TITLE 12. HEALTH

STATE BOARD OF HEALTH

Fast-Track Regulation

Title of Regulation: 12VAC5-66. Regulations Governing Durable Do Not Resuscitate Orders (amending 12VAC5-66-10, 12VAC5-66-40, 12VAC5-66-50, 12VAC5-66-60, 12VAC5-66-80; repealing 12VAC5-66-20, 12VAC5-66-30, 12VAC5-66-70).

Statutory Authority: §§ 32.1-12 and 32.1-111.4 of the Code of Virginia.

Public Hearing Information: No public hearing is currently scheduled.

Public Comment Deadline: January 28, 2026.

Effective Date: February 12, 2026.

Agency Contact: Mohamed G. Abbamin, MPA, Senior Policy Analyst, Office of Emergency Services, Virginia Department of Health, 1041 Technology Park Drive, Glen Allen, VA 23059, telephone (804) 980-6984, or email mohamed.abbamin@vdh.virginia.gov.

Basis: Section 32.1-12 of the Code of Virginia authorizes the State Board of Health to make, adopt, promulgate, and enforce such regulations as may be necessary to carry out the provisions of Title 32.1 of the Code of Virginia. Section 32.1-111.4 of the Code of Virginia requires the board to authorize qualified emergency medical services personnel to follow Do Not Resuscitate (DNR) Orders pursuant to 54.1-2897.1 of the Code of Virginia, and § 32.1-111.5 of the Code of Virginia requires the board to prescribe by regulation qualifications necessary for authorization to follow DNR Orders pursuant to § 54.1-2897.1 of the Code of Virginia.

Purpose: This regulatory action is necessary to ensure compliance with the Code of Virginia and to conform the regulation to Virginia Administrative Code form and style. By enacting these amendments, additional clarity and consistency of the regulation will help ensure that health care personnel, emergency medical services providers, and residents of the Commonwealth can effectively access and understand the regulation governing DNRs.

Rationale for Using Fast-track Rulemaking Process: The action is expected to be noncontroversial and therefore appropriate for the fast-track rulemaking process because it ensures that emergency medical services providers can efficiently access and understand the regulation governing Durable DNR Orders.

Substance: This regulatory action repeals 12VAC5-66-20 and 12VAC5-66-30. This action amends 12VAC5-66-10, 12VAC5-66-40, 12VAC5-66-50, 12VAC5-66-60, 12VAC5-66-70, and 12VAC5-66-80, and adds forms. Amendments include (i) terminology updates, that is, adding definitions, removing outdated or irrelevant terms, and expanding some definitions; (ii) structural modifications to improve clarity and organization for providers and citizens; (iii) repealing a section related to issuance of Durable DNR Orders because the board lacks statutory authority for those provisions; and (iv) clarification of procedures on the execution and revocation of DNR Orders thorough instructions on how these orders should be documented, maintained, and verified, especially by emergency medical services personnel, which are current standard practices.

Issues: The primary advantage of the changes are clarity and comprehensiveness of the application of the regulation governing Durable DNR Orders. By updating terminology, ensuring compliance with the Code of Virginia, refining procedural details, and improving the clarity and readability of the chapter, the revisions will benefit health care providers, patients, and citizens of the Commonwealth. There are no disadvantages associated with the changes.

Department of Planning and Budget Economic Impact Analysis:

The Department of Planning and Budget (DPB) has analyzed the economic impact of this proposed regulation in accordance with § 2.2-4007.04 of the Code of Virginia and Executive Order 19. The analysis presented represents DPB's best estimate of the potential economic impacts as of the date of this analysis.¹

Summary of the Proposed Amendments to Regulation. The State Board of Health (board) proposes several amendments in order to reflect current standards and practices, remove non-regulatory language, improve clarity, and conform text to the Virginia Register of Regulations Form, Style and Procedure Manual for Publication of Virginia Regulations (Virginia Register Manual).²

Background. The board proposes changes to each section of Regulations Governing Durable Do Not Resuscitate Orders (12VAC5-66) as follows:³

12VAC5-66-10: Add relevant definitions, remove definitions that are no longer used, and amend existing definitions for improved clarity.

12VAC5-66-20: Repeal entire section as it is non-regulatory.

12VAC5-66-30: Repeal entire section as it is non-regulatory.

12VAC5-66-40: Add text to clarify that either a POST or POLST form is recognized as a DNR order. This is current practice. Remove nonregulatory language and amend text to conform with the Virginia Register Manual.

12VAC5-66-50: Remove redundant language, add new text for improved clarity, and amend existing text to conform with the Virginia Register Manual.

12VAC5-66-60: Remove unnecessary language and amend existing text to conform with the Virginia Register Manual.

12VAC5-66-70: Repeal entire section as regulation of the issuance of durable DNR orders exceed the board statutory authority The provisions that exceed the board statutory authority have not been applied in practice.

12VAC5-66-80: Remove unnecessary language, update and amend existing text to reflect existing conditions and to conform with the Virginia Register Manual.

Estimated Benefits and Costs. None of the proposed amendments change requirements in practice. Nevertheless, the proposed amendments to improve the clarity of the regulation would be beneficial for readers of the regulation in understanding the requirements in practice.

Businesses and Other Entities Affected. The regulation and proposed amendments pertain to individuals who wish to have a Durable DNR Order and those who must comply with it. The Code of Virginia requires DPB to assess whether an adverse impact may result from the proposed regulation.⁴ An adverse impact is indicated if there is any increase in net cost or reduction in net benefit for any entity, even if the benefits exceed the costs for all entities combined.⁵ As the proposed amendments neither increase cost nor reduce benefit, no adverse impact is indicated.

Small Businesses⁶ Affected.⁷ The proposed amendments do not adversely affect small businesses.

Localities⁸ Affected.⁹ The proposed amendments neither disproportionally affect any particular localities nor affect costs for local governments.

Projected Impact on Employment. The proposed amendments do not affect employment.

Effects on the Use and Value of Private Property. The proposed amendments neither affect the use and value of private property, nor costs related to the development of real estate.

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¹ Section 2.2-4007.04 of the Code of Virginia requires that such economic impact analyses determine the public benefits and costs of the proposed amendments. Further the analysis should include but not be limited to: (1) the projected number of businesses or other entities to whom the proposed regulatory action would apply, (2) the identity of any localities and types of businesses or other entities particularly affected, (3) the projected number of persons and employment positions to be affected, (4) the projected costs to affected businesses or entities to implement or comply with the regulation, and (5) the impact on the use and value of private property.

² See https://register.dls.virginia.gov/documents/agency_resources/stylemanual.pdf.

³ The regulation defines "Durable Do Not Resuscitate Order" in part as "a written order issued pursuant to § 54.1-2987.1 of the Code of Virginia, in a form authorized by the board, to withhold cardiopulmonary resuscitation from an individual in the event of cardiac or respiratory arrest."

⁴ Pursuant to § 2.2-4007.04 D: In the event this economic impact analysis reveals that the proposed regulation would have an adverse economic impact on businesses or would impose a significant adverse economic impact on a locality, business, or entity particularly affected, the Department of Planning and Budget shall advise the Joint Commission on Administrative Rules, the House Committee on Appropriations, and the Senate Committee on Finance. Statute does not define "adverse impact," state whether only Virginia entities should be considered, nor indicate whether an adverse impact results from regulatory requirements mandated by legislation.

⁵ Statute does not define "adverse impact," state whether only Virginia entities should be considered, nor indicate whether an adverse impact results from regulatory requirements mandated by legislation. As a result, DPB has adopted a definition of adverse impact that assesses changes in net costs and benefits for each affected Virginia entity that directly results from discretionary changes to the regulation.

⁶ Pursuant to § 2.2-4007.04, small business is defined as "a business entity, including its affiliates, that (i) is independently owned and operated and (ii) employs fewer than 500 full-time employees or has gross annual sales of less than $6 million."

⁷ If the proposed regulatory action may have an adverse effect on small businesses, § 2.2-4007.04 requires that such economic impact analyses include: (1) an identification and estimate of the number of small businesses subject to the proposed regulation, (2) the projected reporting, recordkeeping, and other administrative costs required for small businesses to comply with the proposed regulation, including the type of professional skills necessary for preparing required reports and other documents, (3) a statement of the probable effect of the proposed regulation on affected small businesses, and (4) a description of any less intrusive or less costly alternative methods of achieving the purpose of the proposed regulation. Additionally, pursuant to § 2.2-4007.1 of the Code of Virginia, if there is a finding that a proposed regulation may have an adverse impact on small business, the Joint Commission on Administrative Rules shall be notified.

⁸ "Locality" can refer to either local governments or the locations in the Commonwealth where the activities relevant to the regulatory change are most likely to occur.

⁹ Section 2.2-4007.04 defines "particularly affected" as bearing disproportionate material impact.

Agency Response to Economic Impact Analysis: The Virginia Department of Health has reviewed and concurs with the Department of Planning and Budget's economic impact analysis.

Summary:

The amendments (i) update terminology by adding definitions, removing outdated or irrelevant terms, and expanding some definitions; (ii) modify the structure of the regulation to improve clarity and organization for providers and citizens; (iii) repeal a section related to issuance of Durable Do Not Resuscitate Orders because the board lacks statutory authority for the specific provisions in that section; (iv) clarify procedures on the execution and revocation of DNR orders thorough instructions on how these orders should be documented, maintained, and verified, especially by EMS personnel, which are current standard practices; and (v) update forms.

Part I

Definitions

12VAC5-66-10. Definitions.

The following words and terms when used in this chapter shall have the following meanings unless the context clearly indicates otherwise:

"Agent" means an adult appointed by the declarant under an advance directive, executed or made in accordance with the provisions of § 54.1-2983 of the Code of Virginia to make health care decisions for him.

"Alternate Durable DNR jewelry" means a Durable DNR bracelet or necklace issued by a vendor seller approved by the Virginia Office of Emergency Medical Services. A Durable DNR Order must be obtained by the patient, from a physician, to obtain Alternate Durable DNR jewelry.

"Board" means the State Board of Health.

"Cardiac arrest" means the cessation of a functional heartbeat.

"Commissioner" means the State Health Commissioner.

"CPR" or "cardiopulmonary resuscitation" shall include cardiac compression, endotracheal intubation and other advanced airway management, artificial ventilation, defibrillation, administration of cardiac resuscitative medications, and related procedures.

"Durable Do Not Resuscitate Order" or "Durable DNR Order" means a written physician's order issued pursuant to § 54.1-2987.1 of the Code of Virginia in a Durable Do Not Resuscitate Order form or forms authorized by the board, to withhold cardiopulmonary resuscitation from an individual in the event of cardiac or respiratory arrest. For purposes of this chapter, cardiopulmonary resuscitation shall include cardiac compression, endotracheal intubation and other advanced airway management, artificial ventilation, defibrillation, administration of cardiac resuscitative medications, and related procedures. As the terms "advance directive" and "Durable Do Not Resuscitate Order" are used in this article, a Durable Do Not Resuscitate Order or other Other DNR Order is not and shall not be construed as an advance directive. When used in these regulations this chapter, the term "Durable DNR Order" shall include any authorized Alternate Durable DNR jewelry issued in conjunction with an original Durable DNR Order. "Durable DNR Order" shall also include a physician order for scope of treatment (POST) or physician orders for life sustaining treatment (POLST) form. Durable DNR orders Order Forms, including POST or POLST forms, shall be completed filled out and signed by a licensed practitioner physician and signed by the patient or patient's authorized representative.

"Emergency Medical Services medical services" or "EMS" means the services rendered by an agency licensed by the Virginia Office of Emergency Medical Services, an equivalent agency licensed by another state or a similar agency of the federal government when operating within this Commonwealth. shall have the same meaning as in § 32.1-111.1 of the Code of Virginia.

"Emergency medical services agency" or "EMS agency" means any agency, licensed to engage in the business, service, or regular activity, whether or not for profit, of transporting or rendering immediate medical care to such persons who are sick, injured, wounded, or otherwise incapacitated or helpless. shall have the same meaning as in § 32.1-111.1 of the Code of Virginia.

"Emergency medical services personnel" or "EMS personnel" shall have the same meaning as in § 32.1-111.1 of the Code of Virginia.

“Health care personnel" means any qualified emergency medical services personnel and any licensed health care practitioner functioning in any facility, program, or organization operated or licensed by the State Board of Health, the Department of Social Services, or the Department of Behavioral Health and Developmental Services (DBHDS) or operated, licensed, or owned by another state agency, or a continuing care retirement community registered with the State Corporation Commission pursuant to Chapter 49 (§ 38.2-4900 et seq.) of Title 38.2 of the Code of Virginia.

"Incapable of making an informed decision" means the inability of an adult patient, because of mental illness, intellectual disability, or any other mental or physical disorder that precludes communication or impairs judgment, to make an informed decision about providing, withholding, or withdrawing a specific medical treatment or course of treatment because he is unable to understand the nature, extent, or probable consequences of the proposed medical decision, or to make a rational evaluation of the risks and benefits of alternatives to that decision. For purposes of this article, persons who are deaf or dysphasic or have other communication disorders but who are otherwise mentally competent and able to communicate by means other than speech, shall not be considered incapable of making an informed decision. The determination that the patient is "incapable of making an informed decision" shall be made in accordance with § 54.1-2983.2 have the same meaning as in § 54.1-2982 of the Code of Virginia.

"Office of EMS" or "OEMS" means the Virginia Office of Emergency Medical Services. The Virginia Office of Emergency Medical Services is a state office located within the Virginia Department of Health (VDH).

"Other Do Not Resuscitate Order" or "Other other DNR Order" means a written physician's order not to resuscitate a patient in the event of cardiac or respiratory arrest on a form other than the authorized state standardized Durable DNR Order Form, POST form, or POLST form under policies and procedures of the health care facility to which the individual who is the subject of the order has been admitted.

"Person authorized to consent on the patient's behalf" means any person authorized by law to consent on behalf of the a patient incapable of making an informed decision as defined by § 54.1-2982 of the Code of Virginia or, in the case of a minor child, the parent or parents other legal guardian having custody of the child or the child's legal guardian or as otherwise provided by law.

"Physician" means a person licensed to practice medicine in the Commonwealth of Virginia or in the jurisdiction where the treatment is to be rendered or withheld.

"Qualified emergency medical services personnel" means personnel certified to practice as defined by § 32.1-111.1 of the Code of Virginia when acting within the scope of their certification.

"Qualified health care facility" means a facility, program, or organization operated or licensed by the State Board of Health, the Department of Social Services, or by the Department of Behavioral Health and Developmental Services (DBHDS) or operated, licensed, or owned by another state agency and licensed health care practitioners at any continuing care retirement community registered with the State Corporation Commission pursuant to Chapter 49 (§ 38.2-4900 et seq.) of Title 38.2 of the Code of Virginia.

"Qualified health care personnel" means any qualified emergency medical services personnel and any licensed health care provider or practitioner functioning in any facility, program, or organization operated or licensed by the State Board of Health or by DBHDS or operated, licensed, or owned by another state agency.

"Respiratory arrest" means cessation of breathing.

Part II

Purpose and Applicability

12VAC5-66-20. Authority for regulation. (Repealed.)

Section 54.1-2987.1 of the Code of Virginia vests authority for the regulation of Durable DNR Orders in the State Board of Health and directs the board to prescribe by regulation the procedures, including the requirements for forms to authorize qualified health care personnel to follow Durable DNR Orders. All EMS DNR Orders and all Durable Do Not Resuscitate Orders issued or in effect between July 1, 1999, and March 27, 2002, are to be considered valid Durable DNR Orders and shall remain valid until revoked.

12VAC5-66-30. Purpose of regulations. (Repealed.)

The board has promulgated these regulations in order to carry out the intent of Virginia law that a person shall have the opportunity to execute a Durable DNR Order that comports with his wishes.

Part III

Requirements and Provisions

12VAC5-66-40. The Durable Do Not Resuscitate Order Form.

The Durable DNR Order Form shall be a standardized document as approved by the board and consistent with these regulations. The this chapter, including the following requirements and provisions shall apply to the approved Durable DNR Order Form.:

1. Content of the Form - A Durable DNR Order Form shall contain, from a physician with whom the patient has a bona fide physician/patient physician-patient relationship, a do not resuscitate determination, signature and the date of issue, the signature of the patient, or, if applicable, the person authorized to consent on the patient's behalf.

2. Effective Period for a Signed Durable DNR Order - A signed Durable DNR Order shall remain valid until revoked in accordance with § 54.1-2987.1 of the Code of Virginia and 12VAC5-66-80 E or until rescinded, in accordance with accepted medical practice, by the provider who issued the Durable Do Not Resuscitate Order.

3. Durable DNR Order Form - A Durable DNR Order or Alternate Durable DNR jewelry that complies with 12VAC5-66-50 shall be valid for the purposes of withholding or withdrawing cardiopulmonary resuscitation by qualified health care personnel in the event of cardiac or respiratory arrest.

4. Availability of the Durable DNR Order Form. The An original or a legible photocopy of the Durable DNR Order Form that complies with this section or Alternate Durable DNR jewelry that complies with 12VAC5-66-50, POST Form, or POLST Form shall be maintained and readily available to qualified health care personnel at the patient's current location or residence.

5. Qualified health care personnel may honor a legible photocopy of a Durable DNR Form or Other Durable DNR Order as if it were an original.

6. A patient who is traveling outside his home or between health care facilities should have an original or photocopied Durable DNR Order, Other Durable DNR Order, or Alternate Durable DNR jewelry accompany him.

7. Distribution of Durable DNR Order Forms - The authorized Virginia 5. Three identical Durable DNR Order Form Forms shall be a standardized form available for download via the Internet from the Office of Emergency Medical Services website. The downloadable form will contain directions for completing the form and three identical Durable DNR Order Forms: one original form filled out and distributed as follows:

a. Copy one - to be kept by the patient, the second .

b. Copy two - to be placed kept in the patient's permanent medical record, and the third.

c. Copy three - to be used by the patient for requesting to order Alternate Durable DNR jewelry.

8. Hard copies of the 6. A Durable DNR Order Form shall also be made available to physicians or licensed health care facilities by the Office of EMS. The Office of EMS may utilize a vendor to print and distribute the Durable or Other DNR Order Form and a nominal fee may be charged in an amount necessary to cover printing and shipping fees may only be revoked in accordance with § 54.1-2987.1 D of the Code of Virginia.

12VAC5-66-50. Authorized alternate Alternate Durable DNR jewelry.

The board authorizes the use of Alternate Durable DNR jewelry in conjunction with the issuance of a Durable DNR Order. These A. Alternate Durable DNR jewelry items shall be uniquely-designed and, uniquely-identifiable bracelets and necklaces that are, and available only from a vendor seller approved by the Virginia Department of Health, Office of EMS. The Alternate Durable DNR jewelry must be purchased from the approved vendor by the person

B. Only the patient to whom a Durable DNR Order Form applies, or the person authorized to consent on the patient's behalf may purchase Alternate Durable DNR jewelry.

An original C. The person to whom a Durable DNR Order Form must be obtained from a physician and provided to the vendor in order to receive Alternate Durable DNR jewelry. Such a necklace or bracelet may be utilized either to validate the applies or the person authorized to consent on the patient's behalf shall present the Durable DNR Order in the event that the original order is not readily available at the site where the person to whom the order applies is found. In order to be honored by qualified health care personnel in place of the standard Durable DNR Order Form, the to the approved seller for purchase of approved Alternate Durable DNR jewelry must contain the minimum information approved by the State Board of Health in 12VAC5-66-60.

D. The Alternate Durable DNR jewelry shall display the following information:

1. The words: Do Not Resuscitate;

2. The patient's full legal name;

3. The physician's name and telephone number; and

4. The Virginia Durable DNR issuance date.

12VAC5-66-60. Other DNR Orders.

A. Nothing in these regulations this chapter shall be construed to preclude licensed health care practitioners from following any Other Do Not Resuscitate Order in accordance with the applicable policies and procedures of the health care facility in which they practice.

B. Qualified health Health care personnel are authorized to shall honor any an Other Do Not Resuscitate (DNR) Order as if it were a Durable Do Not Resuscitate Order when if the Other DNR Order includes the information required in 12VAC5-66-40 and the patient is currently admitted to a hospital or other or in transit from a qualified health care facility or is in transit from a qualified health care facility provided that such order includes the same information as listed in subdivision 1 of 12VAC5-66-40, except that an Other DNR Order shall not be required to include the signature of the patient or a person authorized to consent for the patient on the order itself.

C. Nothing in these regulations this chapter shall prohibit qualified health care personnel from following any a direct verbal order issued by a licensed physician not to resuscitate a patient in cardiac or respiratory arrest when such the physician is physically present.

Part IV

Implementation Procedures

12VAC5-66-70. Issuance of a Durable DNR Order. (Repealed.)

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.

12VAC5-66-80. Durable DNR Order implementation procedures.

A. Qualified health Health care personnel shall comply with the following general procedures and published Virginia Durable DNR Order Implementation Protocols follow the procedures in this section when caring for a patient who is in cardiac or respiratory arrest and who is known or suspected to may have a Durable DNR Order in effect.

B. Initial assessment and intervention. Perform Health care personnel shall initiate 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. Health care personnel may withhold or terminate resuscitation efforts only when:

1. An intact, unaltered original or photocopy of the Durable DNR Order Form, POST Form, or POLST Form, approved Alternate Durable DNR jewelry or Other DNR Order is located; and

2. The patient for whom the Durable DNR Order or Other DNR Order was issued is verified by identification with a photograph and signature or by positive identification by a family member or other person who knows the patient.

D. If the Durable DNR Order or Other DNR Order is intact, unaltered, and verified as issued for the patient, health care personnel may consider it valid.

E. 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 patient's 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:

F. Health care personnel may provide the following interventions to a patient with a valid Durable DNR Order or Other DNR Order to provide comfort care or to alleviate pain.

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 G. If 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 If 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. 1. Describe assessment of the patient's cardiac or respiratory arrest status.;

3. 2. Document which identification (e.g., Durable DNR Order Form, 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 and not officially revoked.; and

4. 3. Record the name of the patient's physician who issued the Durable DNR Order, or Other DNR Order.

5. H. If the patient is being transported, keep the Durable DNR Order, Alternate Durable DNR jewelry, or Other DNR Order shall remain with the patient.

G. General considerations. The following general principles shall apply to implementation of all Durable DNR Orders.

1. I. If there is misunderstanding with family members or others present at the patient's location or if there are other concerns about following contest the Durable DNR Order or Other DNR Order, EMS personnel shall contact the patient's physician or EMS medical control for guidance.

2. J. If there is any question about the validity of a Durable DNR Order, resuscitative measures should shall be administered until the validity of the a Durable DNR Order or Other DNR Order is established confirmed.

FORMS (12VAC5-66)

Durable Do Not Resuscitate Order - Virginia Department of Health, EMS-7105 (eff. 6/2011)

National POLST Form (eff. 4/2023)

Virginia Physician Order for Scope of Treatment Form (rev. 5 2017)