This is a required section in which the Declarant (the person who the Living Will is prepared for) states his/her intention to make a Living Will. Press [Ctrl+F1] for more information.
This is an optional section in which the Declarant can request that this document should be effective if the Declarant becomes permanently unconscious. Press [Ctrl+F1] for more information.
This is an optional section in which the Declarant states whether artificially administered nutrition and hydration (nourishment) should be withheld or withdrawn. Press [Ctrl+F1] for more information.
This optional section states what effect should be given to the Living Will if the Declarant is pregnant. Press [Ctrl+F1] for more information.
This is an optional section which allows for additional specific instructions and requests. Press [Ctrl+F1] for more information.
This recommended provision provides that the inclusion of an invalid request or instruction does not invalidate the other provisions. Press [Ctrl+F1] for more information.
This required section provides the signature line for the Declarant who must sign in the presence of witnesses and/or a Notary Public. Press [Ctrl+F1] for more information.
This required section provides signature lines for the witnesses in accordance with state law requirements. Press [Ctrl+F1] for more information.
This is a required section in which a public official, such as Notary Public, acknowledges the signatures of the Declarant and the witnesses. Press [Ctrl+F1] for more information.
Times New Roman
Living Will
LIW_CO
The Living Will is a document under which a competent adult, prior to becoming unconscious or incompetent, declares his/her intention that withholding or withdrawal of life-sustaining procedures should be withheld or withdrawn under certain circumstances.
A Living Will is prepared for a "Declarant". Enter the Declarant's name or edit the information as desired. Use the P.I. Manager to select and paste a record.
Enter the FIRST witness' name or use the P.I. Manager to select and paste a record. The following information regarding the name and address of the witness may be left blank and be completed when the document is signed.
Enter the SECOND witness' name or use the P.I. Manager to select and paste a record. The following information regarding the name and address of the witness may be left blank and be completed when the document is signed.
WCO01
! Declaration Section (1 of 9)
DECLARATION AS TO MEDICAL OR SURGICAL TREATMENT
I, !, being of sound mind and at least eighteen years of age, direct that my life shall not be artificially prolonged under the circumstances set forth below and hereby declare that:
If at any time my attending physician and one other qualified physician certify in writing that:
I have an injury, disease, or illness which is not curable or reversible and which, in their judgment, is a terminal condition, and 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 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.
A Living Will is prepared for a "Declarant". In this required section, the Declarant states his/her intentions regarding life-sustaining procedures or treatment during terminal and/or coma circumstances. Press [Ctrl+F1] for more information.
A Living Will is prepared for a "Declarant". Enter the Declarant's name or edit the information as desired. Use the P.I. Manager to select and paste a record.
Enter an X if you wish to be kept alive on life support for a minimum of seven days after becoming comatose or incompetent before life support can be removed. Press [Ctrl+F1] for more information.
Enter an X if you want to specify the number of days you wish to be kept alive on life support after becoming comatose or incompetent before life support can be removed. Press [Ctrl+F1] for more information.
Enter the number of days you wish to be kept alive on life support after becoming comatose or incompetent before life support can be removed.
WCO02
! Coma Section (2 of 9)
It is my request that the term "terminal condition" be interpreted to include a state of permanent unconsciousness.
Enter an X to include a sentence which states that the term "terminal condition" includes a state of permanent unconsciousness. Press [Ctrl+F1] for more information.
WCO03
! Optional Nutrition Section (3 of 9)
If the only procedure that I am being provided is artificial nourishment, I direct that
! ________ (Declarant's initials) artificial nourishment shall not be continued when it is the only procedure being provided.
! ________ (Declarant's initials) artificial nourishment shall be continued for ! days when it is the only procedure being provided.
! ________ (Declarant's initials) artificial nourishment shall be continued when it is the only procedure being provided.
Enter an X to include a paragraph that states whether you wish to receive or not to receive artificial nutrition and hydration (nourishment) if you are terminally ill or permanently unconscious. Press [Ctrl+F1] for more information.
Enter an X to direct the discontinuance of artificial nutrition and hydration when it is the only procedure provided.
Enter an X to direct the continuation of artificial nutrition and hydration for a specified number of days when it is the only procedure provided.
Enter the number of days during which artificial nutrition and hydration shall continue when it is the only procedure provided.
Enter an X to direct the continuation of artificial nutrition and hydration indefinitely when it is the only procedure provided.
LAL04
! Optional Pregnancy Section (4 of 9)
If I have been diagnosed as pregnant and that diagnosis is known to my physician, this document shall have no force or effect during the course of my pregnancy.
! [Optional additional sentence] However, if at any point it is determined that it is not possible that the fetus could develop to the point of live birth with continued application of life-sustaining procedures, it is my preference that this document be given effect at that point.
! [Optional additional sentence] If life-sustaining procedures will be physically harmful or unreasonably painful to me in a manner that cannot be alleviated by medication, I request that my desire for personal physical comfort be given consideration in determining whether this document shall be effective if I am pregnant.
Enter an X to include a pregnancy section which states that this Living Will will not be enforced if you are pregnant. Certain exceptions to this statement are presented. Press [Ctrl+F1] for more information.
Enter an X to provide an exception to the invalidity of the Living Will if you are pregnant. This exception permits enforcement of the Living Will if the fetus could not develop to the point of live birth with the continued application of life-sustaining procedures.
Enter an X to provide an exception to the invalidity of the Living Will if you are pregnant. This exception requests that pain or physical harm to you be considered in determining whether life-sustaining procedures or treatment should be withheld or withdrawn.
LAL05
! Optional Other Specific Requests Section (5 of 9)
Other specific requests:
Enter an X to include a paragraph that allows you to state other specific requests or instructions.
Use this space to state any other specific requests or instructions.
LAL06
! Optional Severability Section (6 of 9)
If any provision in this document is held to be invalid, such invalidity shall not affect the other provisions which can be given effect without the invalid provision, and to this end the directions in this document are severable.
It is recommended that this severability provision be included to prevent one invalid provision from invalidating the entire document. However, if you do not want to include it, press the spacebar to deselect the checkbox. Press [Ctrl+F1] for information regarding the reasons for including a severability paragraph.
WCO07
! Declarant Signature Section (7 of 9)
I execute this declaration, as my free and voluntary act, this _____ day of _______________, 19___.
________________________________________
Signature
Declarant Name: !
Declarant Address:City: !
State: !
! Country: !
! SSN: !
! Birthdate: !
This required section provides a signature line for the Declarant, and requests additional information regarding the Declarant. The date of the document should be entered on the blank lines at the time the document is signed.
Enter the Declarant's city or edit the information as desired.
Enter the Declarant's state/province or edit the information as desired.
Enter an X to include the country in which the Declarant resides, if outside the United States.
Enter the country or edit the information as desired.
Enter an X to include the Declarant's social security number (SSN). By providing the SSN, the health care providers will be assisted in maintaining their Living Will files. Press [Ctrl+F1] for more information.
Enter the Declarant's social security number or edit the information as desired.
Enter an X to include the Declarant's date of birth. By providing the date of birth, the health care providers will be assisted in maintaining their Living Will files. Press [Ctrl+F1] for more information.
Using the format MM/DD/YYYY, enter the Declarant's date of birth or edit the information as desired.
WCO08
! Witness Signature (8 of 9)
The foregoing instrument was signed and declared by the Declarant to be his/her declaration, in the presence of us, who, in his/her presence, in the presence of each other, and at the Declarant's 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. Neither of the witnesses is a patient of a health care facility of which the Declarant is a patient or resident.
[WARNING: Any blanks which were not completed at the time the document was written must be filled in when the document is signed.]
Dated at !, Colorado, this _____ day of _______________, 19___.
This required section provides signature lines for the witnesses, and requests additional information regarding the witnesses. Press [Ctrl+F1] for more information. The date of the document should be entered on the blank line at the time the document is signed.
Enter the city where the document will be signed or edit the information as desired.
Enter the FIRST witness' name or use the P.I. Manager to select and paste a record. The following information regarding the name and address of the witness may be left blank and be completed when the document is signed.
Enter the witness' street address or edit the information as desired.
Enter the witness' extended street address or edit the information as desired.
Enter the witness' city or edit the information as desired.
Enter the witness' state/province or edit the information as desired.
Enter the witness' zip/postal code or edit the information as desired.
Enter an X to include the witness' country, if outside the United States.
Enter the country or edit the information as desired.
Enter the SECOND witness' name or use the P.I. Manager to select and paste a record. The following information regarding the name and address of the witness may be left blank and be completed when the document is signed.
WCO09
! Notary Section (9 of 9)
[This is a required section in which a public official, such as a Notary Public, acknowledges that the witnesses and the Declarant signed this document.]
STATE OF COLORADO )
) ss:
COUNTY OF _________________________ )
SUBSCRIBED and sworn to before me by !, the Declarant, and ! and !, witnesses, as the voluntary act and deed of the Declarant this _____ day of _______________, 19___.
My commission expires: _______________ _____, 19___.
__________________________________________
Notary Public
This is a required section in which a public official, such as a Notary Public, acknowledges that the witnesses and the Declarant signed this document.
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