Documents

Advance Care Planning Workbook

This workbook will walk you through the process of advance care planning. You will find conversation tools, a quality of life assessment worksheet, treatment wishes worksheet, and end-of-life plans that are very helpful tools to guide the conversation with your loved ones. Helping to define what is important to you based on your goals, your perspectives, and your values are extremely important parts of this conversation.

Download the Advanced Care Planning Workbook PDF.

Advance Medical Directive and Treatment Preferences

This is the legal document that allows you to name the person(s) you trust most to speak for you only in times when you become too sick to make medical decisions for yourself.n You can also list your treatment preferences for end of life care in this document. Munson Healthcare treats this document the same as a durable power of attorney for healthcare. You can revoke or change this document at any time. In the event you are hospitalized and do not have an advance medical directive or durable power of attorney of healthcare, a guardian may need to be appointed by the court if you are too sick to make your own medical decisions. This document is recommended for all competent adults 18 years of age and older.

Download the Advance Medical Directive and Treatment Preferences PDF.

A Temporary Delegation of Parental Rights and Consent to Medical Treatment of a Minor or Dependent Adult

This form is valid for 6 months and is useful during times when you are going to be separated from your children or those under your care. By law, hospital emergency personnel cannot provide treatment in the event he or she becomes ill or injured, except in life or death situations, without parental/guardian authorization. Completing this form allows you to name authorized persons a limited power of attorney to act for you on behalf of your minor child/children or dependent adult. A completed form should be provided to the hospital in advance or accompany the people you have authorized to act for you. 

Download the temporary delegation.

A Guide to CPR

CPR stands for Cardiopulmonary Resuscitation and is an emergency medical process involving a number of emergent medical techniques that try to replicate the function of a person’s beating heart and lungs which have stopped working. Stating you do not want CPR in an advance directive is a preference, not a DNR medical order. Learn more about CPR and DNR orders using this guide. 

Download the ACP Decisions Guide to CPR.

Do-Not-Resuscitate (DNR) Order

This document is an out-of-hospital DNR document. EMS personnel are required to perform CPR on all patients when 911 is called. If you do not want to have CPR performed, you must have this document available when 911 is called. You must print this from the link and take it to your physician because it requires your physician’s signature for it to be acted on. It is highly recommended that a DNR medical alert bracelet be worn. These can be purchased at most pharmacies when you present the signed physician DNR document. 

NOTE: If you have an out-of-hospital DNR document completed, this does not authorize a DNR order in the hospital setting. Because you can change your mind at any time, hospital personnel will ask you what your wishes are for CPR on each Emergency Department visit. If you have a DNR treatment preference written in your advance medical directive or medical durable power of attorney, this does not serve the same purpose and EMS personnel cannot act on an advance medical directive. 

Download the Do-Not-Resuscitate Order PDF.

Dementia Directive

Today, dementia affects many people. It can take several years to progress and cause numerous health and function issues, including the inabilities to communicate or make decisions. Planning ahead for the medical treatment you would prefer is important. This Dementia Directive is a specifically-designed communication tool that outlines the kind of medical care and quality of life you would want if you develop or have moderate or severe dementia. Because an advance directive or medical durable power of attorney document cannot always address the unique circumstances associated with the progression of dementia, we recommend using the Dementia Directive in conjunction with the Advance Medical Directive and Treatment Preferences. Doing this now, before dementia progresses, will help your loved ones and your healthcare team to provide the best care possible based on your values and goals for living a meaningful life. 

NOTE: A living will is not legally binding in Michigan and therefore should accompany the Advance Medical Directive and Treatment Preferences.

Visit the Dementia Directive website.

Understanding Code Status

All patients admitted to a hospital or an outpatient facility (such as a dialysis center or outpatient surgery center) will be asked to choose a code status for the duration of their stay. Your chosen code status describes the type of resuscitation procedures, such as CPR, you would like the health care team to conduct if your heart stopped beating and/or you stopped breathing. Learn more about your code status options, definitions, and frequently asked questions from other patients.

Download the Understanding Code Status PDF.

Questions? 

Contact our office at 231-935-6176 or svanslyke@mhc.net.