[Health Care Directive] Colorado

Using these Materials

BEFORE YOU BEGIN

1. Check to be sure that you have the materials for each state in which you may receive health care.

2. These materials include:
   • Instructions for preparing your advance directive, please read all the instructions.
   • Your state-specific advance directive forms, which are the pages with the gray instruction bar on the left side.

ACTION STEPS

1. You may want to photocopy or print a second set of these forms before you start so you will have a clean copy if you need to start over.

2. When you begin to fill out the forms, refer to the gray instruction bars — they will guide you through the process.

3. Talk with your family, friends, and physicians about your advance Be sure the person you appoint to make decisions on your behalf understands your wishes.

4. Once the form is completed and signed, photocopy the form and give it to the person you have appointed to make decisions on your behalf, your family, friends, health care providers and/or faith leaders so that the form is available in the event of an emergency.

5. You may also want to save a copy of your form in an online personal health records application, program, or service that allows you to share your medical documents with your physicians, family, and others who you want to take an active role in your advance care planning.

Introduction to Your Colorado Advance Medical Directive

This packet contains a legal document that protects your right to refuse medical treatment you do not want, or to request treatment you do want, in the event you lose the ability to make decisions yourself. You may complete Part One, Part Two, or both, depending on your advance planning needs.

Part One. The Colorado Medical Durable Power of Attorney lets you name someone, called an agent, to make decisions about your medical care including decisions about life support if you can no longer speak for yourself. The Medical Durable Power of Attorney is especially useful because it appoints an agent to speak for you any time you are unable to make your own medical decisions, not only at the end of life.

Part Two. The Colorado Declaration is your state’s living will. It lets you state your wishes about medical care in the event that you develop a terminal condition or are in a persistent vegetative state. Your declaration becomes effective when your doctor and one other doctor certify that you have one of these conditions and you lack the decisional capacity to accept or reject medical or surgical treatment. Decisional capacity means the ability to provide informed consent to or refusal of medical treatment or the ability to make an informed health care benefit decision.

Part Three contains the signature and witness provisions so that your document will be effective.

Following your, Colorado Advance Medical Directive is a Colorado Organ Donation form, which allows you to set out your wishes regarding organ donation. This can be especially helpful if you have not appointed an agent in Part One of your Colorado Advance Medical Directive to communicate those wishes for you.

This form does not expressly address mental illness. If you would like to make advance care plans involving mental illness, you should talk to your physician and an attorney about a durable power of attorney tailored to your needs.

Note: These documents will be legally binding only if the person completing them is a competent adult (at least 18 years old).

Completing Your Colorado Advance Medical Directive

Whom should I appoint as my agent?

Your agent is the person you appoint to make decisions about your medical care if you become unable to make those decisions yourself. Your agent may be a family member or a close friend whom you trust to make serious decisions. The person you name as your agent should clearly understand your wishes and be willing to accept the responsibility of making medical decisions for you.

You can appoint a second and third person as your alternate agent(s). The alternate(s) will step in if the first person you name as an agent is unable, unwilling, or unavailable to act for you.

Should I add personal instructions to my Colorado Advance Medical Directive?

One of the strongest reasons for naming an agent is to have someone who can respond flexibly as your medical situation changes and deal with situations that you did not foresee. If you add instructions to this document it may help your agent carry out your wishes, but be careful that you do not unintentionally restrict your agent’s power to act in your best interest. In any event, be sure to talk with your agent about your future medical care and describe what you consider to be an acceptable “quality of life.”

How do I make my Colorado Advance Medical Directive legal?

You must sign your advance medical directive in the presence of two witnesses. If you cannot do so yourself, you may direct someone to sign your advance medical directive for you.

The person signing on your behalf, at your direction, cannot be:

• A physician,
• An employee of your attending physician or of a health care facility in which you are a patient when you sign your document,
• A person with a claim against your estate, or
• A person entitled to any portion of your

These witnesses cannot be:

• A person signing the document at your direction,
• A physician,
• An employee of your attending physician or of a health care facility in which you are a patient when you sign your document,
• A person with a claim against your estate, or
• A person entitled to any portion of your estate.

Completing Your Colorado Advance Medical Directive (Continued)

What if I change my mind?

You may revoke your Declaration orally, in writing, or by burning, tearing, canceling, obliterating, or destroying the document. Your doctor must be notified of your revocation for it to be effective.

Your agent must be notified for revocation of his/her authority to be effective.

Unless you specify otherwise in your declaration (Part Two), if you designate your spouse as your agent, that designation will automatically be revoked by divorce, dissolution or annulment of your marriage, or by a legal separation from your spouse.

What other important facts should I know?

Your declaration (Part Two) will not be honored while you are pregnant with a potentially viable fetus.

COLORADO ADVANCE MEDICAL DIRECTIVE – PAGE 1 OF 5

Part One. Medical Durable Power of Attorney

as my agent to make health care decisions for me if and when I do not have the capacity to make my own health care decisions. This gives my agent the power to consent to giving, withholding or stopping any health care, treatment, service, or diagnostic procedure. My agent also has the authority to talk with health care personnel about my condition, access my medical records, get information and sign forms necessary to carry out those decisions. If the person named as my agent is not available or is unable or unwilling to act as my agent, then I appoint the following person(s) to serve in the order listed below:

COLORADO ADVANCE MEDICAL DIRECTIVE - PAGE 2 OF 5

By this document I intend to create a Medical Durable Power of Attorney which shall take effect upon my incapacity to make my own health care decisions and shall continue during that incapacity.

When making health care decisions for me, my agent should think about what action would be consistent with past conversations we have had, my treatment preferences as expressed in Part Two (if I have filled out Part Two), my religious and other beliefs and values, and how I have handled medical and other important issues in the past. If what I would decide is still unclear, then my health care agent should make decisions for me that my health care agent believes are in my best interest, considering the benefits, burdens, and risks of my current circumstances and treatment options.

COLORADO ADVANCE MEDICAL DIRECTIVE – PAGE 3 OF 5

Part Two. Declaration

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:

a. I have an injury, disease, or illness which is a terminal condition for which the administration of life-sustaining procedures will only serve to prolong the dying process and I am unable to make health care decisions, or

b. I am in a persistent vegetative state,

I direct that, in accordance with Colorado law, life-sustaining procedures shall be (Initial only the option that applies)

COLORADO ADVANCE MEDICAL DIRECTIVE – PAGE 4 OF 5

In the event that the only procedure I am being provided is artificial nourishment, I direct that one of the following actions be taken: (initial the option that applies)

when it is the only procedure being provided; or

COLORADO ADVANCE MEDICAL DIRECTIVE - PAGE 5 OF 5

Part Three. Execution.

SIGN AND DATE THE DOCUMENT AND PRINT YOUR ADDRESS

BY SIGNING HERE I INDICATE THAT I UNDERSTAND THE PURPOSE AND EFFECT OF THIS DOCUMENT.

WITNESS #1

WITNESS #2

For (initial one):

You Have Filled Out Your Advance Directive, Now What?

1. Your Colorado Advance Medical Directive is an important legal Keep the original signed document in a secure but accessible place. Do not put the original document in a safe deposit box or any other security box that would keep others from having access to it.

2. Give photocopies of the signed original to your agent and alternate agent, doctor(s), family, close friends, clergy, and anyone else who might become involved in your health If you enter a nursing home or hospital, have photocopies of your document placed in your medical records.

3. Be sure to talk to your agent(s), doctor(s), clergy, family, and friends about your wishes concerning medical treatment. Discuss your wishes with them often, particularly if your medical condition chanqes.

4. You may also want to save a copy of your form in an online personal health records application, program, or service that allows you to share your medical documents with your physicians, family, and others who you want to take an active role in your advance care planning.

5. If you want to make changes to your documents after they have been signed and witnessed, you must complete a new doucment.

6. Remember, you can always revoke your Colorado document.

7. Be aware that your document will not be effective in the event of a medical emergency. Ambulance and hospital emergency department personnel are required to provide cardiopulmonary resuscitation (CPR) unless they are given a separate directive that states These directives called “prehospital medical care directives” or “do not resuscitate orders” are designed for people whose poor health gives them little chance of benefiting from CPR. These directives instruct ambulance and hospital emergency personnel not to attempt CPR if your heart or breathing should stop.

Colorado authorizes Medical Orders for Scope of Treatment (MOST forms), which allow you to specify the scope of treatment you receive, including the withholding of CPR. We suggest you speak to your physician if you are interested in obtaining one.