Michigan Living Will Template
This Living Will is designed to comply with the Michigan Do-Not-Resuscitate Procedure Act and other relevant Michigan statutes. It is a legally binding document that outlines the medical treatments you wish to receive, or not receive, should you become unable to communicate your decisions due to illness or incapacity.
Personal Information
Full Legal Name: _________________________
Date of Birth: _________________________
Address: _________________________
City: _________________________, State: Michigan, Zip Code: _________________________
Phone Number: _________________________
Email: _________________________
Agent Information
If you are unable to make health care decisions for yourself, an agent may do so on your behalf. Please provide the following information about your designated agent:
Agent's Full Name: _________________________
Relationship to You: _________________________
Phone Number: _________________________
Alternate Phone Number: _________________________
Directives
If I am in a condition specified below, I direct that my health care providers and my agent follow the instructions I have marked:
- In the case of terminal illness, where recovery is not expected:
- ____ I wish to receive all available treatment, extending life as long as possible.
- ____ I wish to receive only treatments that are necessary for my comfort and to ease pain, but not those intended to extend life.
- If I am in a coma or persistent vegetative state that doctors reasonably feel to be irreversible:
- ____ I wish to receive all available treatment, extending life as long as possible.
- ____ I wish to receive only treatments that are necessary for my comfort and to ease pain, but not those intended to extend life.
- If I require artificial nutrition and hydration (tube feeding):
- ____ I wish to receive this treatment.
- ____ I do not wish to receive this treatment.
Signature
This document reflects my wishes. I have discussed these wishes with my family, my healthcare agent, and my healthcare providers. I understand the consequences of having a Living Will, and I am mentally competent to make these decisions.
Signature: _________________________
Date: _________________________
Witness (1) Signature: _________________________
Date: _________________________
Witness (2) Signature: _________________________
Date: _________________________
Notarization (Optional)
This section is not required for your Living Will to be valid in Michigan, but you may choose to have it notarized for additional legal assurance.
State of Michigan, County of _________________________
On this day, my authority is personally appeared _________________________, known to me (or proved to me on the oath of _________________________ ) to be the person whose name is subscribed to the within instrument, and acknowledged that he/she executed the same for the purposes therein contained.
In Witness Whereof, I have hereunto set my hand and official seal.
Notary Public Signature: _________________________
My Commission Expires: _________________________