West Virginia Out-of-Hospital Do-Not-Resuscitate Order

(A Court-Ready Medical Directive Template)

[// GUIDANCE: This template is drafted to comply with W. Va. Code § 16-4C-24 (Out-of-Hospital DNR) and the implementing rules of the West Virginia Department of Health & Human Resources (DHHR). Customize bracketed terms, remove guidance comments before execution, and confirm no subsequent statutory changes have occurred.]

TABLE OF CONTENTS

I. Document Header
II. Definitions
III. Operative Provisions
IV. Representations & Warranties
V. Covenants & Restrictions
VI. Revocation; Default & Remedies
VII. Risk Allocation
VIII. Dispute Resolution
IX. General Provisions
X. Execution Block

I. DOCUMENT HEADER

1. Title. West Virginia Out-of-Hospital Do-Not-Resuscitate Order (the “Directive”).
2. Parties.
   a. “[PATIENT NAME],” an individual with date of birth [DOB] and residence at [ADDRESS] (the “Patient”);
   b. “[SURROGATE NAME],” if any, acting pursuant to a valid medical power of attorney or as otherwise authorized under the West Virginia Health Care Decisions Act (the “Surrogate”); and
   c. “[PHYSICIAN NAME],” a physician licensed in the State of West Virginia, WV License No. [NUMBER] (the “Attending Physician”).
3. Effective Date. This Directive becomes effective on the date set forth in Section X below (the “Effective Date”).
4. Governing Law. This Directive shall be governed by and construed in accordance with the health-care laws of the State of West Virginia.

II. DEFINITIONS

For purposes of this Directive, capitalized terms have the meanings set forth below:

“CPR” means cardiopulmonary resuscitation, including chest compressions, artificial ventilation, defibrillation, cardiac medications, and advanced airway management.

“DNR” means an order to withhold CPR and all other resuscitative efforts in the event the Patient is found pulseless and/or apneic.

“EMS Personnel” means emergency medical service providers certified or licensed under W. Va. Code § 16-4C-1 et seq.

“Good Faith” means an honest belief, absent malice or willful misconduct, that the actions taken are consistent with the Patient’s directives and applicable law.

“Health-Care Provider” means any individual or facility licensed, certified, or otherwise authorized to provide health-care services in West Virginia.

“Supportive Care” means comfort-focused medical interventions, including but not limited to oxygen, pain control, hemorrhage control, and emotional support.

III. OPERATIVE PROVISIONS

3.1 Directive to Withhold Resuscitation.
(a) The Patient does NOT consent to the initiation of CPR or any other resuscitative measures.
(b) EMS Personnel and all Health-Care Providers SHALL withhold CPR upon confirmation of pulselessness and/or apnea.

3.2 Scope of Treatment.
(i) Supportive Care is expressly authorized.
(ii) Artificial nutrition and hydration, antibiotics, or other non-resuscitative treatments are neither requested nor refused by this Directive and remain subject to separate medical orders or directives.

3.3 EMS Recognition.
(a) A copy of this Directive, an approved DNR bracelet, or other DHHR-approved identifier constitutes valid evidence of the Patient’s wish.
(b) EMS Personnel acting in Good Faith reliance on this Directive are immune from civil or criminal liability to the fullest extent permitted by law.

3.4 Conditions Precedent.
This Directive is operable only when the Patient is found pulseless and/or apneic.

IV. REPRESENTATIONS & WARRANTIES

4.1 Patient Representations.
(a) Capacity. The Patient represents that he/she/they is of sound mind and at least eighteen (18) years of age.
(b) Voluntariness. Execution of this Directive is voluntary and free from duress.

4.2 Surrogate Representations.
If applicable, the Surrogate represents that he/she/they is duly authorized to act for the Patient and that no known revocation of such authority exists.

4.3 Physician Warranties.
(a) Compliance. The Attending Physician warrants that this Directive conforms to W. Va. Code § 16-4C-24 and applicable DHHR rules.
(b) Medical Judgment. The Physician has confirmed the Patient’s capacity (or Surrogate authority) and has explained the nature and consequences of a DNR order.

4.4 Survival. The warranties in this Section survive execution and remain effective unless and until this Directive is revoked in accordance with Section VI.

V. COVENANTS & RESTRICTIONS

5.1 Patient Covenants.
(a) The Patient (or Surrogate) shall maintain an original or copy of this Directive on the Patient’s person or in an easily identifiable location.
(b) The Patient shall notify immediate family members and caregivers of the existence of this Directive.

5.2 Provider Restrictions.
Health-Care Providers shall not condition treatment, admission, or insurance coverage upon execution or revocation of this Directive.

5.3 Notice Obligations.
Any Provider unwilling to honor this Directive for reasons of conscience must immediately:
(i) inform the Patient or Surrogate, and
(ii) facilitate transfer of care pursuant to W. Va. Code § 16-30-12.

VI. REVOCATION; DEFAULT & REMEDIES

6.1 Revocation by Patient.
(a) Oral or written revocation to EMS Personnel or any Provider;
(b) Destruction or removal of DNR bracelet; or
(c) Execution of a subsequent directive inconsistent with this DNR.

6.2 Revocation by Surrogate.
A Surrogate may revoke only if the Patient lacks decision-making capacity and if the Surrogate is authorized under applicable law.

6.3 Provider Actions Upon Revocation.
Upon actual knowledge of revocation, Providers shall:
(i) document the revocation in the Patient’s medical record; and
(ii) resume full resuscitative measures unless contraindicated.

6.4 Remedies.
(a) Equitable Relief. Any interested party may seek injunctive relief to prevent the initiation of unwanted resuscitation.
(b) Attorney Fees. Prevailing parties are entitled to reasonable attorney fees and costs incurred in enforcing this Directive.

[// GUIDANCE: Section VI borrows contract-style “default & remedies” language. Practitioners may abbreviate if a more streamlined medical form is preferred.]

VII. RISK ALLOCATION

7.1 Provider Protection & Indemnification.
The Patient (or Estate) shall indemnify and hold harmless Providers and EMS Personnel acting in Good Faith reliance on this Directive against any liability, cost, or expense (including reasonable attorney fees) arising out of such reliance, except in cases of gross negligence or willful misconduct.

7.2 Limitation of Liability.
No Provider or EMS Personnel acting in Good Faith shall be liable for civil damages or subject to criminal prosecution for withholding or withdrawing resuscitative efforts in accordance with this Directive.

7.3 Insurance.
Nothing herein shall be construed to limit or waive coverage under any applicable professional liability policy.

VIII. DISPUTE RESOLUTION

8.1 Governing Law. Refer to Section I.4.

8.2 Forum Selection, Arbitration, Jury Waiver. Not applicable.

8.3 Preservation of Injunctive Relief.
Nothing herein restricts any party’s right to seek emergency injunctive or declaratory relief to enforce the Patient’s health-care decisions.

IX. GENERAL PROVISIONS

9.1 Amendments & Waivers. Must be in writing, signed by the Patient (or authorized Surrogate) and the Attending Physician.

9.2 Assignment. Rights and obligations under this Directive are personal and may not be assigned.

9.3 Severability. If any provision is held invalid, the remaining provisions shall remain in full force to the maximum extent permissible.

9.4 Entire Agreement. This Directive constitutes the entire agreement regarding do-not-resuscitate instructions and supersedes all prior oral or written DNR orders.

9.5 Counterparts; Electronic Signatures. This Directive may be executed in multiple counterparts, including facsimile or electronically transmitted signatures, each of which shall be deemed an original.

X. EXECUTION BLOCK

[// GUIDANCE: Obtain TWO adult witness signatures OR Notarization, in compliance with DHHR form guidelines. Do not use family members who stand to inherit as witnesses.]

A. PATIENT

[PRINTED PATIENT NAME]
Signature: _____ Date: _______

B. SURROGATE (if applicable)

[PRINTED SURROGATE NAME]
Capacity: [Health Care POA / Next of Kin / Other]
Signature: _____ Date: _______

C. ATTENDING PHYSICIAN

I affirm that I have explained the medical consequences of a Do-Not-Resuscitate order to the Patient or Surrogate, have determined capacity/authority, and have signed this Directive in accordance with West Virginia law.

[PRINTED PHYSICIAN NAME], M.D./D.O.
WV License No.: ___
Signature: ____ Date: _____

D. WITNESSES

1. ---

   Signature: _____ Date: ___
   Address: ____

2. ---

   Signature: _____ Date: ___
   Address: ____

[Optional] E. NOTARY ACKNOWLEDGMENT (if witnesses unavailable or if additional authentication desired)

State of West Virginia, County of ___, to-wit:
Subscribed and sworn before me this ___ day of _, 20.

Notary Public
My Commission Expires: ____

EMS IMPLEMENTATION INSTRUCTIONS (NON-OPERATIVE)

• Confirm identity of Patient and presence of original Directive, bracelet, or approved identifier.
• If pulseless/apneic, withhold CPR; provide Supportive Care as clinically indicated.
• Document time and circumstances; notify Medical Command as required.

[// GUIDANCE: Attach a wallet-sized summary card and instructions for revocation on reverse side. Recommend filing copies with primary care physician, facility medical records, and local EMS agency.]