2010 Michigan Compiled Laws
Chapter 333 - HEALTH
Act 193 of 1996 - MICHIGAN DO-NOT-RESUSCITATE PROCEDURE ACT (333.1051 - 333.1067)
Section 333.1054 - Execution of order; form.

Act 193 of 1996

333.1054 Execution of order; form.

Sec. 4.

A do-not-resuscitate order executed under section 3 shall include, but is not limited to, the following language, and shall be in substantially the following form:

"DO-NOT-RESUSCITATE ORDER I have discussed my health status with my physician, _____________________________. I request that in the event my heart and breathing should stop, no person shall attempt to resuscitate me. This order is effective until it is revoked by me. 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) _____________________________________ _______________ (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 individual 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

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