West Virginia Do Not Resuscitate Order Template

West Virginia Do Not Resuscitate Order Template

A West Virginia Do Not Resuscitate (DNR) Order form is a legal document that allows individuals to express their wishes regarding resuscitation efforts in the event of a medical emergency. This form ensures that healthcare providers honor a patient's decision to forgo life-saving measures. To make your preferences known, consider filling out the form by clicking the button below.

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The West Virginia Do Not Resuscitate (DNR) Order form is a crucial document for individuals who wish to express their preferences regarding medical treatment in emergency situations. This form allows patients to communicate their desire not to receive cardiopulmonary resuscitation (CPR) or other life-saving measures in the event of cardiac arrest or respiratory failure. It is designed for those who are facing serious health issues or are nearing the end of life. The DNR form must be completed and signed by a qualified healthcare provider, ensuring that the patient's wishes are legally recognized. Importantly, this document should be readily available to medical personnel, as it guides them in making decisions aligned with the patient’s values and desires. Understanding the implications of a DNR order is essential for patients, families, and healthcare providers, as it plays a significant role in end-of-life care and respects the autonomy of individuals in making informed choices about their health care. Properly executing and discussing this form can foster open conversations about treatment preferences, ultimately leading to more personalized and compassionate care.

West Virginia Do Not Resuscitate Order Example

West Virginia Do Not Resuscitate (DNR) Order

This document serves as a Do Not Resuscitate Order, adhering to the guidelines set forth by West Virginia state laws, including the West Virginia Health Care Decisions Act. It indicates the wish of the undersigned individual or their authorized representative, to forego resuscitative efforts by healthcare professionals in the event that the individual's heart and/or breathing stops.

Please fill out all required sections accurately.

Patient Information:

  • Full Name: ___________________________________________
  • Date of Birth: ________________________________________
  • Address: _____________________________________________
  • City: ______________________ State: WV Zip: ____________
  • Phone Number: ________________________________________

Medical Information:

  • Primary Physician: ____________________________________
  • Physician Phone Number: _______________________________
  • Medical Conditions: ___________________________________

Legal Representative (if applicable):

  • Representative’s Name: ________________________________
  • Relationship to Patient: _______________________________
  • Contact Number: ______________________________________

In accordance with West Virginia law, this document must be completed in the presence of a witness and/or notary public.

Declaration:
I, [Name of Patient or Legal Representative], understanding fully the implications, hereby declare that in the event of cardiac or respiratory arrest, resuscitation efforts including CPR should not be initiated. I understand that this decision will not affect the provision of other emergency treatments aimed at providing comfort and alleviating pain.

______________________________ __________________
Signature of Patient/Representative Date

Witness:

  • Name of Witness: _____________________________________
  • Signature: ___________________________________________
  • Date: ________________________________________________

OR

Notary Public:

  • Name of Notary: ______________________________________
  • Signature: ___________________________________________
  • Seal:

Instructions for Healthcare Providers:
Upon presentation, this Do Not Resuscitate (DNR) Order must be respected and adhered to by all healthcare providers and emergency personnel under the laws of West Virginia. This order should be included in the patient's medical records and carried by the patient or their representative at all times.

For further information, please refer to the West Virginia Department of Health and Human Resources or consult a legal advisor.

File Details

Fact Name Description
Definition A Do Not Resuscitate (DNR) Order is a legal document that instructs medical personnel not to perform cardiopulmonary resuscitation (CPR) in the event of cardiac or respiratory arrest.
Governing Law The West Virginia DNR Order is governed by West Virginia Code §16-30-1 et seq., which outlines the requirements and procedures for creating and recognizing DNR orders in the state.
Eligibility Any adult patient, or a legally authorized representative of a patient, can request a DNR order based on the patient’s medical condition and preferences.
Form Requirements The DNR order must be signed by a physician and the patient (or their representative) to be valid. It should clearly indicate the patient’s wishes regarding resuscitation.
Emergency Medical Services Emergency medical personnel are required to honor a valid DNR order. They must have the order readily available during emergencies to ensure compliance.
Revocation A DNR order can be revoked at any time by the patient or their representative. This can be done verbally or by destroying the written order.
Distribution It is essential to distribute copies of the DNR order to healthcare providers, family members, and keep a copy in the patient’s medical records to ensure all parties are informed.
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