Structure
The Michigan Do Not Resuscitate (DNR) Order form serves as a crucial document for individuals who wish to express their preferences regarding medical interventions in the event of a life-threatening situation. This form is particularly relevant for patients with terminal illnesses or those who wish to avoid aggressive resuscitation efforts. It allows individuals to communicate their desire not to receive cardiopulmonary resuscitation (CPR) and other life-sustaining treatments if their heart stops beating or they stop breathing. The form must be completed and signed by a licensed physician, ensuring that the decision is informed and medically appropriate. Importantly, the DNR Order is recognized across various healthcare settings, including hospitals and nursing homes, providing clarity and respect for the patient's wishes. Additionally, it is essential for individuals to discuss their choices with family members and healthcare providers, as this can facilitate understanding and support during difficult times. In Michigan, this form is not just a piece of paper; it represents a significant aspect of patient autonomy and end-of-life care planning.
Form Example
Michigan Do Not Resuscitate Order
This Do Not Resuscitate (DNR) order template is in accordance with the Michigan Do Not Resuscitate Procedure Act (Public Act 193 of 1996). It is designed to inform medical personnel that the individual named in this document has chosen not to have resuscitation attempts in the event of cardiac or respiratory arrest. Completion and presentation of this document signify the individual's or their authorized representative's clear wish to forego resuscitation efforts.
Personal Information
Patient's Full Name: ___________________________________________________
Date of Birth: ________________________________________________________
Address: _____________________________________________________________
City: ________________ State: MI Zip Code: _______________
Do Not Resuscitate Declaration
I, _____________________________, understand the full implications of this decision and willingly choose to forego resuscitative measures in the event of a cardiac or respiratory arrest. I acknowledge that this decision does not affect the provision of other emergency medical care, including the Heimlich maneuver or emergency surgery, if necessary.
Witness Declaration
This section must be completed in the presence of two adult witnesses who are not related to the patient by blood, marriage, or adoption, and who do not stand to inherit any part of the patient's estate upon death, nor are they the patient's health care provider or employee of a life or health insurance provider for the patient.
Signatures
Patient's Signature: _____________________________________ Date: ___________
Printed Name: ___________________________________________
Witness 1 Signature: _____________________________________ Date: ___________
Printed Name: ___________________________________________
Witness 2 Signature: _____________________________________ Date: ___________
Printed Name: ___________________________________________
Physician Certification
The below-signed medical practitioner certifies that they have discussed the implications and the nature of a Do Not Resuscitate order with the patient or their authorized representative. This certification also indicates that the patient or the patient's authorized representative has the capacity to make this decision and has voluntarily chosen a DNR status.
Physician's Signature: ____________________________________ Date: ___________
Printed Name: ___________________________________________
License Number: _________________________________________
Address: ________________________________________________
City: ________________ State: MI Zip Code: _______________
Please note that presenting this document to healthcare personnel legally binds them to follow the directives contained herein, within the limitations of Michigan law.
Document Properties
| Fact Name | Description |
|---|---|
| Purpose | The Michigan Do Not Resuscitate (DNR) Order form allows individuals to express their wishes regarding resuscitation efforts in the event of cardiac or respiratory arrest. |
| Governing Law | The DNR Order in Michigan is governed by the Michigan Public Health Code, specifically MCL 333.1051 et seq. |
| Eligibility | Any adult can complete a DNR Order, but it must be signed by a physician to be valid. |
| Form Availability | The DNR Order form is available online and can also be obtained from healthcare providers or hospitals. |
| Revocation | Individuals can revoke their DNR Order at any time, verbally or in writing, and this revocation must be documented. |
| Emergency Medical Services | Emergency Medical Services (EMS) personnel are required to honor a valid DNR Order, ensuring that the individual's wishes are respected during emergencies. |
| Notification | It is crucial for individuals to inform family members and healthcare providers about the existence of a DNR Order to avoid confusion during medical emergencies. |
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