West Virginia Do Not Resuscitate Order
This Do Not Resuscitate (DNR) Order is created in accordance with West Virginia Code §16-30-1 et seq. It is intended to communicate the wishes of the individual regarding resuscitation efforts in the event of a medical emergency.
Patient Information:
- Name: ____________________________
- Date of Birth: _____________________
- Address: __________________________
- Phone Number: _____________________
Healthcare Provider Information:
- Name: ____________________________
- License Number: ___________________
- Address: __________________________
- Phone Number: _____________________
Patient's Wishes:
The patient, named above, has made the decision to not receive cardiopulmonary resuscitation (CPR) or other life-sustaining treatments in the event of cardiac or respiratory arrest.
Signature:
By signing below, the patient or their legal representative affirms that this DNR Order reflects their wishes:
- Signature of Patient or Legal Representative: ____________________________
- Date: ____________________________
Witness Information:
- Name: ____________________________
- Signature: _________________________
- Date: ____________________________
This DNR Order should be placed in a prominent location within the patient's medical records and should be readily available to all healthcare providers involved in the patient's care.