Michigan Advance Directive Form

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A Michigan advance directive is a document that lets a person select their end-of-life treatment options in the chance they cannot speak for themselves. This includes an agent that can be nominated to make health care decisions on the person’s behalf in addition to treatment options and organ donation selections. After completing and signing with at least two (2) witnesses, it can be used in the event the patient becomes incapacitated.

Advance Directive Includes

Table of Contents

Laws

Statute§ 700.5501 to § 700.5520 & § 333.5651 to § 333.5661

Signing Requirements (§ 700.5501(b)) – Two (2) witnesses or a notary public.

Versions (9)


AARP

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ALWR Advance Directive

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Blue Cross / Blue Shield

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Helen Newberry Joy Hospital

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Henry Ford

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Making Choices

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Michigan.gov

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Spanish (Español) Version

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University of Michigan

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How to Write

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Step 1 – Access The Michigan Advance Directives

Utilize the “Adobe PDF” link on this page or the “PDF” button displayed with the feature image to access then download the Michigan Advance Directive templates to your machine.

Step 2 – Read Through The Introduction To The Michigan Durable Power Of Attorney For Health Care

You must identify yourself as the Principal issuing an appointment to grant a specific Patient Advocate with the right to speak for you with Michigan Doctors and Medical Responders handling your treatment and care before you can proceed with this designation of authority. The bold heading “This Is An Advance Directive For” shall lead to a section containing several blank lines. Each of these is labeled with a request for information regarding yourself that must be used to present the Principal (the future Michigan Patient) behind this document. Use the lines labeled “Name,” “Date Of Birth,” and “Last 4 Digits Of SSN” to document the Principal’s first, middle, and last name where requested then your birthday and the last four digits of the Principal’s social security number. Once you input your information to these lines, you will be the Principal issuing this document. Continue with a record of your daytime and nighttime telephone numbers on the lines labeled “Telephone (Day) and “(Evening).” If you have a “Cell” phone number, record it on the blank line presented with the previous two.  The full address on your identification papers, for instance, your driver’s license or insurance paperwork, should be presented as first an “Address” (building/street/apt) then “City/State/Zip” on the next two blank lines.   

 

Step 3 – Identify The Michigan Principal Issuing This Appointment

The Patient Advocate you wish to appoint with the representational powers to speak for you with Michigan Physicians when you are unconscious or otherwise unable to effectively communicate must be named underneath the bold words “The Person I Choose As My Patient Advocate Is.” The “Name” line is reserved for the full name of this individual while the “Relationship (If Any)” must be used to define how the Patient Advocate and yourself (as the Principal) know each other. For instance, this may be a good friend, a sibling, a parent, or an adult child (i.e., your offspring or adopted son/daughter).

 

Step 4 – Document Up-To-Date Contact Information Maintained By Your Patient Advocate

Your Patient Advocate must be reachable using the information on this document. This should be considered crucial information since a Michigan Health Care Provider relying on this document for your health care decisions may need to contact your Patient Advocate on an immediate basis. Therefore, Patient Advocate’s phone numbers on the lines labeled “Telephone (Day),” “(Evening),” and “(Cell).”  The residential address maintained by your Patient Advocate should be presented to this section using the blank line labeled “Address” and “City/State/Zip Code.” 

 

Step 5 – Register A Successor Agent To Your Patient Advocate

If you wish to take every step that can be taken when seeking to set the stage in maintaining reasonably reliable representation throughout the time you may need Michigan Doctors to be informed of your directives, then reserving a different individual to take your Patient Advocate’s place should he or she not be willing or able to act in this role would be a wise precaution. The section titled “Second Alternate (Successor) Patient Advocate” will require the full name of the individual who will accept the role of Patient Advocate recorded on the first line and his or her “Relationship (If Any)” with you documented on the second line. Be advised, this person cannot represent you unless the Patient Advocate named originally refuses to, has been revoked, or is unreliable or unavailable.    The telephone numbers where the Successor Patient Advocate can be reached should be produced on the “Telephone(Day)” line, the “(Evening)” line, and the “(Cell)” line.  

 

Step 6 – Reserve A Second Alternate (Successor) Patient Advocate As A Precaution

If both the Patient Advocate being appointed and the First Alternate (Successor) Patient Advocate can not, will not, or no longer have the authority to represent you while you are unconscious and unable to represent yourself then Michigan Doctors seeking your preferences to complicated treatment decisions will be left to their own devices and what is legally required in the absence of your instructions. In the “Second Alternate (Successor) Patient Advocate” section, the first two lines can be used to name someone to take up the role of Patient Advocate if your previous two choices will not fill this role adequately. Report your Second Alternate (Successor) Patient Advocate’s “Name” on the first blank line then explain the “Relationship (If Any)” you and the Second Successor Patient Advocate share.    Once the Second Successor Patient Advocate is named, use the “Telephone(Day)” line to dispense this Party’s phone number during business hours and the “Evening” line to document his or her phone number after business hours. If the Second Successor Patient Advocate has a “Cell” phone, then use the third line in this series to present it. The next line in the “Second Alternate (Successor) Patient Advocate” section requires the “Address” line to be filled with the building, street, and unit number of the Second Successor Patient Advocate’s residential address.  Complete this section with a record Second Successor Patient Advocate’s home or residential address. 

 

Step 7 – Explicitly State The Intent To Grant The Patient Advocate Principal Power Over The Declarant’s Health Decisions

The next page is the “Advance Directive Signature Page.” The first requirement this page sets is the Principal confirmation of the declaration made in the box at the top of this page. The paragraph placed in this area states that the Principal has had a forthright discussion with the chosen Patient Advocate concerning medical scenarios including ventilators, cardiopulmonary resuscitation, artificial feedings/hydration, and dialysis treatments. This declaration shall give the Patient Advocate the right to represent the Principal by acting on his or her behalf to determine, report, and act upon the Principal’s directive. The Principal must read through this statement. Take note of the final portion of this statement that restricts the Patient Advocate from deciding upon pain management and from withdrawing the Principal’s consent to receive comfort care. The checkbox statement at the end of this statement will “…Expressly Authorize” the Patient Advocate to represent the Principal even if his or her decisions may lead to death. Only the Principal may check this box in acknowledgment of this statement. 

 

Step 8 – Review the Optional Directives To Be Attached

Before finalizing this document, an opportunity to document additional concerns and instructions utilizing formatted attachments is presented. Bear in mind that since this document lists these attachments by name, they must be attached. If you do not wish to discuss any of the topics in one of these attachments, there will be an opportunity to indicate this. 

 

Step 9 – Spiritual/Religious Preferences

Locate the page titled “Preferences For Spiritual/Religious And End Of Life Care.” While this is topic is optional, it is recommended that you review this page. Beginning with the checkbox statements beginning with “My Religious Beliefs Prohibit…” declares that the Principal (You) observes a spiritual doctrine that forbids being examined by a doctor, psychologist, or any other medical professional. If this accurately reflects an aspect of the Principal’s belief system, then he or she is should mark the checkbox to this statement. Record the Principal’s church or belief on the first blank line in the next section (found after the term “I Am Of The…”).  If the Principal has a group or congregation that he or she wishes contacted when suffering an end-of-life event, then report its name and contact material on the blank line labeled “I Am Affiliated With…”  If desired, you may use the next available line to present the name and contact information of the “Clergy Or Spiritual Support Person(s)”Now use the final blank lines to list all religious or spirituality concerns relevant to his or her physical care, emotional care, or Spiritual Care. The blank line (labeled “I Choose Not To Complete This Section”) that can be found after the reporting area for your spiritual concerns, should present the Principal’s initials if he or she has opted not to cover this topic. 

 

Step 10 – Discuss The Michigan Principal’s End of Life Preferences

The next section shall address the way you wish Michigan Health Care Providers to act or treat you when all treatments have failed, and your body has commenced shutting down. As the Principal of this paperwork, you have the option of providing certain instructions. One of the first five checkbox options defining the end-of-life care that can be provided should be selected to indicate your preference. The first two options allow your end-of-life event to occur at home or in a “Long-Term Care Facility.” If you prefer to be at home during this time, then select the “In My Home” checkbox. However, if you wish to be admitted or maintained “In A Long-Term Care Facility” then select the checkbox on the right.  If preferred, select the third checkbox to indicate you prefer your end-of-life care “In A Hospital” then select the third checkbox. You may also decide that your Patient Advocate will be best suited for this decision when the time comes. If so, then select the fourth checkbox (as in the example below).   If you “…Would Like Hospice Services In Any Of The Above Settings Or In a Hospice Residence” then select the fifth checkbox.   All other end-of-life preferences you have should be defined on the final blank lines of this section. Find the words “In My Last Days Or Hours If Possible…” then utilize this area for this purpose. This is optional but strongly recommended.  If you wish to leave this section out of your directive, then initial the “I Choose Not To Complete this Section” statement at the bottom of the page. 

 

Step 11 – Discuss Principal Anatomical Gift(s) Preferences

If you have made a determination as to whether you wish to make anatomical gifts, then the next page should be used to display your formal instructions as the Principal. Five choices meant to define this status are presented on the page titled “Anatomical Gift(s) – Donation Of My Organs/Tissue/Body.” Each of the statement choices are attached to a blank line where your initials should be displayed if you agree with it. For instance, if you are already a registered Michigan Donor, then initial the blank line attached to “I Am Registered On The Michigan Donor Registry And/or Michigan Driver’s License.” However, if you are not a registered donor, do not initial the first statement’s line.  In a case where you are not a registered Michigan Organ Donor but will grant your Patient Advocate with the right to effect anatomical gifts on your behalf for the purpose of aiding a Transplant Patient’s chances of survival then initial the second statement in this section.  The third statement should bear your initials if you intend to grant your Patient Advocate the right to donate your organs and tissues but wish to restrict certain body parts from this action. If this is your preference then, initial the blank line and submit a list of every organ or tissue you refuse to donate after your death (regardless of the need).  Initial the fourth statement if you have determined that you do not wish to be an Organ Donor and do not authorize your Patient Advocate to indicate otherwise.   The fifth statement can be chosen through the process of initialing if you have already made an organ/tissue donation arrangement. If so, initial the statement corresponding to the term “I Want To Donate My Body To An Institutions” then record the legal name of the Institution you have promised anatomical gifts to along with its mailing address and phone number on the line following the parenthesis instructional “(Must Be Arranged In Advance).” If you do not wish to establish a directive regarding organ/tissue donation then, locate the statement “I Choose Not To Complete This Section” found at the bottom of the page. Initial this blank line only if you have not selected from the “Anatomical Gift(s) – Donation Of My Organs/Tissue/Body” section.

 

Step 12 – You May Document Autopsy Preferences At Your Discretion

The “Autopsy Preference” section continues the report on your post-death directives and preferences. In the box presented with this title three selections are offered to choose from in defining these instructions. If an autopsy is acceptable then for the benefit of your family members, then initial the first statement just before the words “I Would Accept An Autopsy If It Can Help My Blood Relatives Understand The Cause Of My Death…”  If you would accept an autopsy for the “…Advancement Of Medicine Or Medical Education” then initial the second statement. The third selection should be initialed if you refuse to have an autopsy done.  If you do not wish to issue any instructions, then initial the first statement following the “Autopsy Preference” box.

 

Step 13 – Present Any Directives Regarding Burial Or Cremation Preferences

The “Burial/Cremation Preference” seeks your post-death requirements for your body. Select either “Burial,” “Cremation,” or “Green Burial” by initialing your preference on the blank line preceding the description.

If you have determined that “Burial Or Cremation, At The Discretion…” of your next of kin will be appropriate then initial the blank line fourth selection.

In a case where you have “Appointed A Funeral Representative” then initial the final statement in this box and make sure the final statement is initialed.

Initial the “I Choose Not To Complete This Section” directly below the “Burial/Cremation Preference” box if you do not have any “Burial/Cremation Preference” to set to paper. 

 

Step 14 – Mental Health Treatment

The final optional section, “Preferences For Mental Health Examination & Treatment,” should be completed following an assessment of the Principal (You) state of mind and health by a Michigan Physician or Psychiatrist. He or she must check the box attached to the phrase “A Determination Of My Inability…” to indicate this task has been completed.  Once he or she has confirmed his or her participation, the attending Michigan Licensed Physician or Psychiatrist must prove this by signing the blank line labeled “Physician/Psychiatrist.” If you have opted to complete the “Preferences For Mental Health Examination & Treatment” without a Michigan Physician or Psychiatrist’s assessment, then select the “I Choose Not To Complete This Section” statement by initialing it. 

The next box in this section contains the declaration needed to authorize your Patient Advocate to make mental health decisions when you cannot and will also deliver the ability to approve of Michigan Mental Health and Physician responses regarding a mental health crisis. All uninitialed items on this list will be considered responses that you do not approve while every initialed response will be considered your preferred or authorized response when rendered uncommunicative or incapacitated as a result of this crisis. If you approve of “Outpatient Therapy” (where overnight or long-term hospitalization is not required) then initial the first blank line. 

You may prematurely volunteer your admission to a facility to “Receive Inpatient Mental Health Services” while reserving the right to leave the hospital with three days’ notice by initialing the second statement (“Voluntary Admission To A Hospital…” Initial the third option to approve of your admission for inpatient mental health services to a Michigan hospital without the right to give three days’ notice of your intent to leave. If you approve of the administration of “Psychotropic Medication” then initial the fourth statement.  To approve of “Electro-Convulsive Therapy (ECT)” initial the fifth statement. If you have decided it is appropriate to release your right to have a revocation take effect immediately then initial the final statement. Be advised this means that it will take 30 days for revocation to have the effect of terminating the designation, appointment, or instructions you are revoking. However, you will retain the right to leave a hospital with three days’ notice if your admission to that hospital was voluntary.  The final blank lines can be used to define additional instructions or directives regarding your mental health care. These may be left blank if no further instructions need to be conveyed to Michigan Mental Health Care and Physical Health Care Personel seeking guidance from this attachment. In order to complete your mental health preferences, instructions, or provisions, you must sign your name to the bottom line requesting this action then submit the “Date” of your signature on the next line.  If you have opted not to issue mental health directives, then initial the final statement on this page. Supply your initials on the line preceding the words “I Choose Not To Complete This Section.”

 

Step 15 – The Michigan Advance Directive Must Be Signed To Effect

If you have completed the optional sections attach them to this document, then return to page 3. If you have decided not to fill out one or more of the optional directives, then make sure each intentionally unattended page is initialed as being acknowledged and dismissed. The bold heading “Signature Of The Individual In The Presence Of The Following Witnesses” puts forth a statement of declaration that must be proven by signature. Thus, as the Principal, sign the “Signature” line then dispense the signature “Date” on the line next to it.   The “Address” and “City/State/Zip Code” must be populated with the Signature Principal’s residential address. 

 

Step 16 – Acquire Signature Proof Of The Principal’s Actions From Two Witnesses

Two distinct Witness areas, titled “Witness Number 1” and “Witness 2,” where two Witnesses who meet the criteria of being at least eighteen (18) years old, not appointed as an Advocate, related to Principal, is not a presumptive heir, a beneficiary or entitled to a “Gift From The Patient’s estate, is not responsible for the Patient’s health care, not a Health Care Provider providing care for the Patient or an Employee of such a provider or insurance provider “Directly Serving The Patient.” Both Witnesses must review the Witness Statement and the requirements for this role then attest to the authenticity of the Principal’s signature and the accuracy of the Witness Statement then sign his or her name on the “Signature” line as well as provide the “Date” when this signature was furnished. The first Witness must only tend to the “Witness Number 1” section while the Second Witness may only tend to the “Witness Number 2” section. Therefore, the First Witness must sign and date the lines labeled “Witness 1” and “Date.”The printed name of the First Witness must be supplied by this Party below his or her name and signature “Date”

Finally, The Witness must complete his or her respective section with a record of the address where he or she maintains a home.  The area titled “Witness Number 2” requires attention from the Second Witness. As mentioned earlier, he or she will need to sign the “Signature” line and furnish the current calendar “Date” in the “Witness Number 2” section.  Witness Number 2 is expected to deliver his or her printed name below the provided signature  Finally, the second Witness must complete the “Witness Number 2” section with is or her home address. 

 

Step 17 – The Patient Advocate(s) Must Review Then Complete The Acceptance Form

The “Accepting” section of the “Accepting The Role Of Patient Advocate” must be reviewed by the Patient Advocate. This act will benefit both the Principal and the Patient Advocate. Before this occurs, the Principal must print his or her full name on the “Print Name” line under the “Person Completing Advance Directive” heading then proceed to record his or her “Date Of Birth” on the blank line that follows. Locate the “Patient Advocate” section then record the full name of the Patient Advocate or Agent on the first blank line.  The Patient Advocate must sign his or her name on the “Signature” line then produce the “Date” of his or her signature adjacent to this.  After signing his or her acknowledgment and acceptance, record the “Address” of the Patient Advocate’s home making sure to produce the city, state, and zip code of this address on the “City/State/Zip” line.   The “Phone(Day),” “Evening,” and “Cell” number where the Patient Advocate can be reached should be delivered to the three blank lines bearing these labels in this section. 

 

Step 18 – The Michigan Successor Agents Should Acknowledge Their Potential Role

The “First Alternate (Successor) Patient Advocate” section is optional, but it is strongly recommended that both potential Patient Advocates read the above statement then dispense agree to the responsibility this designation carries. Begin by recording the printed name of the First Alternate (Successor) Patient Advocate” on the blank space preceding the words “Have Agreed To Be…”Once done, the First Alternate (Successor) Patient Advocate must then sign his or her acceptance on the “Signature” line and documenting the “Date” of this signature to the adjacent areas. The residential “Address” and “City/State/Zip” of the First Alternate (Successor) Patient Advocate is required on the next two lines.    After producing these items, the First Alternate (Successor) Patient Advocate should distribute the daytime, night time, and cellular phone numbers across the next three lines.  The final acknowledgment section, “Second Alternate (Successor) Patient Advocate” will also contain an acknowledgment statement that must be supplied with the full name of the Second Alternate (Successor) Patient advocate on the first blank line presented (labeled “Print”).  The Second Successor Patient Advocate should also sign the “Signature” line then dispense the calendar “Date” this signature was produced on the line requesting it.  Additionally, the “Second Alternate (Successor) Patient Advocate” must produce his or her full address down the next two lines. Finally, the Second Alternate (Successor) Patient Advocate’s telephone numbers should be dispensed on the “Phone (Day)” line as well as the “Evening” and “Cell” lines.

 

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