Michigan Advance Health Care Directive(Living Will)
LivingWill
I,
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