Michigan Do Not Resuscitate (DNR) Order FormMichigan Do Not Resuscitate (DNR) Order FormMichigan Do Not Resuscitate (DNR) Order Form
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System Protocols
Date: Sept. 2004

Page 1 of 4

The purpose of this policy is to provide a guideline to prehospital providers, who
under certain circumstances may accommodate patients who do not wish to receive and/or may
not benefit from cardiopulmonary resuscitation. This policy is drafted in accordance with Public
Act 368 of 1978, as amended, as well as Act 192 and 193 of the Public Acts of 1996. This policy
is intended to facilitate kind, humane, and compassionate service for patients who have executed
a valid “Do-not-resuscitate order” under the aforementioned Acts.
1. Definitions
a. Attending Physician – means the physician who has primary responsibility for the
treatment and care of a declarant.
b. Declarant – means a person who has executed a do-not-resuscitate order, or on
whose behalf a do-not-resuscitate order has been executed pursuant to applicable
c. Do-not-resuscitate order – means a document executive