A do-not-resuscitate order executed under section 3, 3a, or 3b must include, but is not limited to, the following language, and must be in substantially the following form:
"DO-NOT-RESUSCITATE
ORDER |
This
do-not-resuscitate order is issued by _______________________________________,
attending physician for _________________________________________. |
(Type
or print declarant's, ward's, or minor child's name) |
Use the
appropriate consent section below: |
A.
DECLARANT CONSENT |
I
have discussed my health status with my physician named above. 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) |
_______________________________________ |
_______________ |
(Signature
of person who signed for declarant, if applicable) |
(Date) |
_______________________________________ |
|
(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) |
|
C.
PARENT CONSENT |
I
authorize that in the event the minor child's heart and breathing should
stop, no person shall attempt to resuscitate the minor child. 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. |
_______________________________________ |
_______________ |
(Parent's
signature) |
(Date) |
_______________________________________ |
|
(Type
or print parent's name) |
|
_______________________________________ |
_______________ |
(Parent's
signature) |
(Date) |
_______________________________________ |
|
(Type
or print parent's name) |
|
D.
GUARDIAN CONSENT |
I
authorize that in the event the ward's heart and breathing should stop, no
person shall attempt to resuscitate the ward. 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. |
_______________________________________ |
_______________ |
(Guardian's
signature) |
(Date) |
_______________________________________ |
|
(Type
or print guardian's 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 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.". |
|
|
|
|
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