Michigan Do Not Resuscitate Order (DNR)
This document serves as a Do Not Resuscitate Order (DNR) in accordance with Michigan state laws. Complete the information below to establish your wishes regarding resuscitation efforts.
By signing this document, you are declaring your intent to refuse resuscitation in the event of cardiac or respiratory arrest.
Patient Information:
- Patient's Full Name: ________________
- Patient's Date of Birth: ________________
- Patient's Address: ________________
- Patient's Phone Number: ________________
Health Care Representative:
- Name: ________________
- Relationship to Patient: ________________
- Phone Number: ________________
Patient's Wishes:
I, the undersigned patient, do not wish to receive cardiopulmonary resuscitation (CPR) or other forms of resuscitation in the event of a cardiac or respiratory arrest.
Signature:
__________________________
Date:
__________________________
Witness Information:
- Witness Name: ________________
- Witness Signature: ________________
- Date: ________________
Make copies of this document and share them with your healthcare providers, family members, and anyone involved in your care. It is critical that your wishes are clearly understood and respected.
