make the Patient and the Physician Affix Their Signatures

step 3.1 to filling out the virginia dnr form - make the patient and the physician affix their signatures

On the bottom part of the page, the patient and the physician must put down their signatures.

step 3.2 to filling out the virginia dnr form - make the patient and the physician affix their signatures

The physician must also input their printed name and emergency phone number.

Published: Oct 18, 2021