Michigan Living Will
This Living Will is designed in accordance with the Michigan Compiled Laws, specifically addressing aspects related to health care decisions and directives when an individual becomes incapacitated. This document allows you to communicate your wishes about medical treatment in situations where you are unable to make decisions for yourself.
Part I: Information
Full Name: ___________________________________________________________
Date of Birth: _________________________
Address: ______________________________________________________________
City: ________________________ State: Michigan Zip: _________________
Primary Phone: _____________________ Alternate Phone: ________________
Email: ________________________________________________________________
Part II: Health Care Directives
This section allows you to outline your preferences for medical treatment if you are in a terminal condition, in a persistent vegetative state, or otherwise unable to communicate your wishes directly.
- Life-sustaining Treatment:
I ____ (initial here) do not want life-sustaining treatment if I am in a terminal condition or permanently unconscious. I understand this may include mechanical ventilation, dialysis, surgical procedures, and other treatments aimed at prolonging my life but not curing my underlying condition.
- Artificial Nutrition and Hydration:
I ____ (initial here) do not want artificial nutrition (feeding) and hydration (fluids) if the provision of such treatments will only serve to prolong the process of dying or I am permanently unconscious.
- Pain Management and Comfort Care:
I ____ (initial here) wish to receive medication or treatment to alleviate pain and discomfort, even if it may hasten my death, as long as it provides significant relief and improves my quality of life.
- Other Instructions:
__________________________________________________________________________
__________________________________________________________________________
Part III: Designation of Patient Advocate
This section allows you to appoint a patient advocate to make health care decisions on your behalf if you are unable to participate in medical treatment decisions. Your patient advocate will have the authority to make decisions in line with your preferences as stated in this document.
Patient Advocate's Name: _______________________________________________
Relationship to You: ___________________________________________________
Primary Phone: _____________________ Alternate Phone: ________________
Address: ______________________________________________________________
City: ________________________ State: ___________ Zip: _________________
In the event that my first choice is unable or unwilling to act as my patient advocate, I designate the following individual as my alternate patient advocate:
Alternate Patient Advocate's Name: ________________________________________
Relationship to You: _____________________________________________________
Primary Phone: _____________________ Alternate Phone: ________________
Address: ______________________________________________________________
City: ________________________ State: ___________ Zip: _________________
Part IV: Signature
I understand that I have the right to revoke this document at any time. I am fully aware of the nature and contents of this directive. This document expresses my legal directions, which should be followed if I am unable to communicate my wishes personally.
______________________________________
Signature
______________________________________
Date
Witnesses:
To affirm the principal's signature, two witnesses or a notary public must sign below, confirming that the principal appears to understand the nature and significance of this Living Will and is free from duress or undue influence at the time of signing.
- Witness 1 Name: ____________________________________________________
Signature: ________________________________ Date: _____________
Address: ________________________________________________________
- Witness 2 Name: ____________________________________________________
Signature: ________________________________ Date: _____________
Address: ________________________________________________________