Colorado Living Will Form (Advance Directive)

The Colorado Advanced Directive is a form which provides a person with the opportunity to instruct their medical practitioners as to their wishes regarding their health care should they reach a state in which they are no longer able to communicate. The document is  is drawn up in accordance with Statutes §§15-18-101 to 15-18-113. The completion of the form requires no witnesses but if the principal is found to be pregnant then the will becomes void.

How to Write

Section 2. Advanced Directives

2a) Medical Durable Power Of Attorney

Enter Principal`s, Agent`s and alternative Agent`s details.

  • Principals name
  • Principals address
  • Agents name
  • Agents address

g) To Make Anatomical Gifts

Initial to denote the type of anatomical gift to authorize/not authorize.

  • Anatomical gifts for limited purposes.
  • Tissue only gifts for limited purposes.
  • Anatomical gifts for medical research.
  • Not to authorize any anatomical gifts.

 

2b) Living Will And Declaration

a) Initial or write `yes` to denote an exception to acceptable medical treatments.

  • (1) Surgery..
  • (2) Antibiotics.
  • (3) Cardiopulmonary resuscitation.
  • (4) Invasive diagnostic tests.
  • (5) Intubation (insertion of a tube to aid respiration).
  • (6) Respirator support..
  • (7) Blood or blood products.
  • (8) Kidney dialysis.
  • (9) Heart-regulating drugs.
  • (10) Steroid therapy.
  • (11) Stimulants if function of heart is impaired.
  • (12) Withholding of pneumonia vaccine.
  • (13) Artificial hydration and nutrition.
  • (14) Eating and drinking by mouth.

b) The principal should initial one option to denote an option regarding life sustaining treatment.

  • Withdraw life sustaining treatment
  •  Withhold life sustaining treatment
  • Continue life sustaining treatment and enter minimum number of days treatment is to be continued.
  • Continue life sustaining treatment indefinitely
  • Initial declaration either `Yes` or `No` to show they understand implications of withholding treatment.

d) Regarding Nourishment And Hydration While Unconscious/Incompetent With Death Expected

Initial one of the options.

  • Initial to refuse assisted nutritional support for life support.
  • Initial to withdraw assisted nutritional support for life support.

 

Resolution Of Principals Wishes Regarding Agents Authority

Initial one of the options.

  • The principals wishes have ultimate power.
  • The agents wishes have ultimate power.

Enter principals details.

  • Signature.
  • Address.
  • Date.

2c) Witnesses Statements

Enter witnesses details.

  • Signature.
  • Print name.
  • Address.
  • Date.
  • Telephone numbers.

2d) Agents

Enter personal details of agent and substitute agents.

  • Signature.
  • Print name.
  • Address.
  • Date.
  • Telephone numbers.

 

Optional Notary

Enter details of notary (Optional).

  • City.
  • County.
  • Name of principal.
  • Name of witnesses.
  • Date.
  • Notary
  • Address of notary
  • Expiration date of notary

2f) Withholding Cardiopulmonary Resuscitation

Enter details.

  • Patient’s name.
  • Name of authorized agent, proxy, guardian, parent (if applicable).
  • Patient’s date of birth.
  • Gender.
  • Eye color.
  • Hair color.
  • Race/Ethnicity.
  • Name of hospice program (if applicable).
  • Attending healthcare professional.
  • Attending healthcare professional’s address.
  • Attending healthcare professional’s telephone number.
  • License.
  • Date.

Check one option

  • Principal initiates directive.
  • Agent initiates directive.

One signature required.

  • Patient`s signature.
  • Agent`s signature.

Signature of health care professional.

  • Health care professional`s signature.

 

Anatomical Gift

Enter details regarding donation of anatomical gift.

  • Any tissues.
  • Skin.
  • Cornea.
  • Bone.
  • Related tissues and tendons.
  • Donor/Agent Signature.

 

3) Last wishes

Initial to agree with denoted last wishes

  • Understanding of health care professionals.
  • Agent`s agreement.
  • Understand choices regarding death.
  • Acknowledge membership of Hemlock society and length of membership.
  • Understanding the correct measures appropriate for prognosis.
  • Understand wishes regarding visitation.
  • Respecting beliefs of principal regarding death.
  • Understanding of (If any) services after death

 

Personal Details Of Principal

Enter principals details.

  • Signature
  • Date

 

4) Consent For Release Of Medical Records

Enter details regarding release of medical records.

  • Name of principal.
  • Name of those who the records are requested from.
  • Name of those to receive the medical records.
  • Signature.
  • Date.

 

Purposes And Effects Of This Consent

Enter principals details.

  • Signature.
  • Date.

 

Optional Notary

Enter details of notary.

  • City.
  • County.
  • Name of principal.
  • Date.
  • Name of notary.
  • Address of notary.
  • Expiration date of commission of notary.

 

5) Medical Information Form

Enter patient`s details.

  • Name.
  • Date of birth.
  • Address.
  • ZIP code.
  • Telephone numbers.

Enter agent`s and alternative agent`s details.

  • Name.
  • Address.
  • Telephone numbers.

Enter doctor`s and alternative doctor`s details and associated information.

  • Doctor’s name.
  • Telephone number.
  • Other doctor’s name.
  • Discussed wishes with doctor.
  • Discussed wishes with family.
  • Discussed wishes with another party.
  • Names of other party wishes were discussed with.
  • Names of any persons who disagree with wishes.
  • Any other concerns.
  • Contact information for attorney (If any).