Advance Directive For Surgical / Medical Treatment (Living Will) (Page 2 of 2) in pdf

Advance Directive for Surgical / Medical Treatment (Living Will) (continued)

IV. CONSULTATION WITH OTHER PERSONS

VIII. DECLARATION OF WITNESSES

I authorize my healthcare providers to discuss my condi-

tion and care with the following persons, understanding that

________________________________________________

these persons are not empowered to make any decisions re-

in our presence, and we, in the presence of each other, and at

garding my care, unless I have appointed them as my Health-

care Agents under Medical Durable Power of Attorney.

nesses. We did not sign the Declarant’s signature. We are not

doctors or employees of the attending doctor or healthcare

facility in which the Declarant is a patient. We are neither

________________________________________________

creditors nor heirs of the Declarant and have no claim

________________________________________________

against any portion of the Declarant’s estate at the time this

________________________________________________

old and under no pressure, undue in uence, or otherwise

________________________________________________

V. NOTIFICATION OF OTHER PERSONS

________________________________________________

Before withholding or withdrawing life-sustaining procedures,

my healthcare providers shall make a reasonable e ort to no-

________________________________________________

tify the following persons that I am in a terminal condition

or Persistent Vegetative State. My healthcare providers have

________________________________________________

my permission to discuss my condition with these persons. I

do NOT authorize these persons to make medical decisions

on my behalf, unless I have appointed one or more of them

________________________________________________

Notary (optional)

State of __________________________

VI. ANATOMICAL GIFTS

County of ________________________

SUBSCRIBED and sworn to before me by

____________________________________ , the Declarant,

organs and/or

tissues, if medically possible.

and ____________________________________________

witnesses, as the voluntary act and deed of the Declarant this

VII. SIGNATURE

day of _________________________, 20____.

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

________________________________________________

Notary Public

day of _________________________, 20____.

My commission expires: ____________________________

________________________________________________

Pursuant to Colorado Revised Statute 15–18.101–113

Advance Directive For Surgical / Medical Treatment (Living Will) Page 2

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