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).