Declaration As To Medical Or Surgical Treatment Form
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1Declaration As To Medical or Surgical Treatment
(Living Will)
I _______________________________________________being of sound mind and at least eighteen years of age,
(Name of Declarant)
direct that my life shall not be artificially prolonged under the circumstances set forth below and hereby declare that:
1.
If at any time my attending physician and one other qualified physician certify in writing that:
a.
I have an injury, disease, or illness which is not curable or reversible and which, in their judgment, is a
terminal condition; and
b.
For a period of seven consecutive days or more, I have been unconscious, comatose, or otherwise
incompetent so as to be unable to make or communicate responsible decisions concerning my person;
then
I direct that, in accordance with Colorado law, life-sustaining procedures shall be withdrawn and withheld
pursuant to the terms of this declaration; it being understood that life-sustaining procedures shall not
include any medical procedure or intervention for nourishment considered necessary by the attending
physician to provide comfort or alleviate pain. However, I may specifically direct, in accordance with
Colorado law, that artificial nourishment be withdrawn or withheld pursuant to the terms of this decision.
2.
In the event that the only procedure I am being provided is artificial nourishment, I direct that one of the following
actions be taken:
________________ a. Artificial nourishment shall not be continued when it is the only procedure being provided;
or
(Initials of the Declarant)
________________ b. Artificial nourishment shall be continued for ______ days when it is the only
procedure being provided; or
(Initials of the Declarant)
________________ c. Artificial nourishment shall be continued when it is the only procedure being provided.
(Initials of the Declarant)
3.
OPTIONAL: If you wish to make an anatomical gift, complete the following:
I hereby make an anatomical gift, to be effective upon my death, of:
________________ a. Any needed organs/tissue
)
(Initials of the Declarant
________________
b. The following organs/tissue _____________________________________
___________________________________________________________
(Initials of the Declarant)
4.
I execute this declaration, as my free and voluntary act on _______________________________
(date)
By _____________________________________________
Declarant
The foregoing instrument was signed and declared by _____________________________________to be his/her
declaration, in the presence of us, who, in his/her presence, in the presence of each other, and at his/her request, have
signed our names below as witnesses, and we declare that, at the time of the execution of this instrument, the declarant,
according to our best knowledge and belief, was of sound mind and under no constraint or undue influence.
Dated at ___________________________ Colorado, this _____________ day of ___________________, 20_____.
Signature ______________________________________
Signature _____________________________________
Address _______________________________________
Address ______________________________________
State of Colorado, County of ____________________________
Subscribed and sworn to before me by ___________________________________, the delcarant, and
_______________________________ and _________________________________ , witnesses, as the voluntary act
and deed of the Declarant, this _____ day of ______________, 20_____.
Witness my hand and seal
Notary Public
_____________________________________________________
My Commission expires:
Address
_________________________________________________________
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