Colorado Advance Directives - Living Will Example
DECLARATION AS TO MEDICAL OR SURGICAL TREATMENT
I________________________________, being of sound mind and at least eighteen years of age, (Name of Declarant)
direct that my life shall not be artificially prolonged under the circumstances set forth below and hereby declare that:
1. If at any time my attending physician and one other physician certify in writing that:
a. I have an injury, disease or illness which is not curable or reversible and which, in their judgment, is a terminal condition; and
b. For a period of _________ consecutive days or more, I have been unconscious, comatose or otherwise incompetent so as to be unable to make or communicate responsible decisions concerning my person; then I direct that, in accordance with Colorado law, life-sustaining procedures shall be withdrawn and withheld pursuant to the terms of this declaration; it being understood that life-sustaining procedures shall not include any medical procedure or intervention for nourishment considered necessary by the attending physician to proved comfort or alleviate pain. However, I may specifically direct, in accordance with Colorado law, that artificial nourishment be withdrawn or withheld pursuant to the terms of this declaration.
2. In the event that the only procedure I am being provided is artificial nourishment, I direct that one of the following actions be taken:
_______(initials of declarant) a. Artificial nourishment shall not be continued when it is the only procedure being provided; or
_______(initials of declarant) b. Artificial nourishment shall be continued for_____days when it is the only procedure being provided; or
_______(initials of declarant) c. Artificial nourishment shall be continued when it is the only procedure being provided.
3. I execute this declaration as my free and voluntary act this______day of this month __________, in this year of________.
By__________________________________________________
The foregoing instrument was signed and declared by____________________to be his/her declaration, in the presence of us, who, in his/her presence, in the presence of each other, and at his/her request, have signed our names below as witnesses, and we declare that, at the time of the execution of this instrument, the declarant, according to our best knowledge and belief, was of sound mind and under no constraint or undue influence. We further declare that neither of us is : 1) a physician; 2) the declarant’s physician or an employee of his/her physician; 3)an employee or a patient of the health care facility in which the declarant is a patient; or 4) a beneficiary or creditor of the estate of the declarant.
Dated at_______________, Colorado, this______ day of ___________, in the year_______.
_______________________________________ ______________________________________
(Signature of Witness) (Signature of Witness)
Address:_______________________________ Address:________________________________
______________________________________ _______________________________________
OPTIONAL
STATE OF COLORADO, County of ___________________________
Subscribed and sworn to or affirmed before me by ____________________, the declarant, and _____________________ , and ______________________________, witnesses, as the voluntary act and deed of the declarant, this ______________ day of __________________, in the year ___________.
My commission expires: ___________________________________________
Notary Public
In Summary
• Federal law directs that any time you are admitted to any health care facility, or served by certain organizations that receive Medicare of Medicaid money, you must be told about Colorado’s laws concerning your right to make health care decisions.
• Upon admission, you must be given information about advance directives.
• Although you have the right to make an advance directive, you cannot be required to have or make an advance directive in order to be admitted to a health care facility or to receive treatment or care.
• Talk to your doctor about medical conditions which might make advance directives useful.
• Talk with your health care providers about your wishes and beliefs. Make sure that copies of your advance directives are included in your medical records. It is your responsibility to provide these copies to your health care providers.
• You must be given written information about your health care providers’ policies and procedures regarding your advance directives. Be sure to discuss whether your directive swill be honored. If you determine their policies are not consistent with your advance directives, you may wish to transfer to another facility or provider.
• If you do not want your family and closer friends to select a substitute decision maker (proxy) to make medical decisions for you, you should have an advance medical directive such as a medical durable power of attorney in which you name the person who will make decisions for you.
• You do not need to use a lawyer to complete your living will, medical durable power of attorney, or CPR Directive. If you have legal questions, however, you may wish to talk to a lawyer.
• If you have a living will, medical durable power of attorney, or CPR Directive, give a copy of it to your doctor, your family, your agent, if applicable, and to your health care facility. Talk with your doctor, family, and agent, if applicable, while you’re still in good health, so they will understand what you want.
• If you have completed a CPR Directive, be sure it is readily available at all times.
• Ordinarily, it is not advisable to have both a living will and a medical durable power of attorney, as long as your medical durable power of attorney contains any instructions you wish to give about your future medical treatment, including treatment when you are terminally ill.
