Sec. 4.
A do-not-resuscitate order executed under section 3 shall include, but is not limited to, the following language, and shall be in substantially the following form:
| "DO-NOT-RESUSCITATE ORDER |
|
|
| I have discussed my health status with my physician, |
| _____________________________. I request that in the event my |
| heart and breathing should stop, no person shall attempt to |
| resuscitate me. |
| This order is effective until it is revoked by me. |
| 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 (Date) |
| declarant, if applicable) |
| _____________________________________ |
| (Type or print full 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 individual 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.". |
