Do-Not-Resuscitate Order
"As treating physician, physician's assistant, or advanced practice registered nurse of
____________________________ and a licensed physician, physician's assistant, or advanced practice registered nurse, I order that this person SHALL NOT BE RESUSCITATED in the event of cardiac or respiratory arrest. This order has been discussed with___________________________________ or his/her representative____________________________________ or his/her surrogate decisionmaker____________________________ who has given consent as evidenced by his/her signature below.
Provider Name
_________________________________________________
Provider Signature __________________________________________________
Address ______________________________________________________________
Person Signature ________________________________________________________
Address _______________________________________________________________
Surrogate Decision Maker Signature _________________________________________
Address ______________________________________________________________ ".
W. Va. Code § 16-30C-6