MICHIGAN DO-NOT-RESUSCITATE (“DNR”) DIRECTIVE
(MCL 333.1051 – .1067)
[// GUIDANCE: This template is built around the Michigan Do-Not-Resuscitate Procedure Act, Mich. Comp. Laws Ann. §§ 333.1051–.1067, and is intended for use by licensed Michigan attorneys. Customize bracketed fields, delete inapplicable options, and review all guidance comments before execution.]
TABLE OF CONTENTS
- Document Header
- Definitions
- Operative Provisions
- Representations & Warranties
- Covenants & Restrictions
- Default & Remedies
- Risk Allocation
- Dispute Resolution
- General Provisions
- Execution Block
1. DOCUMENT HEADER
1.1 Title and Parties
This Do-Not-Resuscitate Directive and Physician/Advanced Practice Clinician (“Directive”) is made by [PATIENT FULL LEGAL NAME] (“Patient”), date of birth [MM/DD/YYYY], Social Security No. [LAST 4], in consultation with:
a. [ATTENDING PHYSICIAN / PA / NURSE PRACTITIONER NAME & LICENSE NO.] (“Clinician”); and
b. (if applicable) [HEALTH CARE AGENT NAME], appointed under the Patient’s valid Patient Advocate Designation (“Agent”).
1.2 Recitals
A. The Patient is an adult of sound mind (or is otherwise authorized pursuant to MCL § 333.1054) and desires, in accordance with Michigan law, that cardiopulmonary resuscitation (“CPR”) not be attempted if both spontaneous respiration and heartbeat cease.
B. The Clinician, having determined that such instruction is medically appropriate, consents to issue a corresponding medical order.
C. This Directive is intended to be honored in all settings, including but not limited to the Patient’s residence, hospitals, extended-care facilities, and by emergency medical services (“EMS”) personnel.
1.3 Effective Date & Governing Law
This Directive is effective upon the latest signature date below (“Effective Date”) and shall be interpreted exclusively under the laws of the State of Michigan.
2. DEFINITIONS
For purposes of this Directive, the following terms have the meanings set forth below:
“Agent” – The individual designated under a valid Patient Advocate Designation to make health-care decisions for the Patient.
“CPR” – Any cardiopulmonary or advanced cardiac life support procedure to restart the heart or breathing.
“Directive” – This Michigan Do-Not-Resuscitate Directive and the medical order executed herein.
“EMS Personnel” – Personnel defined in MCL § 333.20904(5) who provide emergency medical services.
“Good Faith” – Honesty in fact in the conduct or transaction concerned, consistent with MCL § 333.1058(1).
“Qualified Witness” – An individual meeting the requirements of Section 3.6(b) of this Directive and MCL § 333.1053(1).
[// GUIDANCE: Add or delete defined terms to match final drafting.]
3. OPERATIVE PROVISIONS
3.1 Patient Instruction
The Patient hereby instructs that no CPR be administered if the Patient experiences cessation of both spontaneous respiration and heartbeat.
3.2 Clinician Order
Pursuant to MCL § 333.1052, the Clinician orders that no resuscitative measures be initiated on the Patient upon cardiopulmonary arrest. Health-care providers and EMS Personnel shall honor this order in compliance with MCL § 333.1057.
3.3 Scope of Application
This Directive applies:
a. In all health-care settings within Michigan; and
b. To all licensed or certified health-care providers, including EMS Personnel, who are presented with a valid copy, facsimile, or digital image of this Directive, or who observe a valid DNR identification bracelet compliant with MCL § 333.1064.
3.4 Consideration
The parties acknowledge receipt and sufficiency of mutual consideration, including the Patient’s reliance on Clinician’s professional services and Clinician’s reliance on statutory immunities for Good-Faith compliance.
3.5 Revocation
a. The Patient (or Agent while the Patient lacks decisional capacity) may revoke this Directive at any time by oral statement, destruction of the document, or removal of any DNR bracelet.
b. Upon revocation, the Clinician shall record the revocation in the Patient’s chart and notify, or cause notification of, EMS Personnel if reasonably practicable.
3.6 Form & Witness Requirements
a. Format. This Directive shall be executed on a single page, front and back, or on consecutive pages stapled together, each page bearing Patient’s initials.
b. Witnesses. Two Qualified Witnesses must sign Section 10.2. A Qualified Witness:
i. Is at least 18 years of age;
ii. Is not a spouse, parent, child, grandchild, sibling, presumptive heir, or beneficiary under the Patient’s will or trust;
iii. Does not bear financial responsibility for the Patient’s health-care;
iv. Is not the Clinician or an employee of the facility currently providing care to the Patient, unless the employee is a notary public and only signs in that capacity.
3.7 EMS Recognition
A properly executed Directive, or compliant DNR bracelet issued under MCL § 333.1064, constitutes a medical control order that EMS Personnel must honor by withholding resuscitation, absent revocation under Section 3.5.
4. REPRESENTATIONS & WARRANTIES
4.1 Patient represents and warrants that:
a. They are voluntarily executing this Directive after full disclosure of its consequences;
b. They have discussed the medical implications with the Clinician;
c. No undue influence has been exerted.
4.2 Clinician represents and warrants that:
a. The Patient (or Agent) has decision-making capacity or statutory authority;
b. The Clinician has explained alternatives to DNR and answered all questions;
c. Execution of this Directive is clinically appropriate and consistent with the standard of care.
4.3 Survival. The representations and warranties in this Section survive execution and remain enforceable for the duration of the Directive.
5. COVENANTS & RESTRICTIONS
5.1 Patient and/or Agent shall:
a. Maintain readily available copies of this Directive;
b. Inform subsequent treating providers of its existence;
c. Wear or carry a DNR bracelet if continuous recognition is desired.
5.2 Clinician shall:
a. Record this Directive prominently in the Patient’s medical record;
b. Review the Directive at each significant change in the Patient’s condition and re-affirm or amend as appropriate;
c. Educate facility staff regarding compliance responsibilities.
6. DEFAULT & REMEDIES
6.1 Default. Failure of a health-care provider or EMS Personnel to comply with this Directive in Good Faith constitutes a material breach.
6.2 Notice & Cure. Upon becoming aware of non-compliance, the Patient, Agent, or Clinician shall give written notice to the non-complying provider who shall have a reasonable opportunity to cure unless immediate harm is likely.
6.3 Remedies. The Patient (or estate) may seek:
a. Injunctive relief compelling compliance;
b. Recovery of actual damages proximately caused by willful or reckless disregard of the Directive; and
c. Reasonable attorneys’ fees and costs.
[// GUIDANCE: Statutory immunity under MCL § 333.1058 protects providers acting in Good Faith. Tailor remedies accordingly.]
7. RISK ALLOCATION
7.1 Provider Protection & Indemnification
To the fullest extent permitted by law, the Patient and estate shall defend, indemnify, and hold harmless any provider or EMS Personnel who, in Good Faith, honors or attempts to honor this Directive.
7.2 Limitation of Liability
Except for gross negligence or willful misconduct, liability of any provider or EMS Personnel for actions taken in Good Faith reliance on this Directive shall not exceed direct damages and shall exclude consequential, incidental, or punitive damages.
7.3 Force Majeure
No party shall be liable for failure to comply when such failure results from circumstances beyond reasonable control, including but not limited to large-scale disasters causing system-wide protocol overrides.
8. DISPUTE RESOLUTION
8.1 Governing Law. This Directive is governed by and shall be construed in accordance with the laws of the State of Michigan, without regard to conflict-of-laws principles.
8.2 Forum. Any action arising out of or relating to this Directive shall be brought exclusively in the Michigan state courts located in [COUNTY] County.
8.3 Jury Waiver. The parties knowingly waive trial by jury to the extent permitted by law.
8.4 Injunctive Relief. The parties recognize that breach may result in irreparable harm; therefore, injunctive relief is an appropriate and necessary remedy.
9. GENERAL PROVISIONS
9.1 Amendment & Waiver. This Directive may be amended only by a written instrument executed with the same formalities as this Directive. No waiver of any provision shall be deemed a waiver of any other provision.
9.2 Assignment. Rights and obligations hereunder are personal to the Patient and may not be assigned.
9.3 Severability. If any provision is held unenforceable, the remaining provisions shall remain in full force, and the invalid provision shall be re-formed to reflect as nearly as possible the original intent.
9.4 Integration. This Directive, together with any DNR bracelet issued pursuant hereto, constitutes the entire agreement and supersedes all prior oral or written statements concerning resuscitation wishes.
9.5 Electronic Signatures. Signatures transmitted electronically or by facsimile shall be deemed originals for all purposes under Michigan’s Uniform Electronic Transactions Act, MCL § 450.831–.849.
10. EXECUTION BLOCK
10.1 Patient (or Agent) Signature
I understand the information in this Directive and authorize that CPR NOT be attempted.
| Signature | Printed Name | Date |
|---|---|---|
| ________ | [PATIENT / AGENT NAME] | [MM/DD/YYYY] |
If signed by Agent: I certify that I am authorized to act under a valid Patient Advocate Designation and the Patient is currently unable to participate in medical decisions.
10.2 Qualified Witnesses
By signing below, each witness declares under penalty of perjury that the Patient (or Agent) voluntarily signed this Directive in their presence, appeared to be of sound mind, and that each witness meets the criteria of Section 3.6(b).
| Witness # | Signature | Printed Name | Address | Date |
|---|---|---|---|---|
| 1 | ________ | [NAME] | [ADDRESS] | [MM/DD/YYYY] |
| 2 | ________ | [NAME] | [ADDRESS] | [MM/DD/YYYY] |
10.3 Clinician Order & Attestation
I have explained the medical consequences of this Directive to the Patient (or Agent) and, in my professional judgment, it is appropriate. I direct all health-care providers and EMS Personnel to withhold CPR in the event of cardiopulmonary arrest.
| Signature | Printed Name & Credentials | License No. | Phone | Date |
|---|---|---|---|---|
| ________ | [MD / DO / PA / NP NAME] | [NUMBER] | [###-###-####] | [MM/DD/YYYY] |
10.4 Optional Notarization
[// GUIDANCE: Notarization is not required under Michigan law but is included here for additional evidentiary weight, particularly if the Directive may be presented outside Michigan.]
State of Michigan )
County of _ ) ss.
Subscribed and sworn before me on [MM/DD/YYYY] by [PATIENT / AGENT NAME], proved to me on the basis of satisfactory evidence to be the person(s) who appeared before me.
Notary Public, State of Michigan
My Commission Expires: _
Acting in the County of ______
[// GUIDANCE: Upon execution, provide copies to the Patient, Agent, primary care physician, facility medical records, and place a copy in any hospital chart upon admission. If a DNR bracelet is desired, complete and submit Michigan Department of Health & Human Services DCH-3916 or successor form.]