VIRGINIA DURABLE DO-NOT-RESUSCITATE (DDNR) ORDER & ADVANCE MEDICAL DIRECTIVE
(Compliant with Va. Code § 54.1-2983; § 54.1-2987.1; 12 Va. Admin. Code § 5-66-10 et seq.)
TABLE OF CONTENTS
- Document Header
- Definitions
- Operative Provisions
- Representations & Warranties
- Covenants & Restrictions
- Revocation, Default & Remedies
- Risk Allocation
- Governing Law & Dispute Resolution
- General Provisions
- Execution Block
1. DOCUMENT HEADER
1.1 Parties
a. “Patient”: [PATIENT FULL LEGAL NAME], DOB [MM/DD/YYYY], SSN (last 4) [####]
b. “Attending Physician/Authorized Practitioner”: [NAME & CREDENTIALS], Virginia License No. [#######]
1.2 Recitals
a. Patient is a competent adult executing this Directive voluntarily and after consultation with medical professionals.
b. Practitioner attests that issuance of a Durable Do-Not-Resuscitate Order (“DDNR Order”) is clinically appropriate and consistent with the Patient’s wishes.
c. The parties intend this instrument to:
i. Serve as an Advance Medical Directive under the Virginia Health Care Decisions Act; and
ii. Constitute a DDNR Order recognizable by Emergency Medical Services (“EMS”) providers pursuant to 12 VAC 5-66.
1.3 Effective Date & Jurisdiction
This Directive is effective upon the latest signature date set forth in Section 10 and is governed exclusively by the laws of the Commonwealth of Virginia.
2. DEFINITIONS
For ease of reference, the following capitalized terms are used throughout this Directive:
“Advance Directive” – An advance directive as defined in Va. Code § 54.1-2982.
“Cardiopulmonary Resuscitation” or “CPR” – All resuscitative efforts including chest compressions, defibrillation, advanced airway management, artificial ventilation, cardiac drugs, and related emergency measures.
“DDNR Device” – A properly executed DDNR bracelet, necklace, or other device approved under 12 VAC 5-66-40.
“Health Care Provider” – Any physician, nurse, EMT, hospital, or other individual or facility licensed or authorized to provide medical services in Virginia.
“Resuscitative Measures” – Interventions listed in 12 VAC 5-66-20 intended to restore cardiac or respiratory function, including but not limited to CPR.
“Revocation” – Any act meeting the requirements of Section 6.2 herein.
3. OPERATIVE PROVISIONS
3.1 Core Directive
The Patient hereby directs all Health Care Providers, including EMS personnel, NOT to administer Resuscitative Measures in the event of cardiac or respiratory arrest.
3.2 Scope of Withholding
a. The withholding applies to all settings (hospital, outpatient, long-term care, hospice, and pre-hospital).
b. Comfort care, pain management, and other palliative measures ARE expressly authorized.
3.3 Authorization & Obligation of Providers
a. Providers acting in good faith reliance on this Directive shall withhold Resuscitative Measures without liability.
b. Providers shall document compliance in the Patient’s medical record.
3.4 Display & Accessibility
The Patient shall keep this Directive readily available and may utilize a DDNR Device. EMS providers may rely on either the physical Directive or DDNR Device.
3.5 Conditions Precedent
This Directive is valid only when:
i. Signed as required in Section 10; and
ii. The Practitioner determines the Patient is capable of making an informed decision or, if incapacitated, that a valid surrogate has authorized execution.
4. REPRESENTATIONS & WARRANTIES
4.1 Patient
a. The Patient is at least 18 years of age or an emancipated minor.
b. The Patient is of sound mind and not under duress or undue influence.
4.2 Practitioner
a. Practitioner is duly licensed in Virginia and has reviewed the Patient’s medical condition.
b. Practitioner warrants that withholding CPR is medically appropriate and not contrary to reasonable medical standards.
4.3 Survival of Warranties
The representations and warranties herein survive Revocation only as to actions taken prior to Revocation.
5. COVENANTS & RESTRICTIONS
5.1 Patient Covenants
a. To provide copies of this Directive to primary care providers, specialists, and designated agents.
b. To notify Practitioner promptly of any desired changes.
5.2 Practitioner Covenants
a. To record issuance of the DDNR Order in the Patient’s chart within 24 hours.
b. To furnish the Patient (or surrogate) with sufficient copies for dissemination.
5.3 Restriction on Transfer
Neither party may assign or delegate obligations hereunder except as permitted by law (e.g., substitution of attending physician).
6. REVOCATION, DEFAULT & REMEDIES
6.1 Events of Default
Any action inconsistent with Section 3 (e.g., unauthorized administration of CPR) constitutes a default.
6.2 Revocation by Patient or Surrogate
This Directive may be revoked at any time by:
a. A signed, dated writing;
b. An oral statement to a Health Care Provider;
c. Physical destruction of the Directive or DDNR Device; or
d. Execution of a new Advance Directive expressly revoking prior DNR instructions.
6.3 Notice & Cure
Upon receiving notice of Revocation, Health Care Providers shall, without delay, enter the Revocation into the Patient’s record and notify EMS if applicable.
6.4 Remedies
a. Injunctive Relief – The Patient’s estate or surrogate may seek equitable relief to enforce this Directive.
b. Attorney Fees – A prevailing party enforcing this Directive is entitled to reasonable attorney fees incurred.
7. RISK ALLOCATION
7.1 Indemnification – Provider Protection
The Patient (and, if applicable, the Patient’s estate) indemnifies and holds harmless any Health Care Provider who, in good faith and in compliance with this Directive, withholds Resuscitative Measures.
7.2 Limitation of Liability
No Health Care Provider acting in good faith pursuant to this Directive shall incur civil or criminal liability for failure to perform CPR, consistent with Va. Code § 54.1-2988.
7.3 Insurance
[// GUIDANCE: Insert any facility-specific malpractice or professional liability requirements, if desired.]
7.4 Force Majeure
A Provider shall not be liable for non-performance caused by circumstances beyond reasonable control, including equipment failure or mass-casualty events.
8. GOVERNING LAW & DISPUTE RESOLUTION
8.1 Governing Law
This Directive is governed by the laws of the Commonwealth of Virginia without regard to conflict-of-laws principles.
8.2 Forum Selection
Any judicial action arising under this Directive shall be brought exclusively in a court of competent jurisdiction within Virginia.
8.3 Injunctive Relief
The right to seek injunctive or declaratory relief to enforce Patient wishes is preserved.
8.4 Arbitration & Jury Waiver
Not applicable.
9. GENERAL PROVISIONS
9.1 Amendment & Waiver
This Directive may be amended only by a subsequent writing executed with the same formalities as this Directive. No waiver of any provision is effective unless in writing.
9.2 Severability
If any provision is held invalid, the remaining provisions shall remain enforceable to the fullest extent permitted by law.
9.3 Integration
This document constitutes the entire agreement respecting the subject matter and supersedes all prior DNR instructions, except to the extent incorporated herein.
9.4 Counterparts; Electronic Signatures
This Directive may be executed in counterparts and by electronic signature, each of which is deemed an original.
9.5 Copies
Photocopies, facsimiles, and electronic reproductions of this Directive and DDNR Device are as valid as the original.
10. EXECUTION BLOCK
10.1 Patient Signature
I, the undersigned Patient, affirm that I understand the nature of this Directive and voluntarily execute it.
| Patient Signature | Date |
|---|---|
| [SIGN HERE] | [MM/DD/YYYY] |
10.2 Practitioner Signature (Required for DDNR Order)
I certify that the above-named Patient is under my care and that this DDNR Order complies with Va. Code § 54.1-2987.1.
| Practitioner Signature & Credentials | Date |
|---|---|
| [SIGN HERE] | [MM/DD/YYYY] |
10.3 Witnesses
We, the undersigned adults, affirm that the Patient signed this Directive in our presence and appeared to do so willingly, and that neither of us is (i) the Patient’s spouse or blood relative, (ii) entitled to any portion of the Patient’s estate, (iii) directly financially responsible for the Patient’s medical care, or (iv) an employee of the attending health-care facility.
| Witness #1 Signature | Printed Name | Date |
|---|---|---|
| [SIGN HERE] | [NAME] | [MM/DD/YYYY] |
| Witness #2 Signature | Printed Name | Date |
|---|---|---|
| [SIGN HERE] | [NAME] | [MM/DD/YYYY] |
[// GUIDANCE: Notarization is optional under Virginia law but may expedite recognition across state lines. Insert notary block if desired.]
10.4 EMS Verification (Optional)
The EMS provider below acknowledges receipt of a copy of this Directive/DDNR Order.
| EMS Agency | EMS Officer Signature | Date |
|---|---|---|
| [AGENCY] | [SIGN HERE] | [MM/DD/YYYY] |
KEEP THIS DOCUMENT WITH YOU AT ALL TIMES AND INFORM YOUR HEALTH CARE PROVIDERS OF ITS EXISTENCE.