Michigan Legislature

  A do-not-resuscitate order executed for an adherent of a church or religious denomination under section 5 shall include, but is not limited to, the following language, and shall be in substantially the following form:

"DO-NOT-RESUSCITATE ORDER
Use the appropriate consent section below:
A. DECLARANT CONSENT
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)
_______________________________________
(Type or print declarant's full name)
_______________________________________		_______________
(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)
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.".