Michigan Living Will Declaration
This Living Will Declaration is made in accordance with the Michigan Do-Not-Resuscitate Procedure Act (Public Act 193 of 1996). It serves to declare one's desires regarding life-sustaining treatment in the event of terminal illness or injury where recovery is not expected.
Please fill in the following information:
Full Name: ________________________________________________________
Date of Birth: _____________________________
Address: _________________________________________________________
City, State, Zip: _________________________________________________
Primary Phone: ___________________________________________________
Alternative Phone (Optional): ______________________________________
I, _________________________, being of sound mind and at least eighteen (18) years of age, hereby make known my desires regarding medical treatment, should I become unable to participate in decisions regarding my medical care, specifically in the situation where my attending physician has diagnosed me as suffering from a terminal condition that is expected to result in death within a relatively short time and where the application of life-sustaining measures would serve only to artificially prolong the dying process. I direct the following:
Life-Sustaining Treatment Preferences:
- If I am in a coma or a persistent vegetative state, and my doctors have concluded that there is no reasonable expectation of recovery, I do not want life-sustaining treatments, including but not limited to artificial respiration, cardiopulmonary resuscitation (CPR), and artificial means of nutrition and hydration.
- If I am terminal and recovery is not expected, I prefer to receive only such treatments as are necessary for my comfort and to alleviate pain, including pain relief medication even if it may hasten my death.
Designation of Patient Advocate:
I designate the following individual as my patient advocate to make medical treatment decisions on my behalf in the event that I become unable to participate in medical treatment decisions. My patient advocate shall have the power to make any and all health care decisions for me in accordance with my wishes, as stated in this document or as otherwise known to my advocate.
Patient Advocate's Name: ___________________________________________
Relationship to Me: _______________________________________________
Primary Phone: ___________________________________________________
Alternative Phone (Optional): ______________________________________
This document shall remain in effect until I revoke it in writing. I understand that I may revoke this declaration at any time.
Date: ________________________
Signature: __________________________
Witness Declaration:
We, the undersigned, declare that the person who signed this document is personally known to us, that he/she signed or acknowledged this Michigan Living Will in our presence, that he/she appears to be of sound mind and under no duress, fraud, or undue influence. We are not related by blood or marriage to the person who signed this document, nor are we entitled to any portion of his/her estate under a will or by operation of law, and we are not directly financially responsible for his/her medical care.
Witness 1 Signature: _______________________ Date: ________________________
Witness 2 Signature: _______________________ Date: ________________________