Colorado Advance Directive Form (Medical POA + Living Will)

A Colorado advance directive is a 3-part document that lets a person choose someone else to make medical decisions and to select end-of-life treatment options. The form can be completed by a resident and must be signed with two (2) witnesses.

What’s Included?

Laws

Signing Requirements (§ 15-18-106) – Two (2) witnesses

State Definition

Advance Medical Directive – “Advance medical directive” means a written instruction concerning medical treatment decisions to be made on behalf of the adult who provided the instruction in the event that he or she becomes incapacitated. An advance medical directive includes, but need not be limited to:

  • A medical durable power of attorney executed pursuant to section 15-14-506;
  • A declaration executed pursuant to the “Colorado Medical Treatment Decision Act”, article 18 of this title;
  • A power of attorney granting medical treatment authority executed prior to July 1, 1992, pursuant to section 15-14-501, as it existed prior to that date; or
  • A CPR directive or declaration executed pursuant to article 18.6 of this title.

Living Will – “Declaration” means a written document voluntarily executed by a declarant in accordance with the requirements of section 15-18-104.

Medical Power of Attorney – For purposes of sections 15-14-501 and 15-14-502, “power of attorney” means a power to make health care decisions granted by an individual. For purposes of section 15-14-502, “power of attorney” also includes a power or delegation that is:

  • Excluded from the application of part 7 of this article pursuant to section 15-14-703;
  • Not a power to make health care decisions; and
  • Not effective without application of section 15-14-502.
  • For purposes of this part 5 and part 6 of this article, “medical durable power of attorney” and “medical power of attorney” means a power to make health care decisions.

Spanish (Español) Version – Adobe PDF

Versions (4)


blankAARP Advance Directive

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blankColorado Hospital Association Advance Directive

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How To Write

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Advance Medical Directives

(1) Principal Name. The Principal issuing medical directives in the State of Colorado should be identified by name. This must be the Patient whose health care and treatment this document discusses. As the Colorado Principal, you must declare the identity of the Agent by first identifying yourself.

(2) Name Of Agent. The Health Care Agent you wish to operate in the State of Colorado must also be named. This is the Entity that shall represent the directives you set in this paperwork and discuss with him or her to Doctors, Nurses, and other Health Care Providers in this state when you cannot communicate yourself.

(3) Agent’s Home And Work Information. Make sure any Medical Personnel reviewing this document can contact your Health Care Agent with the information it contains. Supply the Colorado Health Care Agent’s home telephone number, work telephone number, and home address.

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Successor Agents

(4) Colorado Successor Agent 1. As the Colorado Principal, you have the option of assigning two additional Parties that can take your Health Care Agent’s place if he or she cannot, shall not, or is unable to act in this capacity. These Reserve Agents will take the principal powers over your medical directives that you intended for the Health Care Agent in a successive manner. Thus, if the role of Colorado Health Care Agent becomes vacant when you are incapacitated, list the full name and address of the First Successor Agent to be approached for your directives.

(5) Successor Agent 2. Record the name and address of the second Party to be asked to be your Health Care Agent when Colorado Health Care Providers cannot obtain your medical preferences from the previous two Agents listed because neither can act in the Colorado Health Care Agent role.

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Colorado Treatment Instructions

(6) Life-Prolonging Care. In a majority of scenarios where you have been incapacitated by a medical event in the state of Colorado, Physicians and Responders will seek to treat your condition with the goal of prolonging your life. If you have a medical condition that severely and negatively impacts your life or if the treatment Health Care Providers opt for will result in a poor quality of life and you prefer a certain level of treatment or care, then you must express your decisions in this document. For instance, you can provide advance consent to being connected to a dialysis machine and other life-saving or life-support procedures. Use the area provided for this task or you can cite a document that contains your preferences and attached to this paperwork.

(7) Special Provisions And Limitations. In addition to setting specific treatment preferences and goals, you can limit the treatments applied, place conditions on when medical techniques can be used, or refuse the administration of unwanted medical procedures. Before completing this section, it is recommended that you have a reasonable consultation with your Physician and make sure your Colorado Health Care Agent is aware of your needs, preferences, and aversions.

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Signature Execution

(8) Declarant Signature. Reviewers will wish to see proof that you, as the Declarant, have appointed the Health Care Agents above and supplied the directives regarding your medical treatment. This proof can be delivered with your signature. Thus, sign your name once this document has been completed and you are satisfied with its content.

(9) Signature Date. Provide the current date.

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Recommended Witness Action

(10) Signature Of Witnesses. There are no requirements in the State of Colorado that necessitate a Witness’s verification of your signature, however, many states place such a requirement. Therefore, even if you do not intend to travel, it is recommended that you sign your name as the Declarant behind this document before two Witnesses who can testify to their eligibility as Witnesses, that you signed your name personally, and when the signing occurred. Each one must read the statement made then sign his or her name.

(11) Witnesses’ Home Address.

(12) Witnesses Signature Date.

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Declaration As To Medical Or Surgical Treatment

(13) Name Of Declarant. This package enables you to issue directives to interrupt and withdraw life-prolonging treatment when you are diagnosed by two Physicians (one must be your Attending Physician) as having an incurable disease or untreatable medical condition while you have been unconscious or entirely unable for at least seven days in a row. Before providing your medical instructions to Colorado Medical Personnel, identify yourself as the Declarant issuing this instruction

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(14) Statement On Artificial Nourishment. While the language needed to inform Colorado Medical Staff that life-prolonging treatment should be halted when it is apparent you will not recover from a significantly debilitating or life-threatening medical condition, some additional specifications will need to be issued directly by the Declarant (you) regarding artificial nourishment (i.e. food and water delivered intravenously). If life-prolonging procedures have been halted you must initial the statement that best defines how Colorado Medical Staff should treat your nutrition and fluid requirements. By placing your initials next to the statement that best defines your stance, you can refuse to receive nourishment artificially, agree to receive artificial nourishment but only for a limited amount of days in case you recover, or agree to receive artificial nourishment and hydration regardless of your medical condition as needed to prevent starvation and dehydration.

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Declarant Signature

(15) Date Of Declarant Signature. Record the current calendar date of the day you sign this document.

(16) Colorado Declarant Signature. Sign your name to this directive once you are sure it accurately reflects your desires. This action must be witnessed by two Private Parties.

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Witness Testimonies

(17) Witness Statement. The Declarant’s name must complete the Witness testimonial before either one reviews and signs it.

(18) Witness Signature Date.

(19) Witness Signatures. The Witnesses, after watching you sign this document, must each sign their names and present their home addresses.

(20) Witness Address.

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Optional Notarization

(21) Notary Public Action. While a properly witnessed signing provides valid proof that you as the Colorado Declarant has executed this form, having your signature notarized by a Notary Public licensed in this state will add further credence to the authenticity of your signature. This will require that you sign the above form before the Notary Public since he or she will need to provide the testimony to your signature and his or her credentials.

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Colorado Medical Orders For Scope Of Treatment

(22) Patient’s Full Name. Your last name, middle name, and first name must be used to claim the Colorado MOST (Medical Orders For Scope Of Treatment) as being your declaration.

(23) Patient’s Description. The Colorado Declarant behind this MOLST must also be described so that Reviewers not familiar with him or her can identify the Declarant easily. This process begins with the Declarant’s date of birth and sex.

(24) Hair Color.

(25) Eye Color.

(26) Race/Ethnicity.

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Cardiopulmonary Resuscitation (CPR)

(27) Patient CPR Directive. Cardiopulmonary Resuscitation, or CPR, is used by Medical Staff and Responders when your heart and/or your lungs stop. When this occurs death is often imminent. You can inform such Medical Personnel on whether you will consent to this resuscitation procedure employed or whether you refuse the administration of CPR should your heart and lungs stop by selecting the appropriate checkbox statement.

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Medical Interventions

(28) Full Treatment In Colorado. A brief discussion can be used to inform Colorado Medical Personnel on the level of medical intervention you expect should your body be incapacitated and in need of treatment not involving CPR. If you wish to receive the full scope of treatment available to attending Colorado Physicians, then select the first statement.

(29) Selective Treatment Option. If you have determined that you would like treatment to be balanced between life-prolonging procedures with a focus on comfort care and specific orders to forbid invasive maneuvers such as intubation or hospitalization in an intensive care unit, then choose the second statement.

(30) Comfort Focused Treatment Directive. To inform Colorado Physicians and other Medical Personnel that you do not wish life-prolonging treatment administered if it is invasive or painful and wish them to focus only on keeping you comfortable then, use the third statement to deliver this directive.

(31) Additional Orders. Any additional directions, instructions, or refusals you wish communicated in the future to Colorado Medical Staff should be documented in this section with the aid of the Physician involved with this paperwork.

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Artificially Administered Nutrition

(32) Patient’s Nutrition Requirements. The issue of artificially administered nutrition and hydration will inevitably need to be covered when developing a treatment plan for a Patient who is incapacitated for an extended period of time. You can choose to accept all forms of artificially administered nutrition and hydration, to only accept nourishment and fluids artificially delivered for a predetermined length of time, or to deny the artificial administration of food and fluids using the MOLST by selecting the appropriate statement but make sure this is consistent with all other paperwork you may have set in place regarding your health care when incapacitated.

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Discussed With

(33) Preparer Identity.  The individual who has worked with the Colorado Physician, Advanced Registered Nurse, or Physician’s Assistant to complete this form should be identified as the Patient, an Agent and the Patient’s Medical Durable Power of Attorney, an assigned Proxy-By-Statute, the Patient’s Legal Guardian, or a Party that is named after the word Other in the checklist provided.

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Signatures Of Provider And Patient, Agent, Guardian Or Proxy

(34) Signature Declarant. The Patient or  Legal Decision Maker of the Patient must sign this form and print his or her name. Additionally, the relationship the Signature Declarant holds with the Patient must be documented, even if it is the Patient signing as “Self.” Finally, the date when this signature is delivered is required as an indication that all other MOST forms issued before it should be disregarded.

(35) Physician Information. The Physician, Advanced Practice Nurse, or Physician’s Assistant working with the Patient to complete the MOST must sign his or her name, report the Colorado License # held to practice medicine, print his or her full name, business address, and phone number, then report the date signed.

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Additional Patient Information

(36) Patient Identity And Contact. The second page of the Most contains a follow-up area and must identify the Patient so that it can always be attached to the correct paperwork. To this end, a display of the Colorado Patient’s full name, and birthday should be reported.

(37) Emergency Contact. The Patient’s primary contact or the person who should be contacted when discussing the (incapacitated) Patient’s care should be named along with the relationship he or she holds with the Patient. It should be considered crucial to make sure the phone number for the Patient’s Primary Contact is reported accurately and remains up-to-date.

(38) Health Care Professional. The Health Care Professional handling this form’s preparation should self-identify and provide his or her formal title, phone number, and email, as well as the preparation date.

(39) Patient Medical Information. Some brief medical information should be included with the above information. To this end, if known, record the Patient’s primary diagnosis, the name of any Hospice Program the Patient is involved with along with its address and phone number.

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Review Of The Colorado MOST Form

(40) Review Status Display. The status of this MOST should always be kept up to date. Thus every time it is reviewed the table at the end of this form will allow a report of the review date, the name of the Reviewer, the location where the review took place as well a record to indicate whether there was no change to the MOST status or whether a new one has been completed and signed.

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