Advance Directive For Medical / Surgical Treatment (Living Will) - Colorado

ADVANCE DIRECTIVE FOR MEDICAL / SURGICAL TREATMENT
(Living Will)
This form may be used to make your wishes known about what medical
treatment or other care you would or would not want if you become too
sick to speak for yourself. You are not required to have an advance
directive. If you do have an advance directive, be sure that your doctor,
family, and friends know you have one and know where it is located.
Definitions:
Life-Sustaining Procedure: Any medical procedure or intervention that, if administered

to a qualified patient, would serve only to prolong the dying process. ALife-sustaining
procedure@ shall not include any medical procedure or intervention for nutrition and
hydration of the qualified patient or considered necessary by the attending physician to
provide comfort or alleviate pain. However, artificial nutrition and hydration may be
withdrawn or withheld pursuant to section 15-18-104(3).
Persistent Vegetative State: A medical state in which an attending physician and

another doctor, qualified to make such diagnosis, agree that within a reasonable degree
of medical probability the patient can no longer think, feel anything, knowingly move, or
be aware of being alive. The physicians must agree this condition will last indefinitely
without hope for improvement and have monitored the patient long enough to make that
decision. APersistent Vegetative State@ is defined by reference to the criteria and
definitions employed by prevailing community medical standards of practice, and not by
the definition above..
Terminal Condition: An incurable or irreversible condition for which the administration

of life sustaining procedures will serve only to postpone the moment of death.
Declaration
I, Jane Smith, being of sound mind and at least eighteen years of age, direct that my
life shall not be artificially prolonged under the circumstances set forth below and I
hereby declare that:
Terminal Condition
Life-Sustaining Procedures:
1
1. If at any time my attending physician and one other physician who is qualified to
certify in writing that:
a. I have a terminal condition, and
b. If I am unable to effectively receive or evaluate information, or communicate

decisions concerning my person, then:
(Select only one)
(Initials) I direct that life–sustaining procedures shall be withdrawn and/or

withheld pursuant to the terms of this declaration, it being understood that life–
sustaining procedures shall not include any medical procedure or intervention
considered necessary by the attending physician to provide comfort or alleviate pain.
(Initials) I direct that life-sustaining procedures shall be continued for a period of

days, and if there be no change in my condition which would indicate to my
physicians that my prognosis has improved, then I direct that life-sustaining procedures
shall be withdrawn and/or withheld pursuant to the terms of this declaration, it being
understood that life-sustaining procedures shall not include any medical procedure or
intervention considered necessary by the attending physician to provide comfort or
alleviate pain.
(Initials) I direct that life-sustaining procedures shall be continued indefinitely,

regardless of my prognosis, if medically feasible and advisable in the determination of
my doctor(s).
Artificial Nutrition and Hydration
2. In the event that the only procedure I am being provided is artificial nutrition and
hydration, I direct that one of the following actions be taken:
(Select only one)
(Initials) Artificial nutrition and hydration shall not be continued when it is the only
procedure being provided.
(Initials) Artificial nutrition and hydration shall be continued for _______ days
when it is the only procedure being provided.
(Initials) Artificial nutrition and hydration shall be continued when it is the only
procedure being provided, if medically feasible and advisable in the determination of my
doctor(s).
.
Persistent Vegetative State
2
Life-Sustaining Procedures:
(Select only one)
3 If at any time my attending physician and one other qualified physician certify in
writing that I am in a persistent vegetative condition:
(Initials) I direct that life–sustaining procedures shall be withdrawn and/or

withheld pursuant to the terms of this declaration, it being understood that life–
sustaining procedures shall not include any medical procedure or intervention
(Initials) I direct that life-sustaining procedures shall be continued for a period of

days, and if there be no change in my condition which would indicate to my physicians
that my prognosis has improved, then I direct that life-sustaining procedures shall be
withdrawn and/or withheld pursuant to the terms of this declaration, it being understood
that life–sustaining procedures shall not include any medical procedure or intervention
(Initials) I direct that life-sustaining procedures shall be continued indefinitely,

regardless of my prognosis, if medically feasible and advisable in the determination of
my doctor(s).
.
Artificial Nutrition and Hydration:
4. In the event that the only procedure I am being provided is artificial nutrition and
hydration, I direct that one of the following actions be taken:
(Initials) Artificial nutrition and hydration shall not be continued when it is the only
procedure being provided.
(Initials) Artificial nutrition and hydration shall be continued for _______ days
when it is the only procedure being provided.
(Initials) Artificial nutrition and hydration shall be continued when it is the only
procedure being provided, if medically feasible and advisable in the determination of my
doctor(s).
.
Other Directions
3
If you do not have other directions, place your initials here: No, I do not have any
other directions.
5.
Resolution with Medical Power of Attorney

(Select one)
My Agent under my medical power of attorney shall have the authority to
override my preferences as stated in this instrument, whether this instrument was
executed before or after appointment of my Agent under my medical power of attorney.
My preferences as stated in this instrument shall prevail over the wishes of my

Agent under my medical power of attorney, whether this instrument was executed
before or after appointment of my Agent under my medical power of attorney.
Notification of Interested Parties

In the event that I have a terminal condition, or I am diagnosed as being in a
Persistent Vegetative State, in addition to my Agents under Medical Power of Attorney,
I direct my medical care providers to notify and discuss my medical situation with the
individuals listed below. I hereby waive any requirements of Public Law 104-191 and
supporting CFRs, otherwise known as the Health Insurance Portability and
Accountability Act of 1996, as amended, or HIPAA, concerning release of medical
information by my medical care providers to these individuals. This direction does NOT
authorize these individuals to make medical decisions on my behalf, unless such
person(s) also are my Agent under medical power of attorney. (This section shall be
considered valid regardless of whether or not the categories of Arelationship@ and
Atelephone number@ are completed.)
Name Relationship
Telephone number
4
ANATOMICAL GIFTS: I hereby authorize the following acts with regard to
donation of my organs, tissue, bone, corneas, and other components of my body:
I wish to be an organ and/or tissue donor, if medically feasible.

I do not wish to be an organ and/or tissue donor.
I execute this declaration, as my free and voluntary act, this day of

, 2010.
Jane Smith
Declarant
5
Declaration of Witnesses
The foregoing instrument was signed and declared by Jane Smith to be the
declarant=s declaration, in the presence of us, who, in the presence of the declarant, in
the presence of each other, and at the declarant=s 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. I did not sign the declarant=s signature, and I
am not a physician; an employee of the attending physician or health care facility in
which the declarant is a patient; a person who has a claim against any portion of the
estate of the declarant at the declarant=s death at the time this declaration was signed;
a person who knows or believes I am entitled to any portion of the state of the declarant
upon the delcarant=s death either as a beneficiary of a will in existence at the time this
declaration was signed, or an heir at law; nor a patient in the health care facility where
the declarant resides. I am eighteen (18) years of age or older, and under no form of
coercion, undue influence or otherwise disqualifying disability.
Signature of Witness Signature of

Witness
Address
Address
State of Colorado }
County of El Paso }
SUBSCRIBED and sworn to before me by Jane Smith , the declarant, and
and , witnesses, as the voluntary act and deed of
the declarant this day of , 2010.
Notary Public
My commission expires:

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ADVANCE DIRECTIVE FOR MEDICAL / SURGICAL TREATMENT

Life-Sustaining Procedure: Any medical procedure or intervention that, if administered

Persistent Vegetative State: A medical state in which an attending physician and

Terminal Condition: An incurable or irreversible condition for which the administration

a. I have a terminal condition, and

b. If I am unable to effectively receive or evaluate information, or communicate

(Select only one)

(Initials) I direct that life–sustaining procedures shall be withdrawn and/or

(Initials) I direct that life-sustaining procedures shall be continued for a period of

(Initials) I direct that life-sustaining procedures shall be continued indefinitely,

Artificial Nutrition and Hydration

(Select only one)

(Select only one)

(Initials) I direct that life–sustaining procedures shall be withdrawn and/or

(Initials) I direct that life-sustaining procedures shall be continued for a period of

(Initials) I direct that life-sustaining procedures shall be continued indefinitely,

Artificial Nutrition and Hydration:

Resolution with Medical Power of Attorney

My preferences as stated in this instrument shall prevail over the wishes of my

Notification of Interested Parties

I wish to be an organ and/or tissue donor, if medically feasible.

I execute this declaration, as my free and voluntary act, this day of

Signature of Witness Signature of

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