I, Chauncey Philips, 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 licensed, attending physician and one other licensed 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 an incurable, terminal condition; and
b. 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I direct that, in accordance with Colorado law, life-sustaining procedures shall be withdrawn and withheld pursuant to the terms of this declaration, it being understood that life-sustaining procedures shall not include any medical procedure or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 However, I may specifically direct, in accordance with Colorado law, that artificial nourishment be withdrawn or withheld pursuant to the terms of this declaration.
2. In the event the only procedure I am being provided is artificial nourishment, I direct that artificial nourishment shall not be continued when it is the only procedure being provided for.
3. I execute this declaration as my free and voluntary act this 14th day of August, 2008.
_________________________________
Chauncey Philips
The foregoing instrument was signed and declared by Chauncey Philips 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.
_________________ __________________
Witness Witness
_________________ __________________
Date Date
State of Colorado )
) ss.
Subscribed and sworn to before me this 14th day of August, 2008, by Chauncey Philips, the declarant, and ______________and____________, witnesses, as the voluntary act and deed of the declarant.
Witness my hand and official seal.
My commission expires:________________
_______________________
Notary Public
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