Michigan § 333.1056 - Execution of order under MCL 333.1055; form.

"DO-NOT-RESUSCITATE ORDER

Use the appropriate consent section below:

A. DECLARANT CONSENT

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)

_______________________________________

(Type or print declarant's full name)

_______________________________________

_______________

(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)

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.".