Advance Directives - Living Will / Medical Durable Power of Attorney Example

Living Will
- Attachment A

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:
a..I have an injury, disease or illness which is not curable or reversible and which, in their judgment, is a terminal condition; and
b..For 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concerning my person; then I direct that, in accordance with Colorado law, life-sustaining procedures shall be withdrawn and withheld pursuant to the terms of this declaration; it being understood that life-sustaining procedures shall not include any medical procedure or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 However, I may specifically direct, in accordance with Colorado law, that artificial nourishment be withdrawn or withheld pursuant to the terms of this declaration.
2..In 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:___________________________________________
Notary Public

In Summary
  • 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 decisions.
  • 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 providers.
  • 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


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 your needs.
  • 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.

- 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.
If 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 below:

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.
My 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:



(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 support, etc.

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>]