Michigan Compiled Laws § 333.1056 Execution Of Order Under Mcl 333.1055; Form.

333.1056 Execution of order under MCL 333.1055; form.

Sec. 6.

A do-not-resuscitate order executed for an adherent of a church or religious denomination under section 5 shall include, but is not limited to, the following language, and shall be in substantially the following 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 (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)

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

Section: Previous  333.1051  333.1052  333.1053  333.1053a  333.1054  333.1055  333.1056  333.1057  333.1058  333.1059  333.1060  333.1061  333.1062  333.1063  333.1064  Next

Last modified: October 10, 2016