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Colorado Living Will Form (Advance Directive) |
The Colorado Advanced Directive is a form that 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. This document requires attestation by two (2) witnesses or a notary public in accordance with § 15-18-106(1).
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).
