Printable Do Not Resuscitate Form Michigan PRINT Witness s name Date mm dd yyyy Witness signature PRINT Witness s name Date mm dd yyyy THIS FORM WAS PREPARED PURSUANT TO AND IN COMPLIANCE WITH THE MICHIGAN DO NOT RESUSCITATE DECLARATION PROCEDURE ACT 1996 PA 193 PROVIDERS PLEASE RETAIN A COPY OF ALL PAGES FOR THE MEDICAL RECORD Do Not Resuscitate Declaration page 1 of 1
Under state law a do no resuscitate order is valid outside of a health care facility A specific bracelet may be worn to signal that an order has been signed When the order is present or the bracelet is worn and emergency responder cannot start resuscitation Some people don t want any special efforts made to prolong their life Many people Upon executing this order the individual has has not received an identification bracelet 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
Printable Do Not Resuscitate Form Michigan
Printable Do Not Resuscitate Form Michigan
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Michigan DNR Order Completion Instructions 1 Make a copy of the Michigan Do Not Resuscitate form If you do not have a copy it can be found at Print this person s name in the type or print full name location Section C GUARDIAN CONSENT 1 If the patient has a legal guardian the guardian may execute the DNR order on the patient If a do not resuscitate order form is presented and is not substantially in the form Type or print witness s name THIS FORM WAS PREPARED PURSUANT TO AND IS IN COMPLIANCE WITH THE MICHIGAN DO NOT RESUSCITATE ACT ANNEX 1 Michigan General Procedures DO NOT RESUSCITATE Date revised March 25 2014 Page 5 of 6
Fact Sheet Do Not Resuscitate DNR Order What is a Do Not Resuscitate DNR order Under Michigan law a do not resuscitate order is a voluntarily signed form by either a person a patient advocate or a guardian The order states that if the person s heart or breathing stops there should be no resuscitation efforts made Resuscitation efforts OBTAINING THE FORM There are several ways to get a DNR order form 1 Blank DNR orders can be purchased 5 65 per pack of 25 and can be ordered through the McKesson E Requisition System item form 2 Calling NMSA Forms Inventory at 231 935 8228 to order a pack if you do not have access to the McKesson E Requisition System
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This act shall be known and may be cited as the Michigan do not resuscitate procedure act History 1996 Act 193 Eff Aug 1 1996 333 1052 Definitions An order executed under this section must be on a form described in section 4 The order must be dated executed voluntarily and signed by each of the following individuals Sample Do Not Resuscitate Order This is a sample out of hospital DNR form as specified in the Michigan DNR Procedures Act This form can be branded and utilized as per organizational policy for any individual 18 years or older or those with religious considerations who do not want resuscitation outside the acute care setting Download DNR
Type or print witness s name Type of print witness s name This form was prepared pursuant to and in compliance with The Michigan do not resuscitate procedure act ANNEX 1 Detroit East 2 1 2024 11 21 2023 Michigan PROCEDURES DO NOT RESUSCITATE Initial Date 5 31 2012 1 The first paragraph requires you as the patient to fill in the full name of your physician the one who will also sign this Michigan DNR form 2 The second paragraph will require your signature the signature of your representative if this is the case and the signature of the physician whose name was written down before 3
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https://www.med.umich.edu/1libr/AdvanceDirectives/Do-Not-ResuscitateDeclaration-MichiganDNRProcedureAct.pdf
PRINT Witness s name Date mm dd yyyy Witness signature PRINT Witness s name Date mm dd yyyy THIS FORM WAS PREPARED PURSUANT TO AND IN COMPLIANCE WITH THE MICHIGAN DO NOT RESUSCITATE DECLARATION PROCEDURE ACT 1996 PA 193 PROVIDERS PLEASE RETAIN A COPY OF ALL PAGES FOR THE MEDICAL RECORD Do Not Resuscitate Declaration page 1 of 1
https://www.michigan.gov/mdhhs/adult-child-serv/adults-and-seniors/sevicesseniors/endoflife/circle/michigans-do-not-resuscitate-procedure-act
Under state law a do no resuscitate order is valid outside of a health care facility A specific bracelet may be worn to signal that an order has been signed When the order is present or the bracelet is worn and emergency responder cannot start resuscitation Some people don t want any special efforts made to prolong their life Many people
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Free Printable Do Not Resuscitate DNR Order Forms Example
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Printable Do Not Resuscitate Form Michigan - If a do not resuscitate order form is presented and is not substantially in the form Type or print witness s name THIS FORM WAS PREPARED PURSUANT TO AND IS IN COMPLIANCE WITH THE MICHIGAN DO NOT RESUSCITATE ACT ANNEX 1 Michigan General Procedures DO NOT RESUSCITATE Date revised March 25 2014 Page 5 of 6
