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Declaration As To Medical Or Surgical Treatment

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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I direct that, in accordance with Colorado law, life sustaining procedures shall be withdrawn and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accordance with Colorado law, that artificial nourishment be withdrawn or withheld pursuant to the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.

In the event that the only procedure I am being provided is artificial nourishment, I direct that

one of the following actions be taken:

____a. Artificial nourishment shall not be continued when it is the only procedure being

provided; or

____b. Artificial nourishment shall be continued for ___ days when it is the only procedure

being provided; or

____c. Artificial nourishment shall be continued when it is the only procedure being provided.

I execute this declaration, as my free and voluntary act, this ___ day of ______________,

20___.

__________________________________________

Declarant

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.

Dated at _________________, Colorado, this _____ day of ______________________, 20___.

_________________________________

________________________________

Name

_________________________________

________________________________

Declaration As To Medical Or Surgical Treatment

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