Michigan Patient Advocate Designation

MICHIGAN PATIENT ADVOCATE DESIGNATION

Durable Power of Attorney for Health Care

MCL 700.5506 through 700.5515 (EPIC Part 5)

This designation lets you name a patient advocate to make care, custody, and medical

treatment decisions if you cannot participate in those decisions. Michigan law does not require a

specific form. This suggested form tracks MCL 700.5506 through 700.5515.

You must be at least 18 and of sound mind. Your patient advocate must be at least 18. Two

qualified adult witnesses must sign with you. A notary is not required. Your patient advocate

must sign the acceptance before acting.

1. MY INFORMATION

____________________________________________________

My full legal name

____________________________

Date of birth (optional)

____________________________________________________________

Address

____________________________

Telephone

________________________________________

E-mail (optional)

2. PATIENT ADVOCATE

I designate the following individual, age 18 or older, as my patient advocate to exercise powers

concerning my care, custody, and medical treatment decisions under MCL 700.5506.

____________________________________________________

Patient advocate name

____________________________

Relationship to me

____________________________________________________________

Address

____________________________

Telephone

________________________________________

E-mail (optional)

Successor patient advocate (optional)

If my first patient advocate does not accept, is unable or unwilling to act, resigns, or is removed,

I designate:

____________________________________________________

Successor patient advocate name

____________________________

Relationship to me

____________________________________________________________

Address

____________________________

Telephone

3. WHEN THIS DESIGNATION IS EFFECTIVE

The authority conferred by this designation is exercisable only when I am unable to participate

in medical treatment decisions. Under MCL 700.5508, my attending physician and another

physician or licensed psychologist must determine that inability in writing after examining me,

place the determination in my medical record, and review it at least annually. Authority is

suspended if I regain the ability to participate and may revive upon a new qualifying

determination.

Before implementation, this designation must be made part of my medical record with my

attending physician or the facility where I am located, as applicable.

4. GENERAL AUTHORITY

Subject to this designation and Michigan law, my patient advocate may consent to or refuse

medical treatment on my behalf, arrange medical services for me, and make decisions about my

care and custody that I could have made myself. My patient advocate shall follow my known

wishes, whether expressed orally, in this designation, or otherwise, and shall act consistent with

my best interests and the standards of care applicable to fiduciaries.

My patient advocate shall not receive compensation for serving, but may be reimbursed for

actual and necessary expenses. My patient advocate may not delegate these powers to another

person without my prior authorization in this designation.

5. MY TREATMENT PREFERENCES AND INSTRUCTIONS

Optional. Describe values, goals, treatments you want or do not want, and how your patient

advocate should decide. If none, write "none."

____________________________________________________________________

____________________________________________________________________

____________________________________________________________________

____________________________________________________________________

____________________________________________________________________

6. LIFE-SUSTAINING TREATMENT

Under MCL 700.5509(1)(e), a patient advocate may make a decision to withhold or withdraw

treatment that would allow me to die only if I have expressed in a clear and convincing manner

that the patient advocate is authorized to make that decision and that I acknowledge that such a

decision could or would allow my death.

Initial ONE box only:

I AUTHORIZE my patient advocate to make decisions to withhold or withdraw treatment

that would allow me to die, and I acknowledge that such a decision could or would allow

my death. My patient advocate shall follow any more specific instructions in Section 5.

I DO NOT authorize my patient advocate to make a decision to withhold or withdraw

treatment that would allow me to die.

Pregnancy limitation (MCL 700.5509(1)(d) and 700.5512): This designation cannot be used to

make a medical treatment decision to withhold or withdraw treatment from a patient who is

pregnant that would result in the patient's death.

7. ANATOMICAL GIFT (OPTIONAL)

Initial ONE box only. If you grant this authority, it remains exercisable after death under

MCL 700.5506(3).

I AUTHORIZE my patient advocate to make an anatomical gift of all or part of my body

under Public Health Code Part 101, and to resolve conflicts between this designation

and means needed to ensure medical suitability of the gift.

I DO NOT authorize my patient advocate to make an anatomical gift on my behalf under

this designation.

8. MENTAL HEALTH TREATMENT (OPTIONAL)

Initial if you want mental health authority included. Mental health activation uses the certification

process in MCL 700.5515, not only the medical determination in MCL 700.5508.

I also authorize my patient advocate to make mental health treatment decisions for me

when I am unable to give informed consent to mental health treatment, subject to MCL

700.5509 and 700.5515.

Optional mental health instructions:

____________________________________________________________________

____________________________________________________________________

9. REVOCATION

I may revoke this designation at any time and in any manner sufficient to communicate an intent

to revoke. My patient advocate may revoke acceptance at any time and in any manner sufficient

to communicate an intent to revoke. Photostatic copies of this signed and witnessed designation

have the same legal force as the original.

10. MY SIGNATURE

I sign this designation after careful consideration. I understand its meaning and I accept its

consequences. I execute it voluntarily.

________________________________________________

My signature

________________________________________________

Print my name

Date: ________________________

____________________________________________________________

Address

11. WITNESSES

Two witnesses must sign. Under MCL 700.5506(4), a witness shall not be my spouse, parent,

child, grandchild, sibling, presumptive heir, known devisee at the time of witnessing, physician,

or patient advocate, or an employee of a life or health insurance provider for me, of a health

facility treating me, of a home for the aged where I reside, or of a community mental health

services program or hospital providing mental health services to me.

We sign as witnesses. This designation was signed in our presence. The patient appears

to be of sound mind and under no duress, fraud, or undue influence. Each of us is

eligible to serve as a witness under MCL 700.5506(4).

First witness

________________________________________________

Witness signature

________________________________________________

Print witness name

Date: ________________________

____________________________________________________________

Witness address

Second witness

________________________________________________

Witness signature

________________________________________________

Print witness name

Date: ________________________

____________________________________________________________

Witness address

12. ACCEPTANCE BY PATIENT ADVOCATE

Before acting as patient advocate, the proposed patient advocate must sign an acceptance that

includes substantially all of the statements required by MCL 700.5507(5).

I understand and accept the following:

1. This patient advocate designation is not effective unless the patient is unable to participate in

decisions regarding the patient's medical or mental health, as applicable. If I am authorized to

make an anatomical gift, that authority remains exercisable after the patient's death.

2. A patient advocate shall not exercise powers concerning the patient's care, custody, and

medical or mental health treatment that the patient, if the patient were able to participate in the

decision, could not have exercised on the patient's own behalf.

3. This designation cannot be used to make a medical treatment decision to withhold or

withdraw treatment from a patient who is pregnant that would result in the patient's death.

4. A patient advocate may make a decision to withhold or withdraw treatment that would allow a

patient to die only if the patient has expressed in a clear and convincing manner that the patient

advocate is authorized to make such a decision, and that the patient acknowledges that such a

decision could or would allow the patient's death.

5. A patient advocate shall not receive compensation for the performance of the patient

advocate's authority, rights, and responsibilities, but a patient advocate may be reimbursed for

actual and necessary expenses incurred in the performance of those duties.

6. A patient advocate shall act in accordance with the standards of care applicable to fiduciaries

when acting for the patient and shall act consistent with the patient's best interests. The known

desires of the patient expressed or evidenced while the patient is able to participate in medical

or mental health treatment decisions are presumed to be in the patient's best interests.

7. A patient may revoke his or her designation at any time or in any manner sufficient to

communicate an intent to revoke.

8. A patient may waive the right to revoke the patient advocate designation as to the power to

make mental health treatment decisions, and if such a waiver is made, the patient's ability to

revoke as to certain treatment is limited to 30 days after the patient communicates a desire to

revoke.

9. A patient advocate may revoke his or her acceptance of the designation at any time and in

any manner sufficient to communicate an intent to revoke.

10. A patient admitted to a health facility or agency has the rights enumerated in section 20201

of the public health code, 1978 PA 368, MCL 333.20201.

I understand the above conditions, and I accept the designation as patient advocate for:

________________________________________________

Name of patient

________________________________________________

Patient advocate signature

________________________________________________

Print patient advocate name

Date: ________________________

____________________________________________________________

Patient advocate address

Successor patient advocate acceptance (if named)

I understand the above conditions, and I accept the designation as successor patient advocate

for:

________________________________________________

Name of patient

________________________________________________

Successor patient advocate signature

________________________________________________

Print successor name

Date: ________________________

This form is a suggested instrument based on MCL 700.5506 through 700.5515. It is not a

government publication. It is not legal advice.