Colorado Declaration As To Medical Or Surgical Treatment - Medical Durable Power Of Attorney For Healthcare

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CO
Colorado Declaration as to Medical or Surgical Treatment
C.R.S. 15-18-104
I, ________________________________________ (name of declarant), 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 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I direct that, in accordance with Colorado law, life-sustaining procedures shall be withdrawn and withheld pursuant to the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direct, in accordance with Colorado law, that artificial nourishment be withdrawn or withheld pursuant to the terms of this declaration.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
The foregoing instrument was signed and declared by ________________________________________ 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 ________________________, Colorado, this _________ day of _________, 20__.
_____________________________________________________________________
_____________________________________________________________________
Name and Address
_____________________________________________________________________
_____________________________________________________________________
Name and Address
STATE OF COLORADO
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 _________, 20
My commission expires:____________________________________
______________________________________
Notary Public

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