Declaration Provided by Colorado Medical Treatment Decision Act:  Colorado Statutes 15-18-104

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: 
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I direct that life-sustaining procedures shall be withdrawn and withheld, it being understood that life-sustaining procedures shall not include any medical procedure or intervention for nourishment or considered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 _____________________, 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 _______, _______, 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________. 

                        ________________________________________ 
Notary Public 

Declaration Provided by Colorado Medical Treatment Decision Act:  Colorado Statutes 15-18-104
Review List

This review list is provided to inform you about this document in question and assist you in its preparation.  This simple Life Sustaining Declaration is valid in Colorado.  Check with a local hospital or doctor’s office, as well as with an experienced medical attorney, to assure yourself of its compliance with current statute (s) in your state.

1.	Make multiple copies.  Give one to your doctor (s), the local hospital, and have others available through your attorney and family.  Remember, these kinds of documents are needed in emergency situations at worst and under stressful circumstances at best.  So be sure they are available to the appropriate people easily, when needed.