Advance Directive For Surgical / Medical Treatment (Living Will)
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2Advance Directive for Surgical / Medical Treatment (Living Will)
I. DECLARATION
procedure considered necessary by my healthcare providers
to provide comfort or relieve pain.
I, ______________________________________________ ,
communicate my own decisions. It is my direction that the
following instructions be followed if I am diagnosed by two
________________________________________________
Vegetative State.
2. Artificial Nutrition and Hydration
If I am receiving nutrition and hydration by tube, I direct
A. Terminal Condition If at any time my physician
have a terminal condition, and I am unable to make or com-
municate my own decisions about medical treatment, then:
not be continued.
1. Life-Sustaining Procedures (initial one)
-
dures shall be withdrawn and/or withheld, not including any
________________________________________________
procedure considered necessary by my healthcare providers
to provide comfort or relieve pain.
be continued, if medically possible and advisable according
to my healthcare providers.
II. OTHER DIRECTIONS
________________________________________________
Please indicate below if you have attached to this form any
2. Artificial Nutrition and Hydration
other instructions for your care a er you are certi ed in a
If I am receiving nutrition and hydration by tube, I direct
-
stance, to be enrolled in a hospice program, remain at or be
transferred to home, discontinue or refuse other treatments
such as dialysis, transfusions, antibiotics, diagnostic tests,
not be continued.
________________________________________________
III. RESOLUTION WITH MEDICAL POWER OF
be continued, if medically possible and advisable according
ATTORNEY (initial one)
to my healthcare providers.
Power of Attorney shall have the authority to override any of
B. Persistent Vegetative State If at any time my
the directions stated here, whether I signed this declaration
before or a er I appointed that Agent.
that I am in a Persistent Vegetative State, then:
1. Life-Sustaining Procedures (initial one)
overridden or revoked by my Agent under Medical Durable
Power of Attorney, whether I signed this declaration before
shall be withdrawn and/or withheld, not including any
or a er I appointed that Agent.
Pursuant to Colorado Revised Statute 15–18.101–113
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