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5004.ARM
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1991-04-22
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/* Colorado living will*/
DECLARATION PROVIDED BY COLORADO MEDICAL TREATMENT DECISION
ACT, COLORADO STATUTES 15-18-104
DECLARATION AS TO MEDICAL OR SURGICAL TREATMENT
I @001, 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:
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 forty-eight consecutive hours or more,
I have been unconscious, comatose, or otherwise incompetent
so as to be unable to make or communicate responsive decisions
concerning my person; then,
I direct that life-sustaining procedures shall be withdrawn
and withheld, it being understood that life-sustaining procedures
shall not include any medical procedure or intervention for
nourishment or considered necessary by the attending physician
to provide comfort or alleviate pain.
2. I execute this declaration, as my free and voluntary act,
this ___________________ day of _____________________, 19______.
By ___________________________________
@001, Declarant
The foregoing instrument was signed and declared by
@001 to be his declaration, in the presence of us, who, in his
presence, in the presence of each other, and at his 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 @002, Colorado, this ___________
day of _____________________________________, 19________.
________________________________________________________
Name and address
________________________________________________________
Name and address
STATE OF COLORADO
COUNTY of @003
Subscribed and sworn to before me by @001,
the declarant, and __________________________________, and
____________________________________, witnesses, as the voluntary
act and deed of the declarant, this ________________ day of
____________________ 19________.
________________________________________
Notary Public