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Living will
About The Ala Firm
Advanced Medical Directive ("Living Will")
This document allows you to make decisions regarding the continuation of life support if you have a terminal condition, or if you are in a persistent vegetative state. If you are married, each spouse should fill out this form separately.
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Your Name
First
Middle
Last
Terminal Condition
A "Terminal Condition" is an incurable or irreversible condition for which the administration of life-sustaining procedures will serve only to postpone the moment of your death.
If two doctors certify in writing that you have a terminal condition and you are not able to effectively receive or evaluate information or communicate decisions, please choose one of the following:
Life-sustaining procedures are to be withdrawn and/or withheld.
Life-sustaining procedures shall be continued for a specified period of time.
I direct that life-sustaining procedures shall be continued indefinitely.
"Life Sustaining Procedures" include any medical procedure or intervention that, if administered to a qualified patient, would serve only to prolong the dying process. It does not include any medical procedure or intervention for nutrition or hydration of the qualified patient or considered necessary by the attending physician or advanced practice nurse to provide comfort or alleviate pain.
How long do you want to have life-sustaining procedures continued? (Days, Weeks, Months)
Do you wish to continue artificial nutrition or hydration if you have been diagnosed with a terminal condition?
Yes, indefinitely
Yes, for a specified period of time
No
How long do you want to have artificial nutrition or hydration continued? (Days, Weeks, Months)
Persistent Vegetative State
“Persistent Vegetative State” is not specifically defined in Colorado, but rather is decided by reference to the criteria and definitions employed by the prevailing medical community standards of practice. It generally includes a medical state in which, within a reasonable degree of medical probability, the patient can no longer think, feel anything, knowingly move, or be aware of being alive. The physicians must agree this condition will last indefinitely without hope for improvement and they must have monitored the patient long enough to make that decision.
If two doctors certify in writing that you are in a persistent vegetative state and you are not able to effectively receive or evaluate information or communicate decisions, please choose one of the following:
Life-sustaining procedures are to be withdrawn and/or withheld.
Life-sustaining procedures shall be continued for a specified period of time.
I direct that life-sustaining procedures shall be continued indefinitely.
How long do you want to have life-sustaining procedures continued? (Days, Weeks, Months)
Do you wish to continue artificial nutrition or hydration if you have been diagnosed to be in a persistent vegetative state?
Yes, indefinitely
Yes, for a specified period of time
No
How long do you want to have artificial nutrition or hydration continued? (Days, Weeks, Months)
Other Directions
Do you have any other directions or instructions that you wish to include with your living will?
Yes
No
Please describe your additional instructions or directions here
Resolution with Medical Power of Attorney
Do you want the terms of your living will to control over the decisions to be made by the agent identified in your medical power of attorney?
Yes (Typically recommended)
No
Choose "no" if you want your agent to be able to over-ride your wishes in your living will.
HIPAA Release and Communications
Select one or both of the following
I would like my medical care providers to notify and discuss my medical situation with the persons identified below.
If asked, my health care providers may discuss my condition with the persons identified below.
You have the ability to notify any persons of your choosing of your diagnosis, and/or have those persons speak with your health care providers about your condition.
Provide the following information for each person to be provided a HIPAA release:
Full Name
Relationship to You
Telephone Number
