West Virginia Do Not Resuscitate Order
This Do Not Resuscitate (DNR) Order template is designed according to West Virginia State Laws, specifically addressing the rights and procedures for patients choosing not to undergo cardiopulmonary resuscitation (CPR) in cases of cardiac or respiratory arrest. This document should be completed with the assistance of a qualified healthcare provider.
Patient Information:
- Name: ___________________________________________________
- Address: _________________________________________________
- City: ______________________ State: WV Zip Code: ___________
- Date of Birth: ___________________ Phone: __________________
- Social Security Number: ___________________________________
Medical Provider Information:
- Physician Name: ___________________________________________
- Address: _________________________________________________
- City: ______________________ State: WV Zip Code: ___________
- Phone: ____________________ Fax: _________________________
- West Virginia Medical License Number: ______________________
Under the laws of the State of West Virginia, this Do Not Resuscitate Order acknowledges that the above-named patient has decided against undergoing CPR including medical interventions such as intubation, mechanical ventilation, or defibrillation, should they experience a cardiac or respiratory arrest.
This decision is made with a clear understanding of the patient's medical condition, the probable outcome of resuscitation efforts, and the implications of a DNR order. It is vital that this order be stored in a location that is easily accessible to emergency responders.
Order Instructions
- The patient or their legally authorized representative must sign this document, indicating a voluntary and informed decision to forego resuscitation efforts.
- This document must be witnessed by two adults who understand the nature of the decision and affirm that the decision is made voluntarily by the patient or on the patient's behalf.
- The attending physician must sign and date this order, confirming that the patient (or their representative) understands the full implications of the DNR status.
Patient or Legal Representative Signature: _______________________________ Date: _________
Witness Signature: ______________________________________ Date: _________
Witness Signature: ______________________________________ Date: _________
Attending Physician Signature: ____________________________ Date: _________
This Do Not Resuscitate Order is valid unless it is revoked by the patient or their legal representative.
It is the responsibility of the patient or their representative to notify healthcare providers of the existence of this DNR order. If the patient wishes to rescind this order, a new directive must be completed and signed.
For further information or assistance in completing this form, please contact a healthcare provider or legal advisor knowledgeable in West Virginia state healthcare laws.