Michigan Living Will
This document outlines your healthcare wishes in accordance with Michigan state laws regarding living wills. It is important to keep this document updated and to discuss your wishes with your healthcare providers and loved ones.
Principal Information:
- Name: ______________________________
- Date of Birth: ______________________
- Address: ____________________________
- City, State, Zip: ___________________
Healthcare Agent:
If I am unable to make my own healthcare decisions, I appoint the following person as my healthcare agent:
- Name: ______________________________
- Phone Number: ______________________
- Address: ____________________________
Statement of Intent:
I declare that if I become unable to make my own healthcare decisions, I wish to have my healthcare agent make decisions on my behalf. My healthcare agent should consider my wishes and values as explained in this document and any discussions we have had.
Patient’s Preferences:
- I do not wish to receive life-sustaining treatment if I am:
- In a terminal condition
- Persistent vegetative state
- Facing irreversible conditions that prevent me from communicating.
- I wish to receive pain relief even if it may hasten my death.
- If I am unable to communicate my wishes, I trust my healthcare agent's decision-making ability.
Signatures:
This document must be signed and dated in the presence of a notary public or witnesses. This will ensure that it meets Michigan requirements.
Signature of Principal: ________________________ Date: ______________
Signature of Witness 1: _______________________ Date: ______________
Signature of Witness 2: _______________________ Date: ______________