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Colorado Advance Medical Directive Form 3

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Colorado Advance Medical Directive Form 3
Colorado Advance Medical Directive Form 3
Colorado Advance Directives - Living Will Example
DECLARATION AS TO MEDICAL OR SURGICAL TREATMENT
I________________________________, being of sound mind and at least eighteen years of age,
(Name of Declarant)
direct that 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 _________ 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procedures shall be withdrawn and withheld pursuant to the terms of this declaration; it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law, that artificial nourishment be withdrawn or withheld pursuant to the terms of this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________.
By__________________________________________________
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
his/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)
Colorado Advance Medical Directive Form 3
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