Colorado Declaration as to Medical or Surgical Treatment

Colorado Declaration as to Medical or Surgical Treatment

I, ___________________________ (name of declarant), being of sound mind and at least eighteen (18) years of age, 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 qualified 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I direct that, in accordance with Colorado law, life-sustaining procedures shall be withdrawn and withheld pursuant to the terms of this declaration, it being understood that life-sustaining procedures shall not include any medical procedure or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 provide 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 However, I may specifically direct, in accordance with Colorado law, that artificial nourishment be withdrawn or withheld pursuant to the terms of this declaration.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 ___________________, 20______.

By:



_________________________________
Declarant

STATEMENT OF WITNESSES

The foregoing instrument was signed and declared by ___________________________________ to be his/her declaration, in the presence of us, who, in his 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.

Dated at ______________________, Colorado, this _________ day of ____________________, 20______.

Name and Address of Witness #1:

____________________________________________

____________________________________________

____________________________________________

Name and Address of Witness #2:

____________________________________________ 

____________________________________________

____________________________________________

My commission expires:

___________________
Notary Public