Issued under Code of Virginia 54.1-2987.1 and 12VAC5-66, this physician's order directs qualified health care personnel to withhold CPR if the patient has a cardiac or respiratory arrest. It can be honored by EMS and licensed providers in any setting. Clinicians complete it with the patient, or the person authorized to consent, after explaining the alternatives and how to revoke it.
A physician with a bona fide physician/patient relationship completes the order, certifying whether the patient is capable and, if not, the advance directive basis; VDH guidance also covers nurse practitioners and physician assistants. The patient or person authorized to consent signs all three copies.
Download the current version from the source each time; forms change without notice.
Authorized Durable Do Not Resuscitate Order Form
A form is listed only after its name and number were confirmed on the issuing agency’s or insurer’s own website, or in the form itself. Each entry links to that source. The list was last checked in October 2026. Forms and their requirements change without notice, so check the official page for the current version before you complete one.
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Yes. The physician issues three copies, one for the patient, one for the medical record and one for ordering jewelry, and all three may be honored by qualified health care personnel whether original or photocopy. The National POLST form is also honored as a Durable DNR in Virginia.
The patient, or an authorized decision maker who initiated the order, can revoke it at any time by destroying the form and any jewelry, or having someone do so in their presence, or by orally expressing the intent to revoke. If a facility's other DNR order is revoked, staff update or destroy it so the revocation is honored.