Sec. 4.
A do-not-resuscitate order executed under section 3 or 3a shall include, but is not limited to, the following language, and shall be in substantially the following form:
| "DO-NOT-RESUSCITATE ORDER |
| This do-not-resuscitate order is issued by |
| _______________________________________, attending physician for |
| _________________________________________. |
| (Type or print declarant's or ward'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 (Date) |
| declarant, if applicable) |
| _______________________________________ |
| (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. 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.". |
History: 1996, Act 193, Eff. Aug. 1, 1996 ;-- Am. 2013, Act 155, Eff. Feb. 4, 2014
Last modified: October 10, 2016