Part IV. Implementation Procedures
12VAC5-66-70. Issuance of a Durable DNR Order.
A. A Durable DNR Order may be issued to a patient by a physician, with whom the patient has established a bona fide physician/patient relationship, as defined by the Board of Medicine in their current guidelines, only with the consent of the patient or, if the patient is a minor or is otherwise incapable of making an informed decision regarding consent for such an order, upon the request of and with the consent of the person authorized to consent on the patient's behalf.
B. The use of the authorized Durable DNR Order Form is encouraged to provide uniformity throughout the health care continuum.
C. The authorized Durable DNR Order can be honored by qualified health care personnel in any setting.
D. Qualified health care personnel are authorized to honor only a Durable DNR Order on an authorized form or Alternate DNR jewelry, except as provided in 12VAC5-66-60 of these regulations.
E. Prior to issuing a Durable DNR Order, the physician shall explain to the patient or the person authorized to consent on the patient's behalf, the alternatives available for response in the event of cardiac or respiratory arrest. If the option of a Durable DNR Order is agreed upon, the physician shall have the following responsibilities:
1. Explain the circumstances under which qualified health care personnel may follow a Durable DNR Order.
2. Explain how to and who may revoke the Durable DNR Order.
3. Document the patient's full legal name.
4. Document the execution date of the Durable DNR Order.
5. Obtain the signature of the patient or the person authorized to consent on the patient's behalf on all three forms: the patient's copy, medical record copy, and the copy used for obtaining Alternate DNR jewelry.
6. Make sure that the issuing physician's name is clearly printed and the form is signed.
7. Record the contact telephone number for the issuing physician.
8. Issue the original Durable DNR Order Form, and the patient and Alternate DNR jewelry copies to the patient and maintain the medical record copy in the patient's medical file.
F. The person to whom a Durable DNR Order applies or the person authorized to consent on the patient's behalf must present the following information to the approved vendor in order to purchase and be issued an approved Alternate Durable DNR necklace or bracelet. The necklace or bracelet must contain the following information:
1. The following words: Do Not Resuscitate;
2. The patient's full legal name;
3. The physician's name and phone number; and
4. The Virginia Durable DNR issuance date.
Statutory Authority
§§ 32.1-12 and 32.1-111.4 of the Code of Virginia.
Historical Notes
Derived from Virginia Register Volume 18, Issue 12, eff. March 27, 2002, amended, Virginia Register Volume 27, Issue 21, eff. July 20, 2011.
12VAC5-66-80. Durable DNR Order implementation procedures.
A. Qualified health care personnel shall comply with the following general procedures and published Virginia Durable DNR Order Implementation Protocols when caring for a patient who is in cardiac or respiratory arrest and who is known or suspected to have a Durable DNR Order in effect.
B. Initial assessment and intervention. Perform routine patient assessment and resuscitation or intervention until a valid Durable DNR Order, Alternate DNR jewelry, or Other DNR Order can be confirmed, as follows:
1. Determine the presence of a Durable DNR Order, approved Alternate Durable DNR jewelry, or Other DNR Order.
2. If the patient is within a qualified health care facility or in transit between qualified health care facilities, any qualified health care personnel may honor an Other DNR Order as set forth in 12VAC5-66-60.
3. Determine that the Durable DNR form or Alternate DNR jewelry is not altered.
4. Verify, through driver's license or other identification with photograph and signature or by positive identification by a family member or other person who knows the patient, that the patient in question is the one for whom the Durable DNR Order, Alternate DNR jewelry, or Other DNR Order was issued.
5. If the Durable DNR Order, Alternate DNR jewelry, or Other DNR Order is intact, unaltered, and verified as issued for the patient, qualified health care personnel may consider it valid.
C. Resuscitative measures to be withheld or withdrawn. In the event of cardiac or respiratory arrest of a patient with a valid Durable DNR Order, Alternate Durable DNR jewelry, or Other DNR Order under the criteria set forth in subsection B of this section, qualified health care personnel shall withhold or withdraw cardiopulmonary resuscitation (CPR) unless otherwise directed by a physician physically present at the patient location. CPR shall include:
1. Cardiac compression;
2. Artificial ventilation;
3. Defibrillation;
4. Endotracheal Intubation or other advanced airway management including supra-glottic devices such as the LMA, or other airway devices that pass beyond the oral pharynx, such as the Combi Tube, PTL etc.; or
5. Administration of related procedures or cardiac resuscitation medications as prescribed by the patient's physician or medical protocols.
D. Procedures to provide comfort care or to alleviate pain. In order to provide comfort care or to alleviate pain for a patient with a valid Durable DNR Order of any type or Other DNR Order the following interventions may be provided, depending on the needs of the particular patient:
1. Airway management, including positioning, nasal or pharyngeal airway placement;
2. Suctioning;
3. Supplemental oxygen delivery devices;
4. Pain medications or intravenous fluids;
5. Bleeding control;
6. Patient positioning; or
7. Other therapies deemed necessary to provide comfort care or to alleviate pain.
E. Revocation.
1. If a patient is able to, and does, express to a health care provider or practitioner the desire to be resuscitated in the event of cardiac or respiratory arrest, such expression shall revoke the provider's or practitioner's authority to follow a Durable DNR Order or Other DNR Order. In no case shall any person other than the patient have authority to revoke a Durable DNR Order or Other DNR Order executed upon the request of and with the consent of the patient himself.
If the patient is a minor or is otherwise incapable of making an informed decision and the Durable DNR Order or Other DNR Order was issued upon the request and with the consent of the person authorized to consent on the patient's behalf, then the expression by said person to a health care provider or practitioner of the desire that the patient be resuscitated shall so revoke the provider's or practitioner's authority to follow a Durable DNR Order or Other DNR Order.
2. The expression of such desire to be resuscitated prior to cardiac or respiratory arrest shall constitute revocation of the order; however, a new order may be issued upon consent of the patient or the person authorized to consent on the patient's behalf.
3. The provisions of this section shall not authorize any qualified emergency medical services personnel or licensed health care provider or practitioner who is attending the patient at the time of cardiac or respiratory arrest to provide, continue, withhold or withdraw treatment if such provider or practitioner knows that taking such action is protested by the patient incapable of making an informed decision. No person shall authorize providing, continuing, withholding or withdrawing treatment pursuant to this section that such person knows, or upon reasonable inquiry ought to know, is contrary to the religious beliefs or basic values of a patient incapable of making an informed decision or the wishes of such patient fairly expressed when the patient was capable of making an informed decision.
F. Documentation. When following a Durable DNR Order or Other DNR Order for a particular patient admitted to a qualified health care facility, qualified health care personnel shall document care rendered or withheld as required by facility policies and procedures. When following a Durable DNR Order or Other DNR Order for a particular patient who is not admitted to a qualified health care facility or who is in transit from a health care facility, qualified health care personnel shall document in the patient's medical record the care rendered or withheld in the following manner:
1. Use standard patient care reporting documents (i.e. patient chart, pre-hospital patient care report).
2. Describe assessment of patient's cardiac or respiratory arrest status.
3. Document which identification (Durable DNR Order, Alternate Durable DNR jewelry, or Other DNR Order or alternate form of identification) was used to confirm Durable DNR status and that it was intact, not altered, not canceled or not officially revoked.
4. Record the name of the patient's physician who issued the Durable DNR Order, or Other DNR Order.
5. If the patient is being transported, keep the Durable DNR Order, Alternate Durable DNR jewelry, or Other DNR Order with the patient.
G. General considerations. The following general principles shall apply to implementation of all Durable DNR Orders.
1. If there is misunderstanding with family members or others present at the patient's location or if there are other concerns about following the Durable DNR Order or Other DNR Order, contact the patient's physician or EMS medical control for guidance.
2. If there is any question about the validity of a Durable DNR Order, resuscitative measures should be administered until the validity of the Durable DNR Order or Other DNR Order is established.
Statutory Authority
§§ 32.1-12 and 32.1-111.4 of the Code of Virginia.
Historical Notes
Derived from Virginia Register Volume 18, Issue 12, eff. March 27, 2002; amended, Virginia Register Volume 27, Issue 21, eff. July 20, 2011.