Authorized Durable Do Not Resuscitate Order Form (Page 4 of 5) in pdf

Durable Do Not Resuscitate Order

Virginia Department of Health

Patient’s Full Legal Name _______________________________________________ Date _______________

Physician’s Order

I, the undersigned, state that I have a bona fide physician/patient relationship with the patient named above. I have certified in

the patient’s medical record that he/she or a person authorized to consent on the patient’s behalf has directed that life-prolonging

procedures be withheld or withdrawn in the event of cardiac or respiratory arrest.

I further certify (must check 1 or 2):

The patient is CAPABLE of making an informed decision about providing, withholding, or withdrawing a specific

medical treatment or course of medical treatment. (Signature of patient is required)

ecision about providing, withholding, or withdrawing a specific

medical treatment or course of medical treatment because he/she is unable to understand the nature, extent or probable

consequences of the proposed medical decision, or to make a rational evaluation of the risks and benefits of

alternatives to that decision.

If you checked 2 above, check A, B, or C below:

hat

life-prolonging procedures be withheld or withdrawn.

“Person Authorized to Consent on the Patient’s Behalf” with authority to direct that life-prolonging procedures be

withheld or withdrawn. (Signature of “Person Authorized to Consent on the Patient’s Behalf is required.)

lth care).

(Signature of “Person Authorized to Consent on the Patient’s Behalf is required)

I hereby direct any and all qualified health care personnel, commencing on the effective date noted above, to withhold

cardiopulmonary resuscitation (cardiac compression, endotracheal intubation and other advanced airway management, artificial

ventilation, defibrillation, and related procedures) from the patient in the event of the patient’s cardiac or respiratory arrest. I

further direct such personnel to provide the patient other medical interventions, such as intravenous fluids, oxygen, or other

therapies deemed necessary to provide comfort care or alleviate pain.

____________________________ ____________________________ ____________________________

Physician’s Printed Name

Physician’s Signature

Emergency Phone Number

____________________________ __________________________________________________________

Patient’s Signature

Signature of Person Authorized to Consent on the Patient’s Behalf

Copy 2 – To be kept in patient’s permanent medical record

Authorized Durable Do Not Resuscitate Order Form Page 4