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 Life-Sustaining Procedures (initial one ): (Initials ) I direct that all life-sustaining procedures shall be withdrawn and/or withheld, not including any procedure considered necessary by my healthcare providers to provide comfort or relieve pain.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 Life-Sustaining Procedures (initial one ): (Initials ) I direct that life-sustaining procedures shall be withdrawn and/or withheld, not including a ny procedure considered necessary by my healthcare providers to provide comfort or relieve pain.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 2Relevant 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.