This information is approved and/or reviewed by U-M Health System providers but it is not a tool for self-diagnosis or a substitute for medical treatment. You should speak to your physician or make an appointment to be seen if you have questions or concerns about this information or your medical condition. en Español | Complete disclaimer

(also available in printable PDF format with Physician signature or without Physician Signature from the State Bar of Michigan)

DO-NOT-RESUSCITATE ORDER

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 and Date)

___________________________________

(Type or print declarant's full name)

___________________________________ ___________________

(Signature of person who signed for declarant, if applicable and Date)

___________________________________

(Type or print 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 indentification bracelet.

_______________________________________

(Witness signature) (Date)

_______________________________________

(Type or print witness's name)

_______________________________________

(Witness signature) (Date)

_______________________________________

(Type or print witness's name)

THIS FORM WAS PREPARED PERSUANT TO, AND IN COMPLIANCE WITH, THE MICHIGAN DO-NOT-RESUSCITATE PROCEDURE ACT.

 

DO-NOT-RESUSCIATE 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 and Date)

___________________________________ ___________________

(Type or print declarant's full name and Date)

___________________________________ ___________________

(Signature of person who signed for declarant, if applicable and Date)

___________________________________

(Type or print full name)

___________________________________ ___________________

(Physician's signature and 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 indentification bracelet.

_________________________________

(Witness signature and Date)

_________________________________

(Type or print witness's name)

_________________________________

(Witness signature and Date)

_________________________________

.(Type or print witness's name)

THIS FORM WAS PREPARED PERSUANT TO, AND IN COMPLIANCE WITH, THE MICHIGAN DO-NOT-RESUSCITATE PROCEDURE ACT.