This Living Will is designed in accordance with the Michigan Do-Not-Resuscitate Procedure Act and pertains specifically to residents of Michigan. It is used to document your wishes regarding medical treatment in situations where you are unable to communicate them yourself.
Full Legal Name: _______________________________________________
Date of Birth: ________________
Address: ______________________________________________________
City: ______________________ State: MI Zip: _________________
Primary Phone: ____________________ Secondary Phone: ________________
Declaration
I, _________________________, being of sound mind, hereby direct that my life should not be extended by life-sustaining treatment, if
- I suffer from an irreversible, incurable, and terminal condition confirmed by two physicians and
- I am unable to participate in decisions regarding my medical treatment and
- The application of life-sustaining treatment would only serve to artificially prolong the dying process.
I understand the full significance of this declaration and I am emotionally and mentally competent to make this declaration.
Additional Instructions (Optional):
________________________________________________________________
________________________________________________________________
Signature: _______________________________ Date: _________________
Witness Section
This document must be signed in the presence of two adult witnesses, who are not related to me by blood, marriage, or adoption, and not entitled to any portion of my estate according to the laws of Michigan or under any will of mine or codicil thereto, or directly financially responsible for my medical care.
Witness 1 Name: _______________________________________________
Signature: _______________________________ Date: _________________
Address: ______________________________________________________
Witness 2 Name: _______________________________________________
Signature: _______________________________ Date: _________________
Address: ______________________________________________________
Physician Acknowledgment
This section is to be completed by a physician to acknowledge receipt and understanding of this living will.
Physician’s Name: _____________________________________________
Signature: _______________________________ Date: _________________
Address: ______________________________________________________
By signing this document, I acknowledge that the patient named above has discussed their decisions regarding life-sustaining treatment with me. I have informed the patient of their medical condition, the nature of the life-sustaining treatment, and its likely impact on the patient’s medical condition.