Michigan Living Will
This document serves as a legal declaration to outline your wishes regarding medical treatment in the event that you become unable to communicate your preferences. This Living Will is governed by the Michigan Compiled Laws.
Personal Information
- Full Name: _____________________________
- Date of Birth: _____________________________
- Address: _________________________________
- City, State, Zip: _______________________
Declaration
I, the undersigned, being of sound mind, voluntarily make this declaration in accordance with the Michigan Compiled Laws.
Medical Preferences
In the event that I am diagnosed with a terminal condition, or if I am in a persistent vegetative state, I indicate my preferences as follows:
- I do/ do not wish to receive life-sustaining treatment. (Please circle one)
- I do/ do not want to receive artificial nutrition and hydration. (Please circle one)
Additional Instructions
If there are specific medical interventions you wish to include or exclude, please specify them here:
_______________________________________________________________
Appointment of Patient Advocate
If you wish to appoint a patient advocate to make healthcare decisions on your behalf, please provide the following information:
- Patient Advocate Name: ________________________________
- Relationship: ________________________________________
- Address: ___________________________________________
- Phone Number: ______________________________________
Signature
By signing below, I confirm that I understand the contents of this Living Will and that it reflects my wishes:
Signature: ____________________________ Date: _______________
Witnesses
This document must be signed by two witnesses who are not related to you or your appointed patient advocate:
- Witness 1: ____________________________ Date: _______________
- Witness 2: ____________________________ Date: _______________