Blank Living Will Form for Michigan State

Michigan Living Will Template

This Michigan Living Will is made in accordance with the Michigan Compiled Laws, specifically sections pertaining to advance directives and end-of-life decisions. It serves as a directive for the medical treatment preferences of the undersigned, in the event that they are unable to communicate their wishes due to illness or injury.

Personal Information

Name: ___________________________________

Date of Birth: ___________________________

Address: ________________________________

City: _________________ State: MI Zip: _________

Phone Number: ____________________________

Directive

I, __________________________ [insert your name], resident of the State of Michigan, being of sound mind, willfully and voluntarily declare my desire that my dying shall not be artificially prolonged under the circumstances set forth below. I hereby direct that, if I am in an end-stage medical condition or am permanently unconscious, the following treatments be withheld or withdrawn:

1. Life-prolonging procedures that serve only to prolong the dying process and do not address my comfort or the alleviation of pain.
2. Artificially provided food and water (tube feeding).
3. Mechanical respiration.
4. Cardiopulmonary resuscitation (CPR).
5. Antibiotics, if my quality of life would not benefit from their use.

Power of Attorney Designation

I hereby designate the following individual as my durable power of attorney for health care, to make decisions on my behalf should I become unable to do so:

Name: ___________________________________

Relationship to me: ______________________

Phone Number: ____________________________

Should the above-named individual be unwilling or unable to serve, I designate the following alternative:

Name: ___________________________________

Relationship to me: ______________________

Phone Number: ____________________________

Signature

I understand the full import of this declaration and I am emotionally and mentally competent to make this declaration.

Signature: _______________________________ Date: _________________

Witnesses (must not be relatives or beneficiaries):

1. Name: ____________________________ Signature: ____________________________ Date: _________
2. Name: ____________________________ Signature: ____________________________ Date: _________

Note: This document does not authorize the withholding of comfort care, including the provision of pain relief, and does not constitute a suicide or assisted suicide document. The directives stated herein apply only when the possibility of recovery to a meaningful quality of life, as judged by the individual or their designated power of attorney, has been deemed medically and reasonably impossible.