Colorado Advance Directive Form

Create a high quality document online now!

A Colorado advance directive is a document that outlines a person’s plan if they should not be able to speak for themselves due to a medical condition. In addition, the form gives guidance on how they would like to be medically treated if they should be in a state where there is no cure, such as the refusal of breathing and feeding assistance.

Advance Directive Includes

Table of Contents

Laws

Statute – § 25.5-4-413

Signing Requirements (§ 15-14-506§ 15-18-104) – Two (2) witnesses.

Versions (3)


Compassion & Choices

Download: Adobe PDF

 

 

 


 

Colorado Hospital Association

Download: Adobe PDF

 

 

 


UCHealth Advance Directive

Download: Adobe PDF

 

 

 

How to Write

Download: Adobe PDF

Medical Durable Power Of Attorney

(1) Name. The first segment of this directive expects the Colorado Principal issuing it to name the Health Care Agent or Representative who should be granted the authority or power to inform Colorado Physicians of the Principal’s treatment preferences. Begin this process by documenting the full name of the Colorado Principal issuing this document to ensure representation when he or she is in need of medical treatment but cannot communicate in an understandable way.

(2) City And State. The city and the state where the Colorado Principal or potential Patient maintains his or her residence. It should be noted the Colorado Principal is not required to maintain a residence in the State of Colorado, this document is meant to be a valid representation of the Principal’s wishes in the State of Colorado should the Principal require medical attention and cannot speak, sign, or even blink or nod to communicate with Colorado Medical Responders. For instance, the Principal may maintain a residence in another state but expects to spend a significant period of time in Colorado. Naturally, this document remains effective for anyone maintaining a Colorado residence as well.

(3) Colorado Health Care Agent. The Health Care Agent the Colorado Principal intends to grant the power to act as a Medical Representative must be identified. The Health Care Agent first approached by Colorado Physicians seeking definitions of the Principal’s preapproved treatment options as well as those the Principal refuses. Identify the Colorado Principal’s Health Care Agent by documenting his or her full name and address where requested.

(4) First Substitute Agent. It is important to keep in mind that even if the Health Care Agent named by the Colorado Principal is extremely reliable and capable of acting in this role, there may be a scenario where he or she is unable to occupy this role (i.e., the Health Care Agent is on extended travel, has been revoked or disqualified, or is incapacitated). To handle such a circumstance, it would be wise of the Colorado Principal to also set up a Substitute Agent. While no real representational powers will be given to the Colorado Substitute Agent while the Health Care Agent is active, this document will immediately authorize the  Colorado Substitute Agent to step into the role of Health Care Agent should be it become necessary and will simultaneously grant him or her the power needed to speak for the Principal. Name the Colorado Principal’s Substitute Health Care Agent and produce a record of this Party’s city and state.

(5) Second Substitute Agent. Many would consider it wise to take an added precaution when it comes to a Colorado Principal who requires a guarantee that he or she will have a consistent level of representation with Colorado Physicians. A Second Substitute Agent can be held in reserve once his or her name, city, and state have been attached to this role. Through this document, the Second Substitute can be immediately given the authority to represent the Colorado Principal when both the Primary Agent and First Substitute Agent will not fill this role.

Agent Powers

(6) Agent’s Representational Powers. The power to represent the Colorado Principal’s treatment goals to Physicians in this state is comprised of several types of actions the Health Care Agent will be authorized to take. By default, this document will grant these powers by listing them in the list lettered (A) through (G). These authorizations allow the Health Care Agent to consent to or refuse treatments, manage the Principal’s medical records for discussions and conversations, authorize the Principal’s admittance and discharge from medical facilities (even if it is not recommended by the attending Physician), obtain and discharge Colorado Medical Personnel, and to authorize medications and procedures meant to manage the Principal’s pain levels. These items are discussed in letters (A) through (H). Any part of these may be struck out or removed or an entire statement may be deleted at the discretion of the Colorado Principal however, it is strongly recommended that a consultation with an appropriate Professional take place before doing so because any alteration to the default powers granted to the Colorado Health Care Agent may result in impeding this Party’s ability to represent the Principal to Colorado Doctors.

(7) Anatomical Gifts Authorization. Statement (G) will require direct Principal authorization before this list can be considered reviewed and completed. Here, the Colorado Principal will decide and report if he or she authorizes the Agent to make anatomical gifts upon the Principal’s death for the purpose of transplantation, only authorize tissue gifts made for the purpose of transplantation, approve anatomical gifts made for the purpose of medical research, or the Principal can refuse to make anatomical gifts through this document. The Colorado Principal should be encouraged to initial each statement that applies to the post-death powers of making an anatomical gift on his or her behalf to the Health Care Agent before reviewing the final statement.

Living Will And Declaration As To Medical Surgical Treatment

Review And Select Any That Apply

(8) Surgery And Antibiotics. The Colorado Principal can declare which treatments and procedures are acceptable if he or she has a terminal condition, is in a prolonged/permanent coma, or is suffering from the advanced stage of dementia and which are not acceptable. The first item seeks the Principal’s standing on the use of surgery. If the Principal does not wish to receive surgery for any treatment unless to lessen his or her pain, then he or she must initial Statement 1 to formally declare this refusal.

(9) Antibiotics. Statement 2 will discuss the use of antibiotics to fight infection. If the Colorado Principal does not wish to receive antibiotics unless such treatment will address the pain he or she is in, then this statement should be initialed.

(10) Cardiopulmonary Resuscitation. To deny the use of CPR or cardiopulmonary resuscitation as a way to restart his or her heart or lungs, the Colorado Principal must initial the third statement.

(11) Invasive Procedures. The Colorado Principal can deny the administration of invasive diagnostic tests by initialing Statement 4.

(12) Breathing. This document will enable the Colorado Principal to deny the insertion of a tube to breath (known as intubation) by initialing

(13) Respirator Support. Equipment such as respirators and/or breathing machines should be approved with Statement 6 if they will be allowed as treatment.

(14) Blood Treatments. The Colorado Principal should initial the seventh statement to refuse blood transfusions or the administration of blood projects by initialing Statement 7.

(15) Kidney Dialysis. Similarly, Statement 8 should be initialed by the Colorado Principal to deny dialysis treatments.

(16) Medication. Statements 9 through 12 are set to allow the Colorado Principal to deny the administration of cortisone and other steroid therapy, stimulants, diuretics, and withholding pneumonia vaccine. The Colorado Principal can deny the medications discussed in these statements by providing his or her initials.

(17) Nutrition And Hydration. The Colorado Principal can inform Physicians that he or she does not wish to receive nutrition and hydration artificially (through an IV) by initialing Statement 13 and is able to deny having food and water administered by mouth by initialing Statement 14.

(18) Life Support. The Colorado Principal must also consider the fact that any condition that leaves him or her incapacitated or unable to maintain bodily functions for an extended period of time will result in the attending Medical Staff’s use of life support or life-prolonging treatment to keep him or her alive. The Colorado Principal can use this area to instruct attending Medical Staff to withdraw any life support he or she was currently put on before reviewing his or her directive, to deny the administration of life support so that it is withheld if it is determined he or she cannot survive independently of machines, instruct Medical Staff that life-prolonging techniques may only be used for a certain number of days, or approve all life support measures for as long as necessary to maintain his or her life by initialing the status statements provided in Section (B).

(19) Declarant Acknowledgment. A specific statement of acknowledgment which allows the Principal to reiterate his or her understanding that withholding nutrition, hydration, or life support once all hope of reasonable recovery is gone will result in death so that he or she understands the ramifications of the choices made above to be an appropriate measure to avoiding a severely impaired quality of life that may be burdensome to the Colorado Principal and his or her Survivors. To acknowledge the declaration, the Principal must initial “Yes” otherwise to refrain from making this declaration, the Principal should initial “No.” 

(20) Artificially Delivered Nutrients And Water. The Colorado Principal can declare his or her intention to refuse aided and artificial feedings and hydration when he or she is unable to make decisions or is incognizant but conscious by initialing the first statement presented and deny administered food and hydration when unconscious by initialing Statement 2.

Resolution With These Documents And My Agent’s Wishes

(21) The Advanced Directive Vs. Health Care Agent. The directives placed in this document may not be in line with the Colorado Health Care Agent’s interpretation of the Principal’s wishes. If this happens then Colorado Physicians will seek your decision on the actions that should be taken. The Colorado Principal can declare that his or her directives to take precedence of the representation of his or her Health Care Agent or can inform Colorado Physicians that the Health Care Agent’s instructions are granted the authority to supersede the directives of the Principal by initialing one of the two statements displayed. 

Principal Signature

(22) Execution Date. The Colorado Principal will need to sign this document before one of two Parties (a Notary Public or two Witnesses). Before the Colorado Principal signs this document, he or she must document the date.

(23) Colorado Principal Signature. This document should be reviewed by the Colorado Principal until he or she is satisfied with its representation of his or her medical directives. When he or she is ready to execute his or her medical directives, the Colorado Principal must sign his or her name, record his or her address, then relinquish the signed paperwork to the witnessing Party.

Witness Statement

(24) Witness Statement. If the Colorado Principal has decided to sign this document before two Witnesses, then the Witness Statement will require some preparation. Enter the full name of the Colorado Principal who has been observed signing the directive.

(25) Signature Of Witness 1. Witness 1 will prove his or her agreement with the Witness Statement by signing his or her name then entering the current date. Notice this date should be the same calendar date the Principal reported as his or her signature date.

(26) Printed Name Of Witness 1.

(27) Address Of Witness 1.

(28) Witness No 2 Signature. The next Witness set to sign this document should read the Witness Statement then provide agreement through his or her signature and a record of the calendar date that day.

(29) Printed Name Of Witness 2.

(30) Address Of Witness 2.

Agents’ Acceptance Of Appointment

(31) Printed Name Of Agent. The Colorado Health Care Agent authorized by the Principal in this document should acknowledge his or her role by completing the signature area provided. Before proceeding with this task, the Colorado Agent should print his or her name.

(32) Phone Number. The telephone numbers needed to reach the Colorado Health Care Agent at home and in other areas (i.e., work) should be supplied.

(33) Signature Of Agent. The Colorado Health Care Agent should sign his or her name to accept the appointment being made.

(34) Agent’s Address.

(35) 1st Substitute Agent’s Printed Name. Since the Health Care Agent role may be filled by the 1st Substitute Agent, this Party should also print his or her name to start completing the acceptance area provided.

(36) Phone Number(s).

(37) Signature Of 1st Substitute Agent. The 1st Substitute Agent should sign his or her name to show the intention of assuming the Health Care Agent role should the Colorado Principal’s primary choice is unable to effect the required duties.

(38) Address Of 1st Substitute Agent.

(39) Printed Name Of 2nd Substitute Agent. The 2nd Substitute Agent will be approached to act as the Colorado Principal’s Health Care Agent thus, he or she should also prepare to accept this responsibility if necessary, by printing his or her full name.

(40) Phone Number(s).

(41) 2nd Substitute Agent’s Signature. The signature of the 2nd Substitute Agent should be supplied as a demonstration of his or her willingness to assume the Colorado Health Care Agent position if necessary.

(42) 2nd Substitute Agent’s Address.

Notarization

(43) Notary Public. It is strongly recommended that the Colorado Principal’s signature and those of the Agents are notarized by a Colorado licensed Notary Public who has physically watched the Principal and Agents supply his or her signature.

Directive For Withholding CPR

(44) Patient’s Name. The directive that has just been completed can be considered a standalone document however an additional form that is optional is included with this package. This document is available for the Colorado Principal who wishes to issue a DNR order. This declaration will state the Colorado Principal’s desire that cardiopulmonary resuscitation not be used to revive him or her should the Principal’s hearts or lungs cease functioning and will require signature approval by a licensed Physician. Due to the seriousness of this request (i.e., a severe cardiopulmonary event can cause immediate death), the initial part of this form will be to fully identify the Colorado Principal making this declaration with a presentation of his or her full name.

(45) Name Of Authorized Agent. If this form is being completed by the Colorado Principal’s Health Care Agent, a Court-Appointed Guardian, or some other Legal Proxy or Representative of the Principal, then this Party must self-identify where requested.

(46) Patient Information. Colorado Medical Personnel will seek to positively identify the Principal with some basic facts and a visual inspection. Thus, record the Colorado Principal’s date of birth, gender, eye color, hair color, and (recommended) select the appropriate race or ethnicity of the Principal from the list provided.

(47) Name Of Hospice Program. The Colorado Principal may be participating in a Hospice Program. If so then the full name of the Hospice Program should be dispensed.

(48) Attending Health Care Professional. Along with the identity of the attending Healthcare Professional, the Health Care Professional’s address, the phone number where the Health Care Professional can be reached, and his or her  license number.

(49) Date Of Directive. Since this document is considered additional paperwork, it must be dated. Thus, report the calendar date when the Colorado Principal issues this directive.

(50) Effective Signature. The Colorado Principal or the Colorado Principal’s Authorized Representative must sign this form to complete it. Additionally, this Signature Party must indicate if he or she is the Colorado Principal or Patient or if the Legal Representative of the Colorado Principal or Patient is signing this document.

(51) Issuing Party. As mentioned above, this declaration can be issued directly by the Colorado Principal however, if he or she lacks the motor coordination to complete it or is incapacitated but has issued standing orders that this document be completed upon certain conditions, then the Colorado Principal’s Health Care Agent or other Legal Representative may issue this document on his or her behalf. To this end, one of two statements should be selected with an “X” or checkmark to present the identity of the Party issuing this document. Select the statement that defines the Colorado Principal or Patient as the originator of this form or the statement defining the Preparer of this document as the Colorado Principal’s authorized  Agent, Proxy, Legal Guardian, or Representative.

(52) Signature Of Attending Healthcare Professional. It is imperative that the licensed Healthcare Professional discuss this declaration with the Colorado Principal and sign his or her name to attest that this declaration is appropriate for the Principal.

Formally Approve Organ Donations

(53) Anatomical Gifts In Colorado. If the Colorado Principal wishes to formally approve of organ donation in a separate document then he or she can take advantage of the list provided to officially approve donations of any needed body tissues, can authorize only donations of skin, corneas, bones, and/or the tissues/tendons related to these body parts.

(54) Organ Donor Signature. The Colorado Principal only needs to review this list, then check or place an “X” next to each approved donation, then sign his or her name.Principal’s Last Wishes.

(55) Addendum For Last Wishes. As a matter of convenience, an additional document which will convey some important facts confirming the Colorado Principal’s health directives as understood and desired by this Party has been supplied for delivery to important people in his or her life. By confirming the statements provided with an “X” or a checkmark and circling the correct phrase where additional information is required. , the Colorado Principal can inform those important to him or her that the advanced directives issued are an accurate portrayal of his or her wishes and should be implemented when it is appropriate, where he or she will wish to die (this will require additional information by circling the preferred location), that he or she wishes to be cremated, buried, or to be donated to a Medical Facility after death, and whether a memorial service or funeral will be necessary.

Principal Statement To Loved Ones

(56) Statements Of Requested Support. The Colorado Principal has the option of personally asking those that care about him or her to be present and supportive during an end-of-life experience and to refrain from altering his or her medical directives and last wishes to match their approval and values by confirming the statements of support provided.

Principal Statement Of Desires

(57) Principal Confirmation. The Colorado Principal will have a final opportunity to re-iterate or confirm that he or she wishes all the statements in his or her Advance Directives to be followed.

(58) End-Of-Life. The Colorado Principal should supply his or her initials and provide some information to inform Reviewers if he or she wishes to indicate a desire to die at home, in a hospital, under hospice care or without hospice care, and/or deliver a specific place he or she requests death to occur.

(59) After Death. The Colorado Principal can use the final statements to establish his or her burial/cremation preferences and to request for a memorial service, a funeral, or indicate that neither should be arranged.

(60) Signature Requirement. The Colorado Principal can only issue this addendum if he or she supplies one or more confirmations to the statements provided, believes this to accurately define his or her last wishes, and signs this document as well as provide a signature date. It is recommended that once these actions are completed that a copy of this paperwork and the directive are kept on file with Medical Institutions where the Colorado Principal is known to receive care and sent to the Principal’s loved ones (if appropriate).

Consent For Release Of Medical Records

(61) Patient Requesting Release Of Medical Records. Most would consider it imperative that the Colorado Health Care Agent or at least one trusted Relative be granted the authority to access Colorado Principal’s medical records. The consent form provided enables such consent to be given. First, the Colorado Principal delivering his or her consent to release medical records should be identified.

(62) Medical Records To Be Released. The types of medical records that may not necessarily be readily available (i.e., those created for research purposes). While this consent form will release all medical records held by all Entities, if there are any that require additional release by being specifically named, then make sure to report them by type or title and/or the Institution where they may be stored.

(63) Recipient Of Medical Records. The full name of every Party the Colorado Principal authorizes to request and receive his or her medical records should be established in this paperwork.

(64) Colorado Principal Execution. The signature of the Colorado Principal is mandatory to release records through this document. He or she should supply this item then document the current date immediately after.

(65) Further Patient Statement. Some additional language will be needed for the Colorado Principal to release medical records governed by the Health Insurance Portability And Accountability Act of 1996. The declaration provided for this additional consent should be acknowledged and agreed to by the Colorado Principal with his or her signature and signature date.

(66) Notary Acknowledgment. A distinct area has been supplied for the use of the Notary Public being used to verify the Colorado Principal’s act of signing the provided consent form.

Medical Information Form

(67) Patient’s Name. A form where some basic information regarding the Patient (Colorado Principal) has been included for the benefit of future Reviewers. Identify the Colorado Principal or Patient by name.

(68) Document Date.

(69) Background Information. A record of the Colorado Principal’s birth date, phone number(s), and home address should be documented.

(70) Advocate Information. Present the full name of the Colorado Principal’s Health Care Agent as his or her Advocate. Make sure to also supply the Colorado Health Care Agent’s address and phone number(s).

(71) Alternate Advocate Information. In addition to the Health Care Agent’s identity and contact information, the 1st Substitute Agent should be presented as the Alternate Agent with the address and phone information needed to initiate contact.

(72) Physician Information. Document the full name and professional phone number of the Colorado Principal’s Primary Physician.

(73) Basic Questions. Some questions poised to the Colorado Principal will seek responses regarding the Recipients of his or her directives. If the Principal has any concerns regarding negative reactions from loved ones that can potentially result in interference, then such concerns should be documented using this area. This will include an opportunity to report the name and contact information of the Principal’s Attorney.

 

Related Forms


 

Durable (Financial) Power of Attorney

Download: Adobe PDF

 

 

 


 

Last Will and Testament

Download: Adobe PDF, MS Word, OpenDocument