- Attachment A
DECLARATION AS TO MEDICAL OR SURGICAL TREATMENT
I________________________________, being of sound mind and at least eighteen years of age, direct that
(Name of Declarant)
my life shall not be artificially prolonged under the circumstances set forth below and hereby declare that:
1.If at any time my attending physician and one other physician certify in writing that:
have an injury, disease or illness which is not curable or reversible
and which, in their judgment, is a terminal condition; and
a period of seven consecutive days or more, I have been unconscious,
comatose or otherwise incompetent so as to be unable to make or
communicate responsible decisions concerning my person; then I direct
that, in accordance with Colorado law, life-sustaining procedures shall
be withdrawn and withheld pursuant to the terms of this declaration; it
being understood that life-sustaining procedures shall not include any
medical procedure or intervention for nourishment considered necessary
by the attending physician to proved comfort or alleviate pain.
However, I may specifically direct, in accordance with Colorado law,
that artificial nourishment be withdrawn or withheld pursuant to the
terms of this declaration.
the event that the only procedure I am being provided is artificial
nourishment, I direct that one of the following actions be taken:
_______(initials of declarant) a.
Artificial nourishment shall not be continued when it is the only
procedure being provided; or
_______(initials of declarant) b.
Artificial nourishment shall be continued for_____days when it is the
only procedure being provided; or
_______(initials of declarant) c. Artificial nourishment shall be continued when it is the only procedure being provided.
3..I execute this declaration as my free and voluntary act this______day of this month __________, in this year of________.
The foregoing instrument was signed and
declared by____________________to be his/her declaration, in the
presence of us, who, in his/her presence, in the presence of each
other, and at hi/her request, have signed our names below as witnesses,
and we declare that, at the time of the execution of this instrument,
the declarant, according to our best knowledge and belief, was of sound
mind and under no constraint or undue influence. We further declare
that neither of us is : 1) a physician; 2) the declarant’s physician or
an employee of his/her physician; 3)an employee or a patient of the
health care facility in which the declarant is a patient; or 4) a
beneficiary or creditor of the estate of the declarant.
Dated at_______________, Colorado, this______ day of ___________, in the year_______.
(Signature of Witness)(Signature of Witness)
STATE OF COLORADO, County of ___________________________
Subscribed and sworn to or affirmed before
me by ____________________, the declarant, and _____________________ ,
and ______________________________, witnesses, as the voluntary act and
deed of the declarant, this ______________ day of __________________,
in the year ___________.
My commission expires:___________________________________________
- Federal law directs that
any time you are admitted to any health care facility, or served by
certain organizations that receive Medicare of Medicaid money, you must
be told about Colorado’s laws concerning your right to make health care
- Upon admission, you must be given information about advance directives.
- Although you have the
right to make an advance directive, you cannot be required to have or
make an advance directive in order to be admitted to a health care
facility or to receive treatment or care.
- Talk to your doctor about medical conditions which might make advance directives useful.
- Talk with your health
care providers about your wishes and beliefs. Make sure that copies of
your advance directives are included in your medical records. It is
your responsibility to provide these copies to your health care
- You must be given
written information about your health care providers’ policies and
procedures regarding your advance directives. Be sure to discuss
whether your directive swill be honored. If you determine their
policies are not consistent with your advance directives, you may wish
to transfer to another facility or provider.
- If you do not want
your family and closer friends to select a substitute decision maker
(proxy) to make medical decisions for you, you should have an advance
medical directive such as a medical durable power of attorney in which you name the person who will make decisions for you.
- You do not need to use a lawyer to complete your living will, medical durable power of attorney, or CPR Directive. If you have legal questions, however, you may wish to talk to a lawyer.
- If you have a living will, medical durable power of attorney, or CPR Directive,
give a copy of it to your doctor, your family, your agent, if
applicable, and to your health care facility. Talk with your doctor,
family, and agent, if applicable, while you’re still in good health, so
they will understand what you want.
- If you have completed a CPR Directive, be sure it is readily available at all times.
- Ordinarily, it is not advisable to have both a living will and a medical durable power of attorney, as long as your medical durable power of attorney contains any instructions you wish to give about your future medial treatment, including treatment when you are terminally ill.
Medical Durable Power of Attorney for Health Care Decisions
IMPORTANT INFORMATION ABOUT THE FOLLOWING LEGAL DOCUMENT
Before signing this document, it is very important for you to know and understand these facts:
- This document gives the
person you name as your agent the power to make health care decisions
if you are unable to do so. (These decisions and powers are not limited
to terminal conditions and life support decisions.)
- After you have signed
this document, you still have the right to make health care decisions
for yourself if you are able to do so.
- You may state in this
document any type of treatment that you want to receive or want to
avoid. If you want your agent to make decisions about life sustaining
treatment, if is best to so state in your medical durable power of attorney.
- You have the right to
take away the authority of your agent unless you have been determined
to be incompetent by a court. If you withdraw (revoke) the authority of
your agent, it is recommended that you do so in writing and give copies
to all those who received the original document.
- You should not sign this document unless you understand it. You may wish to talk to others or a lawyer.
- The Medical Durable Power of Attorney
form complies with Colorado law; however, it may not meet your
individual needs. Other medical durable power of attorney forms are
acceptable according to Colorado law. Be sure the form you sign meets
- The enclosed Medical Durable Power of Attorney
form complies with Colorado law; however witness, notary and other
requirements vary from state to state. If you should move to another
state, be sure to check that state’s requirements.
MEDICAL DURABLE POWER OF ATTORNEY FOR HEALTH CARE DECISIONS
- Attachment B
1. I,__________________________________________________, Declarant, hereby appoint:
(Print or Type Your Name)
Name of Agent
Agent’s Home Telephone Number
Agent’s Work Telephone Number
Agent’s Home Address
as my agent to make health care decisions
for me if and when I am unable to make my own health care decisions.
This gives my agent the power to consent, to refuse or stop any health
care, treatment, service or diagnostic procedure. My agent also has the
authority to talk with health care personnel, get information and sign
forms necessary to carry out those decisions.
the person named as my agent is not available or to act as y agent,
then I appoint the following person(s) to serve in the order listed
2. _____________________________________3. ______________________________________
Agent NameAgent Name
Home Telephone #Work Telephone #Home Telephone #Work Telephone #
By this document I intend to create a Medical Durable Power of Attorney which shall take effect upon my incapacity to make my own health care decisions and shall continue during that capacity.
agent shall make health care decisions as I may direct below or as I
make known to him or her in some other way. If I have not expressed
about the health care in question, my agent shall base his/her decision
on what he/she believes to be in my best interest.
(A)Statement of desires concerning life-prolonging care, treatment, services and procedures:
(B)Special provisions and limitations:
BY SIGNING HERE, I INDICATE THAT I UNDERSTAND THE PURPOSE AND EFFECT OF THIS DOCUMENT.
SIGNATURE OF PERSON CREATING MEDICAL DURABLE POWER OF ATTORNEY (DECLARANT) DATE
(Optional But Recommended)
Colorado law does not require
this instrument to be witnessed; however, it is recommended to obtain
the signature of two witnesses or a notary. This is not required by
Colorado law buy may make this document more acceptable in other states.
Home Address:_________________________Home Address:__________________________
Medical Durable Power of Attorney For Health Care Decisions (continued)
Your medical durable power of attorney should contain the following information:
The name, address and telephone number of
the person you choose as your agent, and your second choice of agent to
act if your first agent is unable to act for you.
Any instructions about treatment you do or
do not wish to receive such as surgery, chemotherapy or life sustaining
treatment such as artificial feeding, kidney dialysis or breathing
Advance Directives Coalition
The original version of “Your Right to Make Healthcare Decisions”
was prepared by the Advance Directives Coalition which consisted of
various health organizations and agencies and private attorneys.
For help or more information, contact
your local physician, hospital, senior group, attorney or any of the
organizations listed below:
Buchanan Neville Stouffer, P.C.
Colorado Association of Homes and Services for the Aging
Colorado Association of Home Health Agencies
Colorado Bar Association
Colorado Department of Social Services
Colorado Department of Public Health and Environment
Colorado Health Care Association
Colorado Health and Hospital Association
Colorado Medical Society
Governor’s Commission on Life and Law
Legal Aid Society
Licensed Health Care Facilities
Rocky Mountain Center For Healthcare Ethics
The Legal Center for Persons With Disabilities
Please contact one of the above listed organizations for documents if
you cannot print the documents from your computer.</DIV>]