Michigan Do Not Resuscitate Order Template
This Do Not Resuscitate (DNR) Order is created in accordance with Michigan law regarding advance directives. It allows individuals to express their wishes regarding resuscitation in the event of a medical emergency.
Patient Information:
- Name: ___________________________
- Date of Birth: ___________________
- Address: _________________________
- City, State, Zip: ________________
Physician Information:
- Physician's Name: ________________
- Physician's Phone Number: ________
- Medical License Number: __________
Patient's Wishes:
I, the undersigned, declare that I do not wish to receive cardiopulmonary resuscitation (CPR) in the event of cardiac arrest or respiratory failure. This decision is made after careful consideration of my medical condition and treatment options.
Signature:
__________________________________
Date: ____________________________
Witness Information:
- Witness Name: ___________________
- Witness Signature: _______________
- Date: ___________________________
This DNR Order is valid in the state of Michigan and should be presented to medical personnel in case of an emergency. It is recommended to keep a copy in a visible location and to inform family members of its existence.