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Advance Directive for Medical and Surgical Treatment (Living Will)

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ADVANCE DIRECTIVE FOR MEDICAL / SURGICAL TREATMENT (Living Will) 	
On completion, give copies to your physician, famil y members, and Healthcare Agent. If you wish to rev oke or replace this 
document, mark it clearly as “Revoked” or destroy i t 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.  	
 
I.  DECLARATION 
I, _______________________________________, am  
at least eighteen years old and able to make and  
communicate my own decisions. It is my direction th at 
the following instructions be followed if I am diag nosed 
by two qualified doctors to be in a terminal condit ion or 
Persistent Vegetative State.   
A.  Terminal Condition  
If at any time my physician and one other qualified  
physician certify in writing that I have a terminal  
condition, and I am unable to make or communicate m y 
own decisions about medical treatment, then:  
1.  Life-Sustaining Procedures  (initial one ): 
          	 (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procedures shall be withdrawn and/or withheld, not  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 ) I direct that life-sustaining procedures 
shall be continued for/until ( state timeframe or goal): 
             	
 	
2.  Artificial Nutrition  and Hydration  
If I am receiving nutrition and hydration by tube,  I direct 
that one of the following actions be taken 	
( initial one )	: 
          	
 ( Initials ) Artificial nutrition and hydration shall 
not be continued.  
          
 ( Initials ) Artificial nutrition and hydration shall 
be continued for/until ( state timeframe or goal ): 
             	
  
          	
 ( Initials ) Artificial nutrition and hydration shall 
be continued, if medically possible and advisable  
according to my healthcare providers.	
 	
B.  Persistent Vegetative State  
If at any time my physician and one other qualified  
physician certify in writing that I am in a Persist ent 
Vegetative State, then:   
1.  Life-Sustaining Procedures  (initial one ): 
          	 (Initials ) I direct that life-sustaining procedures 
shall be withdrawn and/or withheld, not including a ny  
       procedure considered necessary by my healthcare  
providers to provide comfort or relieve pain.  
          	
 (
Initials ) I direct that life-sustaining procedures 
shall be continued for/until ( state timeframe or goal): 
                     	
 	
2.  Artificial Nutrition and Hydration  
If I am receiving nutrition and hydration by tube,  I direct 
that one of the following actions be taken 	
( initial  one )	: 
  
          	
 ( Initials ) Artificial nutrition and hydration shall 
not be continued.  
          
 ( Initials ) Artificial nutrition and hydration shall 
be continued for/until ( state timeframe or goal ):  
             	
  
          	
 ( Initials ) Artificial nutrition and hydration shall 
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 other instructions for your care after you are 
certified in a terminal condition or Persistent Veg etative 
State ( for instance, to be enrolled in a hospice program, 
remain at or be transferred to home, discontinue or  
refuse other treatments such as dialysis, transfusi ons, 
antibiotics, diagnostic tests, etc. ) 	
(initial one )	: 
         	
 ( Initials ) Yes, I have attached other directions. 
         
 ( Initials ) No, I do not have any other directions. 
III. RESOLUTION WITH MEDICAL  
POWER OF ATTORNEY	
    (initial one ) 	
           	  ( Initials ) My Agent under my Medical Durable 
Power of Attorney shall have the authority to overr ide 
any of the directions stated here, whether I signed  this 
declaration before or after I appointed that Agent.   
           
  ( Initials ) My directions as stated here may not 
be overridden or revoked by my Agent under Medical  
Durable Power of Attorney, whether I signed this  
declaration before or after I appointed that Agent.  
     	
 Pursuant to Colorado Revised Statute 15-18.101–113               	1

IV. CONSULTATION WITH OTHER  
PERSONS  
I authorize my healthcare providers to discuss my  
condition and care with the following persons, under-
standing that these persons are not empowered to ma ke 
any decisions regarding my care, unless I have appo inted 
them as my Healthcare Agents under Medical Durable  
Power of Attorney. 
Name                       Relationship   
             	
 
             
 
             
 
             
 
             
 	
V. NOTIFICATION OF OTHER PERSONS  
Before withholding or withdrawal life-sustaining  
procedures, my healthcare providers shall make a  
reasonable effort to notify the following persons t hat I 
am in a terminal condition or Persistent Vegetative  State. 
My healthcare providers have my permission to discu ss 
my condition with these persons. I do NOT authorize  
these persons to make medical decisions on my behal f, 
unless I have appointed one or more of them as my  
Agent(s) under Medical Durable Power of Attorney.  
Name                   Telephone number or email   
             	
 
             
 
             
 
             
 
             
 	
VI.  ANATOMICAL GIFTS  
        	
 ( Initials ) I wish to donate my ( check one or both) 
____ organs and/or ____ tissues, if medically possi ble. 
        
 ( Initials ) I do not wish donate my organs or tissues.  
VII. SIGNATURE  
I execute this declaration, as my free and voluntar y act, 
this            	
day of                                       	, 20       	. 
  
             	
                                                
Declarant signature    VIII. DECLARATION OF WITNESSES
 
This declaration was signed by ( name of Declarant) 
             	
 
in our presence, and we, in the presence of each ot her, 
and at the Declarant’s request, have signed our nam es 
below as witnesses. We declare that, at the time th e 
Declarant signed this declaration, we believe that  he or 
she was of sound mind and under no pressure or undu e 
influence. We did not sign the Declarant’s signatur e. We 
are not doctors or employees of the attending docto r or 
healthcare facility in which the Declarant is a pat ient. 
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 declaration was signed. We  are at 
least eighteen (18) years old and under no pressure , 
undue influence, or otherwise disqualifying disabil ity. 	
 
             	 
Signature of Witness          
                                                           
 
Printed Name  
                                                                      
 
Address  
                                                      
 
  
             
 
Signature of Witness          
                                                           
 
Printed Name  
                                                                      
 
Address  
                                                      
 	
Notary Seal (optional ) 
State of ___________________________    
County of                      	
 } 
SUBSCRIBED and sworn to before me by  
                                         ,
 the Declarant,  
and              	
 
and                                              
 
witnesses, as the voluntary act and deed of the Dec larant 
this day of                       	
, 20      	. 
                                                                      	
 
Notary Public  
My commission expires:     	
 	
Pursuant to Colorado Revised Statute 15-18.101–113                  	2
Relevant article from our knowledge database

You can even use an advance directive to state what sorts of treatments you do or don't want, especially the treatments frequently used in a health emergency or close to the conclusion of somebody's life. To get around the decision-making limitations of a healthcare surrogate, you might want to contemplate having one or more advance directives. You may opt to make more than 1 advance directive. Advance directives are made to convey a person's wishes about their health care care to family and physicians at a time while he or she's otherwise unable to achieve that. In some conditions, your directive may state that you need someone aside from an attending physician to determine when you maynot make your own decisions. You don't need to have a healthcare directive. The Five Wishes advance healthcare directive is one of several ways which you may file a living will and get started preparing for what may come.
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If you prefer to modify your power of attorney, you have to do so in writing. You only ought to assign someone power of attorney to create your medical decisions when you have someone who you trust to perform your wishes. A power of attorney might be more flexible, because it's not possible to predict all the healthcare decisions that may come up in the future and spell out your precise preferences for every one of these situations. Whenever you do choose a health power of attorney, you will likely need to place some particular things in writing regarding the sort of care you would wish should you be unable to express your wishes directly. A medical or healthcare power of attorney is a kind of advance directive in which you name somebody to make decisions for you whenever you cannot achieve that. As an example, you could earn a medical care power of attorney, and a living will.

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