Colorado Living Will
This Living Will is made under the authority of the Colorado Medical Treatment Decision Act, articulating the desires of the undersigned regarding medical treatment in the event they are unable to communicate their medical treatment preferences due to illness or incapacity.
1. Declarant Information
Full Name: __________________________________________
Date of Birth: ________________________________________
Address: ____________________________________________
City: ____________________ State: CO Zip Code: _________
Phone Number: ______________________________________
2. Declaration of Desires, Special Provisions, or Limitations
I, ________________ [Declarant’s Full Name], being of sound mind and not under any compulsion, do hereby declare my desires concerning the withholding or withdrawal of life-sustaining treatment should I be in a terminal condition or in a persistent vegetative state and unable to communicate my medical treatment preferences.
Directive:
- If I am in a terminal condition, I direct that my attending physician withdraw or withhold medical interventions that merely prolong the dying process and are not necessary to my comfort or to alleviate pain.
- If I am diagnosed to be in a persistent vegetative state, I direct that life-sustaining treatment, including artificially provided nutrition and hydration, be withheld or withdrawn, except as needed to provide pain relief.
3. Appointment of Health Care Agent (Optional)
I designate the following individual as my agent to make health care decisions for me if I become incapable of making my own decisions:
Name: _______________________________________________
Relationship: ______________________________________
Phone Number: ______________________________________
Alternate Agent (if primary agent is unavailable):
Name: ______________________________________________
Relationship: ______________________________________
Phone Number: _____________________________________
4. Signature and Acknowledgment
This document represents my directives and supersedes any prior directives I have made. Any modifications to this Living Will must be in writing and signed by me or by another person in my presence and at my direction.
Declarant’s Signature: ____________________________ Date: _______________
Witness 1: ________________________________________ Date: _______________
Witness 2: ________________________________________ Date: _______________
Note: Two witnesses who are not related to the declarant by blood, marriage, or adoption and have no interest in the estate of the declarant are required for the execution of this document.