Advance Directive For Medical / Surgical Treatment (Living Will) (Page 2 of 3) in pdf

ADVANCE DIRECTIVE FOR MEDICAL / SURGICAL TREATMENT

(Living Will)

On completion, give copies to your physician, family members, and Healthcare Agent. If you wish to revoke or replace this

document, mark it clearly as “Revoked” or destroy it and all its copies, if possible. If you do not understand the choices and

options, seek advice from a healthcare provider or other qualified advisor.

procedure considered necessary by my healthcare

I. DECLARATION

providers to provide comfort or relieve pain.

I, _______________________________________, am

(Initials) I direct that life-sustaining procedures

at least eighteen years old and able to make and

shall be continued for/until (state timeframe or goal):

communicate my own decisions. It is my direction that

the following instructions be followed if I am diagnosed

by two qualified doctors to be in a terminal condition or

Persistent Vegetative State.

2. Artificial Nutrition and Hydration

A. Terminal Condition

If I am receiving nutrition and hydration by tube, I direct

If at any time my physician and one other qualified

that one of the following actions be taken

(initial one)

physician certify in writing that I have a terminal

condition, and I am unable to make or communicate my

(Initials) Artificial nutrition and hydration shall

own decisions about medical treatment, then:

not be continued.

1. LifeSustaining Procedures (initial one):

(Initials) Artificial nutrition and hydration shall

be continued for/until (state timeframe or goal):

(Initials) I direct that all life-sustaining

procedures shall be withdrawn and/or withheld, not

including any procedure considered necessary by my

healthcare providers to provide comfort or relieve pain.

(Initials) Artificial nutrition and hydration shall

be continued, if medically possible and advisable

(Initials) I direct that life-sustaining procedures

according to my healthcare providers.

shall be continued for/until (state timeframe or goal):

II. OTHER DIRECTIONS

Please indicate below if you have attached to this form

2. Artificial Nutrition and Hydration

any other instructions for your care after you are

If I am receiving nutrition and hydration by tube, I direct

certified in a terminal condition or Persistent Vegetative

that one of the following actions be taken

(initial one)

State (for instance, to be enrolled in a hospice program,

remain at or be transferred to home, discontinue or

(Initials) Artificial nutrition and hydration shall

refuse other treatments such as dialysis, transfusions,

not be continued.

antibiotics, diagnostic tests, etc.)

(initial one)

(Initials) Artificial nutrition and hydration shall

(Initials) Yes, I have attached other directions.

be continued for/until (state timeframe or goal):

(Initials) No, I do not have any other directions.

(Initials) Artificial nutrition and hydration shall

III. RESOLUTION WITH MEDICAL

be continued, if medically possible and advisable

POWER OF ATTORNEY

(initial one)

according to my healthcare providers.

(Initials) My Agent under my Medical Durable

Power of Attorney shall have the authority to override

B. Persistent Vegetative State

any of the directions stated here, whether I signed this

If at any time my physician and one other qualified

declaration before or after I appointed that Agent.

physician certify in writing that I am in a Persistent

Vegetative State, then:

(Initials) My directions as stated here may not

be overridden or revoked by my Agent under Medical

1. LifeSustaining Procedures (initial one):

Durable Power of Attorney, whether I signed this

(Initials) I direct that life-sustaining procedures

declaration before or after I appointed that Agent.

shall be withdrawn and/or withheld, not including any

Pursuant to Colorado Revised Statute 15-18.101–113

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

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