Michigan Compiled Laws, Chapter 333. Health § 333.1054

“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)

____________________________________________________________

________________________

(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)

    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.”.