Colorado Living Will Form

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A Colorado living will, or “Advance Directive for Medical/Surgical Treatment,” allows a person to outline their end-of-life treatment wishes. This includes how they desire to be treated in the chance they cannot speak for themselves such as dementia or being in a vegetative state. The form is created and signed by the declarant with at least two (2) witnesses or the acknowledgment of a notary public and should be kept in an accessible place in the chance it’s needed.

Laws

How to Write

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I. Declaration

(1) Colorado Patient As The Declarant. You have the right to make certain treatment decisions ahead of time when diagnosed in a prolonged (long-term) vegetative state or suffering a fatal medical condition as a Patient, or Potential Patient, in the State of Colorado. Such directives will be considered your declaration to Colorado Medical Personnel seeking your stance on life-saving procedures and any other medical directives you have. To begin, record your full name to the opening statement. This will identify you as the Colorado Declarant in this form.

A. Terminal Condition

Directive 1 Life-Sustaining Procedures

Select Item 2 Or Select Item 3

(2) Deny Colorado Life-Sustaining Treatments. If you are diagnosed in Colorado with a terminal or fatal medical condition, then there will be nearly no hope of recovery. This means that eventually your body may not be able to support your life or can only do so with significant pain. Colorado Medical Professionals will seek to aid your body with life-sustaining treatments (for instance, intubating Patients who cannot breathe, or administering dialysis to help clean the blood). If you do not wish any medical treatment administered simply to prolong your life when it will end shortly, then initial the first directive statement in Directive 1. This will inform Colorado Medical Professionals of your desire to experience a natural death. If you do not wish to adopt this directive, then do not initial this statement.

(3) Approve Of Colorado Life-Sustaining Treatments. If you wish to save time by delivering your consent to Colorado Doctors who seek to apply life-sustaining treatment when you are experiencing a fatal medical condition that is deemed terminal or incurable, then initial the second statement provided under this topic. As the Colorado Declarant issuing medical directives through this form, you also have the option of including specific instruction to the life-sustaining treatment this directive approves. For example, you may not wish to be intubated when diagnosed with certain medical conditions but do wish to receive other life-prolonging measures such as surgery or dialysis). The space provided in this directive option will accept such instructions to Colorado Physicians.

Directive 2 Artificial Nutrition And Hydration

Select Item 4, Item 5, Or Item 6

(4) Discontinue Or Reject Artificial Nutrition. The decision that you have documented over your willingness to accept life-sustaining treatment will not include your stance on receiving artificially provided food and water. Therefore, locate the second directive. If you do not intend to accept the artificial delivery of nutrition or hydration (while experiencing a terminal condition), then initial the first statement in this directive so that Colorado Physicians are aware of your refusal to receive nourishment or water through a tube or machine.

(5) Conditional Acceptance Of Artificial Nutrition And Hydration. You may also exert your right as the Colorado Patient to accept the deliverance of artificial nutrition and hydration so long as your condition meets a criterion you set. For instance, you may wish to engage a trial period of artificially delivered nutrition and hydration under certain circumstances. To do so, the second statement in this directive must bear your initials and your exact instructions delivered to the space provided.

(6) Consent To Artificial Nutrition And Hydration. Initial the third statement to request and consent to the delivery of artificial nutrition or hydration any time it is required after you have been diagnosed with a fatal medical condition.

B. Persistent Vegetative State

Directive 1 Life-Sustaining Procedures

Select Item 7 Or Select Item 8

(7) Withholding Approval For Life-Sustaining Procedures. If Colorado Physicians proclaim you as being in a permanent or long-term vegetative state with no hope of recovering then, your body will require medical aid in staying alive. Such procedures will focus on prolonging your life when you can no longer perform vital functions (such as breathing).  Colorado Physicians will seek to administer life-prolonging procedures to stave off death unless you withdraw your consent to such medical treatment. To withdraw your consent, initial the first statement made in Part B.

(8) Conditional Consent To Life-Sustaining Procedures. If preferred, you may instruct Physicians to apply any life-prolonging medical treatments as needed to keep you alive when in an untreatable vegetative state. By initialing the second statement of this directive, you will give blanket consent to receive life-prolonging medical treatment. If you wish to place limits or a time period of trial on these procedures, then present them on the blank line made available in this statement.

Directive 2 Artificial Nutrition And Hydration

Select Item 9, Item 10, Or Item 11

(9) Instruction To Withhold Artificial Nutrition And Hydration. Your instructions on how or whether artificial nutrition and hydration can be delivered to your system while you are in a permanent coma should also be included to this section. The second directive enables you to inform all Colorado Medical Personnel that you withhold your consent to receive artificial nutrition or artificially delivered hydration. Initial the first statement to make this directive.

(10) Partial Approval To Receive Artificial Nutrition And Hydration. Initial the second statement if you wish to give consent to receive artificially provided nutrition and/or hydration (as required by your current state at the time) after Colorado Medical Personnel have determined you are in a permanent and untreatable vegetative state but only according to your instructions. This selection requires documentation of your instructions on when and how artificial nutrition and hydration be administered while you are in a (permanently) vegetative state be supplied to the space available in this state. You may provide this using the space available in this statement as well as with an attachment that is properly labeled.

(11) Requesting Artificial Nutrition And Hydration. To request that artificially delivered nutrition and/or water be given to you when your body requires it while in a permanent coma, initial the final statement in this directive.

Section II Other Directions

Select Item 12 Or Item 13

(12) Document Additional Colorado Medical Instructions. If you have continued any of the above areas on an attachment (that is properly labeled as such) and/or provided a separate document of your instructions, then submit your initials to the first statement displayed in Section II. This will indicate to future reviewers that additional paperwork accompanies this directive (and should be sought for a complete understanding of your medical preferences.

(13) Confirm No Attachments. If you do not have any additional documents regarding your medical care (i.e. a Medical Power of Attorney or continuation of any above directives) then initial the second statement.

Section III Resolution With Medical Power Of Attorney

Select Item 14 Or Sitem 15

(14) Colorado Health Care Agent Authority. If you have named a Health Care Agent to represent your wishes using a Colorado Health Care Power of Attorney or similar document, then his or her directions over your medical treatment in relation to this document should be discussed. Keep in mind, there may be a time when this document’s instructions and the opinion of your Health Care Agent differ. If you believe your Health Care Agent should be able to carry out your directives even when they countermand the instructions you delivered above, then initial the first declaration in Section III. This can be useful if your Health Care Agent is particularly up-to-date and well-informed on current treatments to your condition.

(15) Overriding The Colorado Health Care Agent. If you have appointed a Health Care Agent or Representative to deliver your medical instructions in the State of Colorado but wish this document to override any contradicting instructions of the Health Care Agent, then the second statement in Section III must be initialed. This will remove your Health Care Agent’s right to disagree with the medical instructions you set in the living will above.

Section IV Consultation With Other Persons

(16) Authorized Consultants For Colorado Health Care. This document can be used to inform Colorado Physicians that you wish certain people in your circle or where you receive medical care to be consulted regarding treatment administered when you are terminally ill, fatally injured, or in a permanent vegetative state. List each such person by name in Section IV as well as his or her relationship to you. Be aware that unless you have listed a deliberately appointed Health Care Agent in this area, no one you name here will have the right to determine what your medical treatment should be. This will only be a list of interested Parties who you wish Colorado Doctors to consult with as needed.

Section V. Notification Of Other Persons

(17) Required Contacts Before Administering Directives. Utilize the area in Section V to dispense the name and telephone number or the email address of anyone you wish contacted and informed of your condition when you are diagnosed as terminally ill or permanently unconscious.

Section VI Anatomical Gifts

(18) Desired Anatomical Donation In Colorado. Initial the first statement in Section IV if you wish to donate your organs and body parts upon death in the State of Colorado.

(19) Preferred Anatomical Donation. If you wish to donate only certain organs or tissues, provide your initials to the second statement. Once done, list the type of tissues you wish to donate in the space provided (you may use an attachment if more room is required).

(20) Refusing To Make Anatomical Donation. To refrain from making an organ or tissue donation in the State of Colorado (upon death), initial the final statement in Section VI.

Section VII Signature

(21) Signature Date Of Execution. Review the directives you have selected from the paperwork above as well as any attachments containing your treatment instructions when in the State of Colorado and incapacitated with a fatal condition or permanently unconscious. To make this official, a dated and witnessed or notarized signature from the document’s Declarant must be submitted. Determine who shall validate your act of signing, gather together, then produce the current date to the signature area.

(22) Signature Of Colorado Patient As Declarant. Sign your full name while a Colorado Witness or Notary observes.

Section VIII Declaration Of Witnesses

(23) Colorado Signature Declarant. If two Colorado Witnesses have observed the act of your signing this document, then your full name must be recorded where it is requested in the Witness Statement.

(24) Signature Of Witness 1 Requirement. A Colorado Witness is an adult Party who is completely impartial to the results of your treatment. The first Witness who has seen you sign this document must review the declaration provided then signify his or her agreement with it by signing and printing his or her name. The First Colorado Witness must also provide his or her mailing address should anyone require additional testimony regarding your signature.

(25) Signature Of Witness 2 Requirement. The Second Colorado Witness must also meet the same criteria as the First to be eligible for this role. If so, then the Second Colorado Witness’s signature, printed name, and residential address must be submitted to the second signature area once he or she has read and agreed to the declaration made.

Notary Seal (Optional)

(26) Colorado Signature Notarization. If your signature was witnessed by a Colorado Notary Public, then he or she will deliver the items revolving around your signature as well as his or her seal and credentials.