Michigan Do Not Resuscitate Order Template
This Do Not Resuscitate (DNR) Order is created in accordance with Michigan law, specifically the Michigan Compiled Laws (MCL) 333.1051 et seq. It is intended to provide clear instructions regarding the wishes of the individual named below in the event of a medical emergency.
Patient Information:
- Patient Name: ______________________________
- Date of Birth: ______________________________
- Address: ______________________________
- City, State, Zip: ______________________________
Physician Information:
- Physician Name: ______________________________
- Medical License Number: ______________________________
- Practice Name: ______________________________
- Contact Number: ______________________________
Order Statement:
I, the undersigned patient, hereby declare that I do not wish to receive cardiopulmonary resuscitation (CPR) or any other life-sustaining treatment in the event of cardiac or respiratory arrest. This order is valid unless revoked by me or my legally authorized representative.
Signature: ___________________________________
Date: ___________________________________
Witness Information:
- Witness Name: ______________________________
- Witness Signature: ______________________________
- Date: ______________________________
This DNR Order should be kept in a location where it can be easily accessed by medical personnel and should be presented during any medical emergency. It is recommended to provide copies to family members and healthcare providers.