Michigan § 333.1054 - Execution of order; form; language.

"DO-NOT-RESUSCITATE ORDER

This do-not-resuscitate order is issued by _______________________________________, attending physician for _________________________________________.

(Type or print declarant's, ward's, or minor child's name)

Use the appropriate consent section below:

A. DECLARANT CONSENT

I have discussed my health status with my physician named above. I request that in the event my heart and breathing should stop, no person shall attempt to resuscitate me. This order will remain in effect until it is revoked as provided by law. Being of sound mind, I voluntarily execute this order, and I understand its full import.

_______________________________________

_______________

(Declarant's signature)

(Date)

_______________________________________

_______________

(Signature of person who signed for declarant, if applicable)

(Date)

_______________________________________

(Type or print full name)

B. PATIENT ADVOCATE CONSENT

I authorize that in the event the declarant's heart and breathing should stop, no person shall attempt to resuscitate the declarant. I understand the full import of this order and assume responsibility for its execution. This order will remain in effect until it is revoked as provided by law.

_______________________________________

_______________

(Patient advocate's signature)

(Date)

_______________________________________

(Type or print patient advocate's name)

C. PARENT CONSENT

I authorize that in the event the minor child's heart and breathing should stop, no person shall attempt to resuscitate the minor child. I understand the full import of this order and assume responsibility for its execution. This order will remain in effect until it is revoked as provided by law.

_______________________________________

_______________

(Parent's signature)

(Date)

_______________________________________

(Type or print parent's name)

_______________________________________

_______________

(Parent's signature)

(Date)

_______________________________________

(Type or print parent's name)

D. GUARDIAN CONSENT

I authorize that in the event the ward's heart and breathing should stop, no person shall attempt to resuscitate the ward. I understand the full import of this order and assume responsibility for its execution. This order will remain in effect until it is revoked as provided by law.

_______________________________________

_______________

(Guardian's signature)

(Date)

_______________________________________

(Type or print guardian's name)

_______________________________________

_______________

(Physician's signature)

(Date)

_______________________________________

(Type or print physician's full name)

ATTESTATION OF WITNESSES

The individual who has executed this order appears to be of

sound mind, and under no duress, fraud, or undue influence.

Upon executing this order, the declarant has (has not)received

an identification bracelet.

________________________________

________________________________

(Witness signature)

(Date)

(Witness signature)

(Date)

________________________________

________________________________

(Type or print witness's name)

(Type or print witness's name)

THIS FORM WAS PREPARED PURSUANT TO, AND IS IN COMPLIANCE WITH, THE MICHIGAN DO-NOT-RESUSCITATE PROCEDURE ACT.".