Michigan Advance Health Care Directive(Living Will)

LivingWill

voluntarilymakethisdeclaration.

amofsoundmind,andI

IfIbecometerminallyillorpermanentlyunconsciousasdeterminedbymydoctorandatleastoneotherdoctor,andifIamunabletoparticipateindecisionsregarding my medical care, I intend this declaration to be honored as theexpressionofmylegalrighttoauthorizeorrefusemedicaltreatment.

Mydesiresconcerningmedicaltreatmentare-

Myfamily,themedicalfacility,andanydoctors,nursesandothermedicalpersonnel involved in my care shall have no civil or criminal liability forfollowingmywishesasexpressedinthisdeclaration.

Imaychangemymindatanytimebycommunicatinginanymannerthatthisdeclarationdoesnotreflectmywishes.

Photostaticcopiesofthisdocument,afteritissignedandwitnessed,shallhavethesamelegalforceastheoriginaldocument.

Isignthisdocumentaftercarefulconsideration.IunderstanditsmeaningandIacceptitsconsequences.

Dated:

Signed:

(Yoursignature)

(Address)

STATEMENTOFWITNESSES

Wesignbelowaswitnesses. Thisdeclarationwassignedinourpresence.Thedeclarantappearstobeofsoundmind,andtobemakingthisdesignationvoluntarily,withoutduress,fraudorundueinfluence.

(PrintName)(SignatureofWitness)

(Address)

(PrintName)(SignatureofWitness)

(Address)

DO-NOT-RESUSCITATEORDER

Ihavediscussedmyhealthstatuswithmyphysician,.

Irequestthatintheeventmyheartandbreathingshouldstop,nopersonshallattempttoresuscitateme.

Thisorderiseffectiveuntilitisrevokedbyme.

Beingofsoundmind,Ivoluntarilyexecutethisorder,andIunderstanditsfullimport.

(Declarant’ssignature)(Date)

(Typeorprintdeclarant’sfullname)

(Signatureofpersonwhosignedfordeclarant,ifapplicable)(Date)

(Typeorprintfullname)

(Physician’ssignature)(Date)

(Typeorprintphysician’sfullname)

ATTESTATIONOFWITNESSES

Theindividualwhohasexecutedthisorderappearstobeofsoundmind,andundernoduress,fraud,orundueinfluence. Uponexecutingthisorder,theindividualhas(hasnot)receivedanidentificationbracelet.

(Witnesssignature)(Date)(Witnesssignature)(Date)

(Typeorprintwitness’sname)(Typeorprintwitness’sname)

THISFORMWASPREPAREDPURSUANTTO,ANDINCOMPLIANCEWITH,THEMICHIGANDO-NOT-RESUSCITATEPROCEDUREACT

DO-NOT-RESUSCITATEORDER

Irequestthatintheeventmyheartandbreathingshouldstop,nopersonshallattempttoresuscitateme.

Thisorderiseffectiveuntilitisrevokedbyme.

Beingofsoundmind,Ivoluntarilyexecutethisorder,andIunderstanditsfullimport.

(Declarant’ssignature)(Date)

(Typeorprintdeclarant’sfullname)

(Signatureofpersonwhosignedfordeclarant,ifapplicable)(Date)

(Typeorprintfullname)

ATTESTATIONOFWITNESSES

Theindividualwhohasexecutedthisorderappearstobeofsoundmind,andundernoduress,fraud,orundueinfluence. Uponexecutingthisorder,theindividualhas(hasnot)receivedanidentificationbracelet.

(Witnesssignature)(Date)(Witnesssignature)(Date)

(Typeorprintwitness’sname)(Typeorprintwitness’sname)

THISFORMWASPREPAREDPURSUANTTO,ANDINCOMPLIANCEWITH,THEMICHIGANDO-NOT-RESUSCITATEPROCEDUREACT