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Withholding and withdrawing life-sustaining treatment

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Title:
Withholding and withdrawing life-sustaining treatment a survey of opinions and exeriences of Colorado physicians ; a report
Creator:
University of Colorado at Denver -- Center for Health Ethics and Policy
Place of Publication:
Denver, Colo
Publisher:
University of Colorado at Denver
Publication Date:
Language:
English
Physical Description:
ii, 41 leaves : ; 28 cm

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Subjects / Keywords:
Physicians -- Colorado ( mesh )
Ethics, Medical ( mesh )
Terminal Care ( mesh )
Euthanasia ( mesh )
Life Support Care ( mesh )
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legislation ( marcgt )
statistics ( marcgt )
non-fiction ( marcgt )

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General Note:
"May, 1988."
Statement of Responsibility:
by the Center for Health Ethics and Policy, Graduate School of Public Affairs, University of Colorado at Denver.

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Resource Identifier:
18403468 ( OCLC )
ocm18403468
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W 50 W824 1988 ( nlm )

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Full Text
WITHHOLDING AND WITHDRAWING LIFE-SUSTAINING TREATMENT:
A SURVEY OF OPINIONS AND EXPERIENCES OF COLORADO PHYSICIANS
A Report By
The Center for Health Ethics and Policy
Graduate School of Public Affairs
University of Colorado at Denver
May, 1988


THE CENTER FOR HEALTH ETHICS AND POLICY
Graduate School of Public Affairs
University of Colorado at Denver
1200 Larimer Street, Campus Box 133
Denver, Colorado 80204
(303) 556-4837
Marshall Kaplan, Dean
Donald W. Hoagland, Director
Principal Investigators:
Fredrick R. Abrams, M.D., Associate Director
Elizabeth D. Gee, Ed.D., Senior Research Associate
Project Staff
Shirley Boeke
Russell A. Cargo, M.A., M.S.B.A.
Carol Jacobson, M.P.A.
Estelle Kennelly
Margaret Noble
C. William Reiquam, M.D.
Deborah Trantin
Eileen Tynan, Ph.D.
The Center was formed in 1987 to address ethical and policy
issues facing Colorado and the nation. The Center serves as a
forum for information exchange, offers educational programs,
assists in development of health policy, conducts applied
research, and assists health care providers with bedside ethical
problems.
The Center for Health Ethics and Policy is supported in part by
grants from the Rose Medical Center Foundation and The Colorado
Trust. This project was also supported by a grant from Mr. Bill
Gossard.


Table of Contents
Page
INTRODUCTION 1
SURVEY METHOD 4
Classification of Physicians 5
Classification of Questions 5
1. Familiarity with Living Will and Durable
Powers of Attorney Statutes 5
2. Decisions to Withhold or Withdraw Life-
Sustaining Treatment 6
3. Active Euthanasia and Assisted Suicide 8
SURVEY FINDINGS 9
1. A significant minority of Colorado physicians
is not familiar with the Colorado living will,
and a large majority is not familiar with the
durable powers of attorney. Many Colorado
doctors do not discuss advance directives with
patients. 10
2. Most Colorado physicians do not personally
have a living will nor have they appointed
a personal attorney-in-fact under the durable
powers of attorney statute. 11
3. When available, advance directives are used in
making decisions to withhold or withdraw life-
sustaining treatment for patients who do not
have the capacity to choose, but their use
is not widespread. 11
4. An overwhelming majority of Colorado physicians
consults with someone when making life-
sustaining treatment decisions for patients
who do not have the capacity to choose. 12
5. A strong majority of physicians expressly
believes that the Colorado living will statute
should permit patients to refuse medical
intervention that provides food and fluid. 14
6. An overwhelming majority of Colorado physicians
does not believe they are obligated to prolong
life regardless of its quality.
15


Page
7. A majority of Colorado doctors has attended
patients for whom they believed active
euthanasia would be justifiable, if legal.
A significant minority of Colorado doctors
would have been willing to administer a lethal
dose to such patients, but for legal
prohibitions. 15
8. Some Colorado physicians have assisted their
patients in stockpiling lethal doses of
medication while aware that they might be
used to commit suicide. 17
9. For permanently comatose patients, doctors
are more willing to discontinue antibiotic
treatment than nutrition. 18
POLICY ISSUES AND RAMIFICATIONS 20
RECOMMENDATIONS 23
ENDNOTES 28
APPENDIX A 29
APPENDIX B 30
APPENDIX C 33
APPENDIX D 40
TABLES
Table 1: Parties with whom Doctors Consult When a Living Will is Used 13
Table 2: Parties with whom Doctors Consult When There is no Living Will 13
Table 3: Treatments for which Doctors Believe an Order to Withhold or Withdraw be Properly Written 18
(ii)


WITHHOLDING AND WITHDRAWING LIFE-SUSTAINING TREATMENT:
A SURVEY OF OPINIONS AND EXPERIENCES OF COLORADO PHYSICIANS
INTRODUCTION
For the majority of Americans, the state of biomedical
knowledge and technology has never been better. The availability
of new and vast medical resources has enabled physicians to offer
patients a high standard of medical care. Yet for critically ill
patients, their families, and their doctors, the miracles of
medical science have created complex ethical questions. Today,
life-sustaining technology may be used to prolong life that is so
poor in quality as to seem not worth living. As such, judgments
about terminating critical life-support treatment have profound
personal and social ramifications. Choices to use or forgo life-
sustaining interventions carry with them grave implications for
patients and family members. Such decisions may determine when a
patient will live or die, what will be the patient's quality of
life, and what emotional, physical and financial burdens will be
thrust upon family members. The public also has an interest in
critical health decisions. Society provides access to care,
guards patients' rights, and protects individuals who, because of
their vulnerability, are not able to participate in decisions
about their own lives.
The special nature of life-sustaining treatment poses unique
considerations for physicians. The doctor's role in making
choices to withhold treatment or withdraw existing life-supports
1


cannot be separated from the interests of patients, their loved
ones, or society. Once life-and-death decisions were of a more
simple order for physicians but today doctors must evaluate the
new profusion of treatment options in the full light of
burgeoning law, institutional mandate, cost constraints, and
public policy. Additionally, physicians making critical health
decisions must do so recognizing the increasing complexity of
ethical issues that necessarily arise when medical practice
becomes more capable of hastening birth or prolonging dying.
Much misunderstanding surrounds the range of options
available to patients for expressing their treatment preferences.
Legal, economic, and ethical justifications for euthanasia1 and
for forgoing various medical interventions often are not clear-
cut. Often blurred are ground rules indicating when, if ever,
deliberately ending patients' lives or assisting patients to end
their own lives is warranted or permitted.
Colorado citizens, as health care providers, purchasers,
prospective patients, and policy makers are deeply concerned
about how life-sustaining treatment decisions are made. In order
for them to face these hard questions squarely, they must
understand the role of the physician in making critical care
decisions. Policy makers particularly need to know how doctors
perceive and respond to these dilemmas.
The Center for Health Ethics and Policy at the Graduate
School of Public Affairs, University of Colorado at Denver, has
completed a survey of Colorado physicians which identifies their
2


opinions about life-sustaining treatment. By undertaking this
project, the Center hopes to initiate rigorous public/private
sector dialogue in Colorado about these opinions and this
critical subject.
This report first reviews the methodology used to develop
and analyze the survey data. The findings of the study are next
presented and discussed. Finally, broad-ranging implications and
issues raised by the survey are considered, and recommendations
are proposed which are intended to promote future discussion and
debate.
3


SURVEY METHOD
In January, 1988, the Center for Health Ethics and Policy
mailed a questionnaire to all licensed physicians, numbering
7,095, currently listed with the Board of Medical Examiners as
living in Colorado.2 Physicians were asked about their opinions
and experiences regarding life-sustaining treatment. The
questionnaire followed a forced-choice format, although some
open-ended questions were included. Demographic information on
religious affiliation and date of medical school graduation (see
Appendix A), age, specialty (see Appendix B), and county of
residence was also collected.
This survey is typical of any mail survey in that the sample
response is not random; rather, it is self-selected or self-
initiated which qualifies generalizing results to the entire
Colorado physician population. Because of the number of
respondents, the strong similarities that exist between
physicians characteristics as reported in the Center survey and a
profile of Colorado physicians published by the Colorado State
Department of Health (see Appendix B),3 and the results of a
limited number of comparable surveys initiated elsewhere in the
country,4 the Center's findings likely can be extrapolated with
reasonable confidence levels to all Colorado physicians. The
reader should keep in mind that findings about physicians'
conduct presented in this study represent the perceptions of
physicians themselves rather than the observations of others
about their conduct.
4


Classification of Physicians
The surveyed physicians were categorized into two groups:
All Doctors and Primary Care Doctors. The term All Doctors
refers to all Colorado physicians who responded to the survey.
For purpose of this study, the term Primary Care Doctors refers
only to family practitioners and internists. The Primary Care
Doctors were separated out for comparison with All Doctors
because they play an important continuing role with the patient.
Classification of Questions
Colorado physicians were questioned about their opinions and
experiences regarding three broad areas of concern.
1. Familiarity with Living Will and Durable Powers of Attorney
Statutes
These questions address the physician's familiarity
with the Colorado living will and durable powers of attorney
statutes (see Appendices C and D).5 Colorado's statutory
living will is a statement written by a competent adult
directing the future withholding or withdrawing of life-
sustaining procedures if the individual develops "a terminal
condition and either is unconscious or otherwise incompetent
to decide whether or not any medical procedure or
intervention should be accepted or rejected."6 The law
protects the doctor from legal liability if conditions
specified in the directive are fulfilled7 and the doctor
complies with the statutory procedures for certification of
5


terminal conditions together with the notice requirements if
applicable under the circumstances. In situations where
patients are able to competently communicate their wishes to
the physicians, the living will has no force. If conditions
of the living will and the statute are met and the physician
is unwilling to withdraw life support, the doctor must
transfer the patient to another doctor who is willing to
comply or risk being subject to disciplinary action for
unprofessional conduct8.
A durable power of attorney for health care is a proxy
directive executed while the individual is competent that
takes effect when the patient is incapable of making
decisions or expressing opinions. Individuals may appoint
other persons to make medical care decisions on their behalf
should they lose decision-making capacity, provided that the
durable power of attorney expressly authorizes the principal
to make such medical care decisions. Decisions made by the
individual empowered by the durable power of attorney are
equivalent to those actually made by the patient.
2. Decisions to Withhold or Withdraw Life-Sustaining Treatment
This series of questions addresses physicians'
involvement in forgoing the use of life-support systems.
Doctors have always had to judge when to withhold or
withdraw treatments that are futile. Sometimes decisions to
terminate life-support must be made when the patient does
not have decision-making capability. As discussed above,
6


occasionally in such situations the physician may be guided
by advance directives; more typically, there is no legal
instrument that expresses the patient's desires. The
surveyed physicians were questioned about their involvement
with choices to forgo life-support and about individuals
with whom they consult at the time of such decisions.
Doctors were asked whether or not they believe an order
to withdraw or withhold life-support may be properly written
for specific treatments dialysis (mechanical process used
to cleanse the blood in the case of kidney failure),
respirator (machine that provides oxygen and forces
breathing), nasogastric tube (feeding tube from the nose
into the stomach), gastrostomy (feeding tube surgically
introduced through the abdominal wall into the stomach), and
intravenous feeding (fluids introduced through the veins).
Physicians' opinions also were sought regarding the
withholding or withdrawing of food and fluids. They were
asked if nourishment should be given patients in permanent
coma.
Additionally, the survey questionnaire asked doctors
their views about the failure of the Colorado living will
statute to provide for the forgoing of nourishment. The
Colorado living will stipulates that "life-sustaining
procedures" which may be refused "shall not include any
medical procedure or intervention to nourish the qualified
patient...".9 In other words, the statute has been
7


integrated to say that an individual cannot use the living
will to direct the withdrawal or withholding of food and
fluids. Physicians were asked whether or not the Colorado
living will statute should be changed to allow patients to
refuse food or fluid.
3. Active Euthanasia and Assisted Suicide
The survey posed a series of questions to physicians
regarding actions which, in fact, accelerate the patient's
death. Colorado doctors were asked whether they had
encountered patients for whom active euthanasia, or "mercy
killing", would be appropriate and whether they would
personally have been willing to administer lethal doses of
medication in situations where they believed active
euthanasia was warranted if legal. Current law prohibits
assisting suicide.
They were also asked if they had assisted patients to
stockpile lethal doses of medication while aware they might
be used to commit suicide. Certain powerful medications are
dispensed in small amounts because of the danger of overdose
leading to death. Despite precautions, some patients, over
a period of time, have "stockpiled", or accumulated large
amounts of drugs, in order to administer a lethal dose to
themselves. Physicians were also asked how they weigh
quality of life relative to prolonging life and about their
experiences in administering treatment that shortened
patient life.
8


SURVEY FINDINGS
Of the 7,095 Colorado physicians who were mailed survey
questionnaires, 31.3 percent, or 2,218, responded. Primary Care
Doctors accounted for 846 or 39.2 percent of all responses.
Seventy percent (69.6) of All Doctors and 71.3 percent of Primary
Care Doctors are in private practice or working in non-hospital
settings, such as clinics, where they deal with patients directly
and on a fee-for-service basis. Other common specialties among
the respondents were pediatrics (8.5 percent), psychiatry (7.8
percent), general surgery (8.1 percent), and obstetrics and
gynecology (6.4 percent). Combined with Primary Care Doctors
responses, these practice types account for 70.0 percent of
survey respondents.
Of all replies, 90.4 percent identified with a specific
religion, including Protestant (54.3 percent), Catholic (17.7
percent), and Jewish (13.4 percent). Although the responses were
analyzed by religious affiliation, with the exception noted in
the text, no substantial differences were identified. Future
analyses will examine the survey data in light of additional
variables.
9


The principal findings of this study are as follows:
l. A significant minority of Colorado physicians is not
familiar with the Colorado living will, and a large majority
is not familiar with durable powers of attorney. Many
Colorado doctors do not discuss advance directives with
patients.
Many Colorado doctors responding to the survey are not
knowledgeable about advance directives. Twenty-four percent
(23.5) of All Doctors and 17.2 percent of Primary Care
Doctors were unfamiliar with the Colorado living will.
Substantially more physicians were not knowledgeable about
the durable powers of attorney: that is, 73.5 percent of
All Doctors and 68.1 percent of Primary Care Doctors lacked
familiarity with the durable powers of attorney statute.
Slightly more Primary Care Doctors than All Doctors had
discussed advance directives with their patients, although
both physician groups indicated that such conversations were
not numerous. Forty-one percent (40.7) of All Doctors and
64.8 percent of Primary Care Doctors had discussed living
wills or durable powers of attorneys with some patients.
Nevertheless, 74.1 percent of All Doctors and 69.6 percent
of Primary Care Doctors who had such discussions noted that
the number of such discussions was negligible in relation to
the total number of patients in their practice.
10


2. Most Colorado physicians do not personally have a living
will nor have they appointed a personal attorney-in-fact
under the durable powers of attorney statute.
Few Colorado doctors have executed advance directives
on their own behalf. Proportionately more physicians have
prepared living wills than have appointed an
attorney-in-fact (someone authorized to act in their name).
Eighty-six percent (86.1) of All Doctors replying to the
survey and 86.6 percent of Primary Care Doctors do not
personally have a living will. Ninety-four percent (94.4)
of All Doctors and 93.6 percent of Primary Care Doctors have
not personally appointed an attorney-in-fact under the
Colorado durable powers of attorney statute.
3. When available, advance directives are used in making
decisions to withhold or withdraw life-sustaining treatment
for patients who do not have the capacity to choose, but
their use is not widespread.
Not many doctors who responded to the survey have
encountered incompetent patients for whom either a living
will or a durable power of attorney was used. Slightly more
Primary Care Doctors than All Doctors report to have been
involved in implementing such legal directives. Twenty-
three percent (23.1) of All Doctors and 35.9 percent of
Primary Care Doctors responding to the survey have had at
least one patient who lacked the capacity to choose and on
11


whose behalf a living will or durable power of attorney was
used.
4. An overwhelming majority of Colorado physicians consults
with someone when making life-sustaining treatment decisions
for patients who do not have the capacity to choose.
Irrespective of whether or not a living will was used,
the vast majority of All Doctors and Primary Care Doctors
responding to the survey consulted with someone when making
decisions to terminate life-supports for patients who lacked
decision-making capability.
Ninety-four percent (94.4) of All Doctors and 97.0
percent of Primary Care Doctors seek advice from
professionals and family members if there is a living will.
Ninety-seven percent (96.9) of All Doctors and 98.7 percent
of Primary Care Doctors seek consultation with these
individuals when there is no living will.
Responses from All Doctors and Primary Care Doctors
indicate they consult with parents, family members,
physicians, clergy, ethics committees, and attorneys shown
in Tables 1 and 2 (see following) when making decisions to
discontinue life-supports for individuals who are unable to
make choices.
12


Table 1
Parties with whom Doctors
Consult When a Living Will is Used
Consultant All Doctors Primary Care Doctors
Family Members 93.8% 97.7%
Parent
(for minor patient) 80.3 75.0
Another Physician 67.8 65.2
Hospital or Other Attorney 24.3 17.7
Clergy 20.5 18.1
Ethics Committee 31.1 23.5
Other 3.2 3.8
*****
Table 2
Parties with whom Doctors Consult
When There is no Livinq Will
Consultant All Doctors Primary Care :
Family Member 94.9% 98.4%
Parent (for minor patient) 82.4 77.5
Another Physician 73.5 72.7
Hospital or Other Attorney 29.5 21.9
Clergy 22.9 21.4
Ethics Committee 37.1 30.5
Other 3.1 3.5
13


In general, All Doctors proportionately consult more with
family members, parents, and other physicians than with
clergy, ethics committees or attorneys. With the exception
of parent consultations, Primary Care Doctors appear to seek
advice of these parties less often than All Doctors.
5. A strong majority of physicians believes that the Colorado
living will statute should expressly permit patients to
refuse medical intervention that provides food and fluid.
All Doctors and Primary Care Doctors responded
similarly to questions about the need for the Colorado
living will statute to allow patients to refuse food and
fluid. A majority of All Doctors and of Primary Care
Doctors disagreed with the Colorado living will statutory
language which defines the life-sustaining procedures that
may be refused as not including medical interventions to
nourish the patient. Many would like to see the statute
changed to allow patients the option of expressly refusing
nutrition and hydration through an advance directive.
Eighty-eight percent (88.1) of All Doctors and 89.1 percent
of Primary Care Doctors indicated that the law should be
changed to allow the patient to decline food or fluid.
Eighty-five percent (85.1) of All Doctors and 85.2 percent
of Primary Care Doctors said they believe that the Colorado
living will statute, which denies the patient the option to
refuse food and fluid, is unsatisfactory.
14


6. An overwhelming majority of Colorado physicians does not
believe they are obligated to prolong life regardless of its
quality.
Almost all physicians responding to the survey
*
indicated that it is not incumbent upon doctors to prolong
life regardless of its quality. Responses from All Doctors
and Primary Care Doctors relevant to this finding were
substantially similar.
Ninety-five percent (95.3) of All Doctors and 94.5
percent of Primary Care Doctors believe they are not duty
bound to sustain life regardless of quality. Ninety percent
(89.9) of All Doctors and 91.7 percent of Primary Care
Doctors agreed that expected quality of life should be a
consideration when deciding whether or not someone is to be
treated with critical care technology.
7. A majority of Colorado doctors has attended patients for
whom they believe active euthanasia would be justifiable, if
legal. A majority of Colorado doctors who have encountered
such patients would have been willing to administer a lethal
dose, but for legal prohibitions.
More than half of survey respondents have cared for
patients they believed to be candidates for active
euthanasia. When asked if they would agree to administer,
if it were legal, a lethal dose of medication to such
15


patients, a slight majority of these respondents who have
encountered such patients reported that they would be
willing to do so.
Sixty percent (60.0) of All Doctors and 60.7 percent of
Primary Care Doctors responding to the survey have attended
patients for whom they believed active euthanasia to be
justifiable if it were legal.
Fifty-nine percent (58.9) of All Doctors and 55.7
percent of Primary Care Doctors who have encountered such
patients indicated that they would have personally been
willing to administer a lethal drug if such measures were
allowed by law.
Responses to this question differ by religious
affiliation. Responses from Catholic doctors, more than
Protestant or Jewish physicians, suggested hesitation to
justify or engage in active euthanasia. Sixty-one percent
(60.9) of Protestants, 66.8 percent of Jewish, and 44.0
percent of Catholic physicians have cared for patients for
whom they believed legal active euthanasia to be
justifiable. Fifty-eight percent (57.6) of Protestant, 61.8
percent of Jewish, and 47.5 percent of Catholic doctors
acknowledged that they would administer a lethal dose to
such patients if it were legal.
A smaller percentage of physicians have administered
pain medication, aware that while shortening a patient's
life was not intended, the effect of the medication was to
16


do so. Responses from Primary Care Doctors indicated that
they gave pain medications in such situations more often
than All Doctors. Thirty-seven percent (36.7) of All
Doctors and 43.3 percent of Primary Care Doctors have
administered pain medication while aware that to do so would
hasten the patient's death. Religious affiliation appeared
only as a slight possible influencing factor in such
decisions. Thirty-five percent (35.4) of Protestant, 42.3
percent of Jewish, and 33.1 percent of Catholic physicians
have given pain medication that resulted in shortening a
patient's life.
8. Some Colorado physicians have assisted their patients in
stockpiling lethal doses of medication while aware that they
might be used to commit suicide.
A relatively few Colorado doctors admit to helping
patients stockpile lethal doses of medication, knowing that
the drugs might be used to commit suicide. Four percent
(4.3) of All Doctors and 4.7 percent of Primary Care Doctors
acknowledge providing such aid to their patients.
17


For permanently comatose patients, doctors are more willing
to discontinue antibiotic treatment than nutrition.
9 .
A relatively small proportion of respondents reported
that doctors ought to sustain patients who are in a
permanent coma or persistent vegetative state by antibiotics
when necessary to treat infection. A larger percentage
indicated that patients in such conditions ought to be
maintained by tube or intravenous feeding.
Fourteen percent (13.6) of All Doctors and 12.8 percent
of Primary Care Doctors responding to the survey indicated
that antibiotics should be given patients in permanent coma.
Thirty percent (29.9) of All Doctors and 30.3 percent of
Primary Care Doctors said comatose patients should be
sustained by tube or intravenous feeding.
All Doctors and Primary Care Doctors also believe
orders to withhold or withdraw treatment may more
appropriately apply to dialysis and respirator life-supports
than to nasogastric, gastrostomy, and intravenous feeding
interventions (see Table 3).
18


Table 3
Treatments for which Doctors Believe an Order to Withhold
or Withdraw may be Properly Written10
(Percentage of physicians who believe such an order
may be properly written)
Type of Treatment All Doctors Primary Care Doctors
Respirator 98.1% 98.5%
Dialysis 88.8 89.9
Gastrostomy 79.9 82.5
Intravenous Feeding 76.9 79.1
Nasogastric Tube 75.5 78.2
Previously presented data suggests that a strong majority of
physicians believe that the Colorado living will statute
should allow patients to refuse food and fluid. Yet some
physicians responding to the survey reported that they
believe an order to withdraw life support may be more
appropriately applied to respirators and kidney machines
than to gastrostomy tubes, intravenous feedings and
nasogastric tubes.
19


POLICY ISSUES AND RAMIFICATIONS
Many concerns were raised by the physicians' response to the
Center's survey. Some issues relate to the relationship between
health care professionals and patients, others concern ground
rules associated with the use of life-sustaining technology.
Several important public policy concerns were suggested by the
study, some of which are summarized below.
Absence of Familiarity with Advance Directives
The survey suggests that not all physicians have familiarity
with advance directive statutes. Just as clearly, the survey
indicates that many physicians do not discuss these legal options
with patients.
Given the sanction of certain kinds of advance directives by
Colorado citizens through their legislature, it is incumbent upon
those who treat and counsel patients to make them aware of their
options. To fail to do so is to deny patients legitimate
opportunities to make choices about their life and, indeed, their
death.
20


Need for Clarification and Reevaluation of Current Law
A relatively large percentage of physicians question the
distinction in current law concerning advance directives that
permits doctors to withdraw some types of life-sustaining
treatment but does not allow them to withdraw nutrition. Many
physicians appear to experience unease about decision-making in
such cases in the absence of a firm legal footing. At a minimum,
given the importance of the subject and the intricate
relationship it has to issues of individual and societal rights,
Colorado citizens should instruct their legislature to provide
clearer instruction regarding interventions that are permitted
when an advance directive is or is not used.
Need for Discussion Concerning Basic Changes in Laws Governing
Active Euthanasia
A substantial number of physician respondents have been
involved in withholding or withdrawing life-sustaining treatment.
Moreover, a large percentage of doctors has had patients for whom
they think active euthanasia would have been appropriate were it
legal. A large percentage of them would have been willing to
practice active euthanasia if the law permitted it. Given these
facts, Colorado citizens should re-evaluate the law and its
consistency with their own perceptions of right and wrong. Is
the significant number of physicians who are tolerant of active
euthanasia indicative of changing community mores? If not, we
must clearly address the uncertainty about current laws; if so,
we should emphatically begin the process of evaluating or
changing current laws.
21


We cannot and should not sweep the Center's findings under
the rug. A society that is confident of itself should find a way
to openly and squarely face what have become legitimate public
policy issues. How we die tells us something about how we live
and value life. Ground rules governing the relationship between
health care professionals and the terminally ill raise questions
about the relationship of individual and societal interests and
rights. They also raise questions about personal and
professional values and responsibilities. Current laws do not
reflect the perceptions and possibly the actions of relatively
large numbers of physicians. This alone suggests the need for a
state-wide dialogue.
Absence of Sustained Ground Rules Governing the Dying Process
Doctors consult with different professionals and non-
professionals about the dying process and about forgoing life-
supports. Most appear to follow varied personal, professional,
and institutional ground rules when considering life and death
choices. While it is unlikely that society will ever clearly
define and apply uniform principles to the treatment of the
terminally ill and permanently comatose, we can and should
develop generally predictable and acceptable decision-making
processes. These procedures should acknowledge patient rights,
economic constraints, public policy complexities, existing
statutes, judicial rulings, the responsibilities of health care
professionals, and community mores.
22


RECOMMENDATIONS
No absolute wisdom exists concerning the care and treatment
of the dying. For theological or empirically-based reasons many
people feel strongly that any enlargement of current options for
shortening the dying process would threaten values they hold
dear. Critics view advance directives as a threat to society's
interest in preserving life. Supporters feel equally strongly
that patients deserve to make decisions not only about their own
lives, but about their own deaths. To these individuals, patient
autonomy is an overriding concern. Further, they claim that it
is often more humane to facilitate dying than to permit or cause
a lingering death, a process that may offer a person a minimal
existence and impose emotional and financial burdens on loved
ones.
The debate over euthanasia has intensified as the use of
costly life-extending technology has become more commonplace.
What is society's obligation to keep permanently comatose and
terminally ill patients alive against their wishes or the wishes
of others close to them? By sanctioning any form of euthanasia
are we proceeding down a slippery slope that endangers the
balance between the rights of the individual and the community?
Are we giving health care professionals enough or too much
authority and responsibility over life and death decisions?
Conversely, can we justify expensive life-saving care for
terminally ill or permanently comatose patients? Can we develop
23


equitable policy equations that will enhance the quality of life
and health care for Coloradans while respecting their values?
These are difficult questions and issues with no easy
answers.
Given the results of the Center's survey, the following
public and private sector initiatives should be forthcoming:
l. The Governor and the Legislature Should Create a
Bi-partisan Representative Commission to Review the Study's
Findings and its Implications.
The commission should be composed of a cross-section of
Colorado's public private sector and community leadership.
It should include among its members clergy, lawyers, medical
professionals, ethicists, economists, public policy
scholars, decision-makers, and lay citizens. Great care
should be taken to ensure that all divergent views are
represented.
The commission should examine Colorado law concerning
advance directives, the forgoing of life-sustaining
treatment and euthanasia in general. It should recommend
amendments to current statutes that remove shortcomings,
ambiguities, and inconsistencies. The Commission should go
further: it should initiate a state-wide public dialogue
exploring legal, ethical, and economic ground rules which
might be developed to help patients and physicians face
difficult choices about life-sustaining medical care. The
24


commission should propose predictable, sensitive, and
acceptable procedures for health care professionals to
follow in making life and death decisions.
2. Medical Schools, Law Schools, and Other Relevant
Professional Schools Should Take the Lead in Training
Students in Current Colorado Law Regarding Advance
Directives and Euthanasia.
Internship instruction and course work in state law,
court decisions, and consent documents relevant to life-
sustaining treatment deliberations should be mandatory in
Colorado medical and professional schools. Knowledge of the
law and recognizing the duty to counsel patients about
critical treatment options should become part and parcel of
professional responsibilities.
3. Relevant Professional Organizations Should Offer Their
Membership Continuous Refresher Courses Regarding Advance
Directives, Euthanasia and Withholding and Withdrawing of
Life-sustaining Treatment.
Continuing education providers should allow ample
opportunities for learning about legal directives that have
a bearing upon life-support choices. Such instruction
should be mandatory for those professionals involved with
such decisions.
25


State and County Health Departments Should Take the
Initiative in Beginning Education Programs to Inform
Colorado Citizens About Advance Directives and About the
Legal and Ethical Ramifications of Withholding and
Withdrawing Life-sustaining Treatment.
A large number of citizens in the state are probably
not aware of the Colorado living will and durable powers of
attorney statutes. They are even less likely to know what
decisions doctors and health care personnel can legally make
about their treatment should they become terminally ill or
lose decision-making capability. They also are unaware of
the degree to which they themselves, or people chosen by
them, can influence such decisions. The state has a
responsibility to take the lead in ensuring that Colorado
citizens are informed about the dying process and how it
might affect them, their families, and their communities.
*****
We end this report as we began it. Through this study, we
have introduced sensitive issues that are controversial and often
hard to discuss in a public forum. Yet our survey indicates that
critical issues related to death and dying must be openly
considered. The strength of a civilized and democratic society
is directly related to a public willingness to discuss the
difficult and to a public capacity to secure consensus on the
26


important. The treatment and care of the dying are difficult
subjects to contemplate, but we believe they must be placed on
the public agenda. We hope we have done so.
27


ENDNOTES
1. Although we recognize absence of precise distinctions
between the words "active" and "passive euthanasia," we use
the term "euthanasia" generally to refer to medical
practices that assist a patient to die more quickly than
would be the case without such action.
2. A copy of the questionnaire may be obtained from the Center
for Health Ethics and Policy, Graduate School of Public
Affairs, University of Colorado at Denver, 1200 Larimer
Street, Campus Box 133, Denver, Colorado 80204.
3. Colorado Department of Health, "Physicians in Colorado,
1983" (1985).
4. For example, "Making Difficult Health Care Decisions", Vol.
I The National Study A Survey Conducted for the Loran
Commission. Louis Harris and Associates, Inc., June (1987).
5. (Living Will), Colorado Medical Treatment Decision Act, C.R.S. S 15-18-101 et seq., (Durable Powers of Attorney) Powers of Attorney, C.R.S. S 15-14-501, et seq.
6 . C.R.S. Sec. 15-18-104.
7 . C.R.S. Sec. 15-18-110 .
8 . C.R.S. Sec. 15-18-113(5).
9 . C.R.S. Sec. 15-18-103(7).
10 . Due to inadequate sample size, the data were not cross-
tabulated according to medical specialty, with the exception
of Primary Care Doctors. Nevertheless, it is interesting to
note that pediatricians may be willing to discontinue
antibiotic treatment more than food and fluids. Forty-three
percent (43.2) of pediatricians responding to the survey
reported that patients in a permanent coma or persistent
vegetative state ought to be sustained by artificial
feeding; fifteen percent (15.2) stated that pneumonia or
sepsis should be treated.
28


APPENDIX A
Respondent Physicians by Religious Affiliation
Center for Health Ethics and Policy Survey (1988)
Protestant 54.4%
Catholic 17.6
Jewish 13.4
Latter-Day Saint 0.9
Moslem 0.1
Other 13.6
TOTAL 100.0%
* * *
Respondent Physicians by Year of Graduation
Center for Health Ethics and Policy Survey (1988)
1930-39 2.9%
1940-49 8.3
1950-59 16.2
1960-69 22.0
1970-79 31.3
1980-87 19.3
TOTAL 100.0%
29


APPENDIX B
Colorado Physicians by Specialty
Comparison of Department of Health 1983 Survey
and Center for Health Ethics and Policy Survey
(as percentage of all respondents)
Center for Health
and Policy Survey
Family Practice* 22.3%
Osteopathic Medicine 0.1
Anesthesiology 3.5
Internal Medicine 16.9
Ob/Gyn 6.4
Pediatrics 8.5
Orthopedics 2.5
Ophthalmology 2.3
Cardiology 1.4
Urology 1.0
Radiology 2.8
Otolaryngology 1.1
Neurology 1.8
Psychiatry 7.8
Pathology 2.3
Gerontology 0.4
General Surgery 8.1
Oncology 1.1
Dermatology 1.0
Hematology 0.1
Retired 0.2
Occupational Medicine 0.9
Infectious Disease 0.1
Endocrinology 0.3
Ethics Colorado Department of
(1988 ) Health Survey (1983 )
18.1%
no data
3.9
13.7
6.2
7.3
3.9
3.4
0.5
1.6
4.2
no data
1.1
8.3
3.2
no data
5.1
no data
1.5
no data
no data
0.7
no data
no data
30


Appendix B, continued
Colorado Physicians by Specialty continued
Center for Health Ethics Colorado Department
and Policy Survey (1988) Health Survey (1983;
Neonatology 0.3 no data
Preventive Medicine 0.6 0.2
Emergency Medicine 3.4 3.4
Pulmonary Medicine 1.4 . 7
No Specialty 1.2 no data
Others** 13.0
TOTAL 100.0% 100.0%
Center for Health Ethics and Policy Survey Categories specialty
designations between the two surveys were not always equivalent.
In order to facilitate comparisons, some of the 1983 specialty
categories were combined (e.g., radiology and diagnostic
radiology), and paired with the 1988 survey categories.
This percentage accounts for responses that did not correspond to
specialty designation in the Center for Health Ethics and Policy
Survey.
* * * *
Colorado Physicians by Age
Comparison of Department of Health 1983 Survey
and Center for Health Ethics and Policy Survey
Center for Health Ethics
and Policy Survey (1988)
Colorado Department of
Health Survey (1983)
<35 17.2% 19.5%
35-44 34.7 35.6
45-54 21.2 21.9
55-64 16.2 15.3
65- 10.7 7.7
TOTAL 100.0% 100.0%
31


Appendix B, continued
Colorado Physicians by County of Residence
Comparison of Department of Health 1983 Survey
and Center for Health Ethics and Policy Survey
Center for Health Ethics Colorado Department of
and Policy Survey (1988) Health Survey (1983)
Adams 3.5% 4%
Arapahoe 8.9 8
Boulder 5.8 5
Denver 41.9 38
El Paso 8.8 9
Jefferson 7.0 7
Larimer 4.6 4
Mesa 3.6 3
Pueblo 3.5 4
Other 12.4 18
TOTAL 100.0% 100%
32


appendix c
LIVING VILL
DECLARATIONS FUTURE MEDICAL TREATMENT
ARTICLE 18
Colorado Medical Treatment Decision Act
lw reviews. For article. "The New Colorado Medical Treatment Decision Act**. see N t
Law. 1190 (1985). For article. "Working With the New Medical Treatment Decision il.i>
W ill) Act'*, see 15 Colo. Law. 645 (1986)
15-18-101.
15-18-102.
15-18-103.
15-18-104.
15-18-105.
15-18-106.
15-18-107.
Short title.
Legislative declaration.
Definitions.
Declaration as to medical
treatment.
Inability of declarant to sign.
Witnesses.
Withdrawal withholding of
life-sustaining procedures.
15-18-108. Determination of validity
15-18-109. Revocation of declaration.
15-18-110. Liability.
15-18-111. Determination of sutode *i
homicide effect of *
lion on insurance.
15-18-112. Application of article.
15-18-113. Penalties.
33


Appendix C, continued
433 Colorado Medical Treatment Decision Act 15-18-103
15-18-101. Short title. This article shall be known and may be cited as
the "Colorado Medical Treatment Decision Act".
Source: L. 85. p. 608. § 1.
15-18-102. Legislative declaration. (1) The general assembly hereby
finds, determines, and declares that:
(a) Colorado law has traditionally recognized the right of a competent
adult to accept or reject medical or surgical treatment affecting his person;
(b) Recent advances in medical science have made it possible to prolong
dying through the use of artificial, extraordinary, extreme, or radical medical
or surgical procedures;
(c) The use of such medical or surgical procedures increasingly involves
patients who are unconscious or otherwise incompetent to accept or reject
medical or surgical treatment affecting their persons;
(d) The traditional right to accept or reject medical or surgical treatment
should be available to an adult while he is competent, notwithstanding the
fact that such medical or surgical treatment may be offered or applied when
he is suffering from a terminal condition and is either unconscious or other-
wise incompetent to decide whether such medical or surgical treatment
should be accepted or rejected;
(e) This article affirms the traditional right to accept or reject medical
or surgical treatment affecting one's person, and creates a procedure by which
a competent adult may make such decisions in advance, before he becomes
unconscious or otherwise incompetent to do so;
(0 It is the legislative intent that nothing in this article shall have the
effect of modifying or changing currently practiced medical ethics or protocol
with respect to any patient in the absence of a declaration as provided for
in section 15-18-104;
(g) It is the legislative intent that nothing in this article shall require any
person to execute a declaration.
Source: L. 85, p. 608. § 1.
15-18-103. Definitions. As used in this article, unless the context other-
wise requires:
(1) "Adult" means any person eighteen years of age or older.
(2) "Attending physician means the physician, whether selected by or
assigned to a patient, who has primary responsibility for the treatment and
care of said patient.
(3) Court means the district court of the county in which a declarant
having a terminal condition is located at the time of commencement of a
proceeding pursuant to this article or, in the city and county of Denver,
the probate court.
(4) "Declarant means a mentally competent adult who executes a decla-
ration.
(5) Declaration means a written document voluntarily executed by a
declarant in accordance with the requirements of section 15-18-104.
34


Appendix C, continued
15-18-104 Probate, Trusts, and Fiduciaries 434
(6) Hospital means an institution holding a license or certificate of
compliance as a hospital issued by the department of health of this state
and includes hospitals operated by the federal government in Colorado.
(7) Life-sustaining procedure means any medical procedure or inter-
vention that, if administered to a qualified patient, would serve only to
prolong the dying process. Life-sustaining procedure" shall not include any
medical procedure or intervention to nourish the qualified patient or consid-
ered necessary by the attending physician to provide comfort or alleviate
pain.
(8) Physician means a person duly licensed under the provisions of
article 36 of title 12. C.R.S.
(9) Qualified patient means a patient who has executed a declaration
in accordance with this article and who has been certified by the attending
physician and one other physician to be in a terminal condition.
(10) Terminal condition" means an incurable or irreversible condition
for which the administration of life-sustaining procedures will serve only to
postpone the moment of death.
Source: L. 85, p. 609, § 1.
15-18-104. Declaration as to medical treatment. (1) Any competent adult
may execute a declaration directing that life-sustaining procedures be with-
held or withdrawn if, at some future time, he is in a terminal condition
and either unconscious or otherwise incompe.tent to decide whether any med-
ical procedure or inteiwention should be accepted or rejected. It shall be
the responsibility of the declarant or someone acting for him to submit the
declaration to the attending physician for entry in the declarants medical
record..
(2) In the case of a declaration of a qualified patient known to the attend-
ing physician to be pregnant, a medical evaluation shall be made as to
whether the fetus is viable and could with a reasonable degree of medical
certainty develop to live birth with continued application of life-sustaining
procedures. If such is the case, the declaration shall be given no force or
effect.
(3) A declaration executed before two witnesses by any cipmpetent adult
shall be legally effective for the purposes of this article and may, but need
not be, in the following form:
DECLARATION AS TO MEDICAL OR SURGICAL TREATMENT
I, (name of declarant) being of sound mind and at least eighteen years
of age, direct that my life shall not be artificially prolonged under the circum-
stances 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 responsible decisions concerning my person; then
35


Appendix C, continued
435 Colorado Medical Treatment Decision Act 15-18-105
I direct that life-sustaining procedures shall be withdrawn and withheld,
it being understood that life-sustaining procedures shall not include any med-
ical 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_____
davof____________, 19____.
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 instru-
ment. the declarant, according to our best knowledge and belief, was of sound
mind and under no constraint or undue influence.
Dated at___________, Colorado, this______day of_____________, 19__.
Name and Address
Name and Address
STATE OF COLORADO )
) ss.
County of______________ )
SUBSCRIBED and sworn to before me by__, the declar-
ant. and_____________________________. and_, witnesses, as the volun-
tary act and deed of the declarant, this___day of_, 19__.
My commission expires:
Notary Public
Source: L. 85. p. 610, § 1.
15-18-105. Inability of declarant to sign. (1) In the event that the declar-
ant is physically unable to sign the declaration, it may be signed by some
other person in the declarants presence and at his direction. Such other
person shall not be:
(a) The attending physician or any other physician; or
(b) An employee of the attending physician or health care facility in
which the declarant is a patient: or
(c) A person who has a claim against any portion of the estate of the
declarant at his death at the time the declaration is signed; or
(d) A person who knows or believes that he is entitled to any portion
of the estate of the declarant upon his death either as a beneficiary of a
will in existence at the time the declaration is signed or as an heir at law.
Source: L. 85. p. 611, § 1.
36


Appendix C, continued
15-18-106 Probate, Trusts, and Fiduciaries 436
15-18-106. Witnesses. (1-) The declaration shall be signed by the declar-
ant in the presence of two witnesses. Said witnesses shall not include any
person specified in section 15-18-105.
(2) If the declarant is a patient or resident of a health care facility, the
witnesses shall not be patients of that facility.
Source: L. 85. p. 611.§ 1.
15-18-107. Withdrawal withholding of life-sustaining procedures. In the
event that an attending physician is presented with an unrevoked declaration
executed by a declarant whom the physician believes has a terminal condi-
tion. the attending physician shall cause the declarant to be examined by
one other physician. If both physicians find that the declarant has a terminal
condition, they shall certify such fact in writing and enter such in the quali-
fied patients medical record of the hospital in which the withholding or
withdrawal of life-sustaining procedures may occur, together with a copy of
the declaration. If the attending physician has actual knowledge of the where-
abouts of the qualified patient's spouse, any of his adult children, a parent,
or attomey-in-fact under a durable power of attorney, the attending physician
shall immediately make a reasonable effort to notify at least one of said
persons, in the order named, that a certificate of terminal condition has been
signed. If no action to challenge the validity of a declaration has been filed
within forty-eight consecutive hours after the certification is made by the
physicians, the attending physician shall then withdraw or withhold all life-
sustaining procedures pursuant to the terms of the declaration.
Source: L. 85, p. 611,§ 1.
15-18-108. Determination of validity. (1) Any person who is the parent,
adult child, spouse, or'attomey-in-fact under a durable power of attorney
of the qualified patient may challenge the validity of a declaration in the
appropriate court of the county in which the qualified patient is located.
Upon the filing of a petition to challenge the validity of a declaration and
notification to the attending physician, a temporary restraining order shall
be issued until a final determination as to validity is made.
(2) (a) In proceedings pursuant to this section, the court shall appoint
a guardian ad litem for the qualified patient, and the guardian ad litem shall
take such action as he deems necessary and prudent in the best interest of
the qualified patient and shall present to the court a report of his actions,
findings, conclusions, and recommendations.
(b) (I) Unless the court for good cause shown provides for a different
method or time of notice, the petitioner, at least five days prior to the hear-
ing, shall cause notice of the time and place of hearing to be given as follows:
(A) To the qualified patients guardian or conservator, if any, and the
court-appointed guardian ad litem; and
(B) To the qualified patients spouse, if the identity and whereabouts of
the spouse are known, to the petitioner, or otherwise to an adult child or
parent of the qualified patient.
(II) Notice as required in this paragraph (b) shall be made in accordance
with the Colorado rules of civil procedure.
37


Appendix C, continued
437 Colorado Medical Treatment Decision Act 15-18-112
(c) The court may require such evidence, including independent medical
evidence, as it deems necessary.
(3) Upon a determination pf the validity of the declaration, the court
shall enter any appropriate order.
Source: L. 85. p. 612, § 1.
15-18-109. Revocation of declaration. A declaration may be revoked by
the declarant orally, in writing, or by burning, tearing, cancelling, oblit-
erating. or destroying said declaration.
Source: L. 85. p. 612, § 1.
15-18-110. Liability. (1) With respect to any declaration which appears
on its face to have been executed in accordance with the requirements of
this article:
(a) Any physician may act in compliance with such declaration in the
absence of actual notice of revocation, fraud, misrepresentation, or improper
execution;
(b) No physician signing a certificate of terminal condition or withhold-
ing or withdrawing life-sustaining procedures in compliance with a declara-
tion shall be subject to civil liability, criminal penalty, or licensing sanctions
therefor,
(c) No hospital or person acting under the direction of a physician and
participating in the withholding or withdrawal of life-sustaining procedures
in compliance with a declaration shall be subject to civil liability, criminal
penalty, or licensing sanctions therefor.
Source: L. 85, p. 612, § 1.
Cross references: For other circumstances under which physicians are not subject to civil or
criminal liability, see § § 13-21-108.13-22-106. and 42-4-1202 (3Xb).
15-18-111. Determination of suicide or homicide effect of declaration on
insurance. The withholding or withdrawal of life-sustaining procedures from
a qualified patient pursuant to this article shall not, for any purpose, consti-
tute a suicide or a homicide. The existence of a declaration shall not affect,
impair, or modify any contract of life insurance or annuity or be the basis
for any delay in issuing or refusing to issue an annuity or policy of life insur-
ance or any increase of the premium therefor. No insurer or provider of
health care shall require any person to execute a declaration as a condition
of being insured for or receiving health care services; nor shall the failure
to execute a declaration be the basis for any increased or additional premium
for a contract or policy for medical or health insurance.
Source: L. 85, p. 613, § 1.
15-18-112. Application of article. (1) Nothing in this article shall be con-
strued as altering or amending the standards of the practice of medicine
38


Appendix C, continued
15-18-113 Probate, Trusts, and Fiduciaries 438
or establishing any presumption, absent a valid declaration, nor as condon-
ing, authorizing, or approving euthanasia or mercy killing, nor as permitting
any affirmative or deliberate act or omission to end life, except to permit
natural death as provided in this article.
(2) In the event of any conflict between the provisions of this article,
or a declaration executed under this article, and the provisions of section
15-14-501, the provisions of this article and the declaration shall prevail.
Source: L. 85, p. 613, § 1.
15-18-113. Penalties. (1) Any person who willfully conceals, defaces,
damages, or destroys a declaration of another, without the knowledge and
consent of the declarant, commits a class 1 misdemeanor and shall be pun-
ished as provided in section 18-1-106, C.R.S.
(2) Any person who falsifies or forges a declaration of another commits
a class 4 felony and shall be punished as provided in section 18-1-105, C.R.S.
(3) Any person who falsifies or forges a declaration of another, and the
terms of the declaration are carried out, resulting in the death of the pur-
ported declarant, commits a class 2 felony and shall be punished as provided
in section 18-1-105, C.R.S.
(4) Any person who willfully-withholds information concerning the revo-
cation of the declaration of another commits a class 1 misdemeanor and
shall be punished as provided in section 18-1-106, C.R.S.
(5) An attending physician who refuses to comply with the terms of a
declaration valid on its face shall transfer the care of the declarant to another
physician who is willing to comply with the declaration. Refusal of an attend-
ing physician to comply with a declaration and failure to transfer the care
of the declarant to another physician shall constitute unprofessional conduct
as defined in section 12-36-117, C.R.S.
Source: L 85, p. 613, § 1.


APPENDIX D
DURABLE POWERS OF ATTORNEY
POWERS OF ATTORNEY
15-14-501. When power of attorney not affected by disability. (1) When-
ever a principal designates another his attorney-in-fact or agent by a power
of attorney in writing and the writing contains the words This power of
attorney shall not be affected by disability of the principal. or This power
of attorney shall become effective upon the disability of the principal. or
similar words showing the intent of the principal that the authority conferred
shall be exercisable notwithstanding his disability, the authority of the attor-
ney-in-fact or agent is exercisable by him as provided in the power on behalf
of the principal notwithstanding later disability or incapacity of the principal
at law or later uncertainty as to whether the principal is dead or alive. The
authority of the attorney-in-fact or agent to act on behalf of the principal
shall be set forth in the power and may relate to any act, power, duty, right,
or obligation which the principal has or after acquires relating to the principal
or any matter, transaction, or property, real or personal, tangible or intan-
gible. including by way of illustration but not limitation, the power to consent
to or approve on behalf of the principal any medical or other professional
care, counsel, treatment, or service of or to the principal by a licensed or
certified professional person or institution engaged in the practice of, or pro-
viding, a healing an. The attomey-in-fact or agent, however, is subject to
the same limitations imposed upon court-appointed guardians contained in
section 15-14-312 (1) (a). All acts done by the attomey-in-fact or agent pur-
suant to the pow-er during any period of disability or incompetence or uncer-
tainty as to whether the principal is dead or alive have the same effect and
inure to the benefit of and bind the principal or his heirs, devisees, and
personal representative as if the principal were alive, competent, and not
disabled. If a guardian or conservator thereafter is appointed for the prin-
cipal. the attorney-in-fact or agent, during the continuance of the appoint-
ment, shall consult with the guardian on matters concerning the principals
personal care or account to the conservator on matters concerning the
principals financial affairs. The conservator has the same power the prin-
cipal would have had if he were not disabled or incompetent to revoke, sus-
pend. or terminate all or any part of the power of attorney or agency as
it relates to financial matters. Subject to any limitation or restriction of the
guardian's powers or duties set forth in the order of appointment and
endorsed on the letters of guardianship, a guardian has the same power to
revoke, suspend, or terminate all or any part of the power of attorney or
agency as it relates to matters concerning the principals personal care that
the principal would have had if the principal were not disabled or incompe-
tent.
(2) An affidavit, executed by the attorney-in-fact or agent, stating that
he did not have, at the time of doing an act pursuant to the power of attorney,
actual knowledge of the termination of the power of attorney by death is.
in the absence of fraud, conclusive proof of the nontermination of the power
at that time. If the exercise of the power requires execution and delivery
of any instrument which is recordable, the affidavit when authenticated for
record is likewise recordable.
Source: R & RE, L. 73, p. 1633, § 1; C.R.S. 1963. § 153-5-501; L. 77, p.
836, §25; L. 83, p. 661, § 1.
U re*ies. For article. "Estate Planning Powers of Attorney, see 14 Colo. Law. 543
for Young Lawyers", see 14 Colo. Law. 53 (1985).
(1985). For article. The Use of Durable
40


Appendix D, continued
15-14-502. Other powers of attorney not revoked until notice of death or
disability. (1) The death, disability, or incompetence of any principal who
has executed a power of attorney in writing, other than a power as described
by section 15-14-501, does not revoke or terminate the agency as to the attor-
ney-in-fact, agent, or other person who, without actual knowledge of the
death, disability, or incompetence of the principal, acts in good faith under
the power of attorney or agency. Any action so taken, unless otherwise invalid
or unenforceable, binds the principal and his heirs, devisees, and personal
representatives.
(2) An affidavit, executed by the attorney-in-fact or agent, stating that
he did not have, at the time of doing an act pursuant to the power of attorney,
actual knowledge of the revocation or termination of the power of attorney
by death, disability, or incompetence is, in the absence of fraud, conclusive
proof of the nonrevocation or nontermination of the power at that time.
If the exercise of the power requires execution and delivery of any instrument
which is recordable, the affidavit when authenticated for record is likewise
recordable.
(3) This section shall not be construed to alter or affect any provision
for revocation or termination contained in the power of attorney.
(4) All powers of attorney executed for real estate and other purposes,
pursuant to law, shall be deemed valid until revoked as provided in the terms
of the power of attorney or as provided by law.
Source: R & RE, L. 73, p. 1634, § 1; C.R.S. 1963, § 153-5-502; L. 75, p.
603, § 52; L. 85, p. 566, § 13.
41


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[ I [ I I I E E I I I E I E I E E [ [ WITHHOLDING AND WITHDRAWING LIFE-SUSTAINING TREATMENT: A SURVEY OF OPINIONS AND EXPERIENCES OF COLORADO PHYSICIANS A Report By The Center for Health Ethics and Policy Graduate School of Public Affairs University of Colorado at Denver May, 1988

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E I [ I [ I E I E I E E E I [ [ [ THE CENTER FOR HEALTH ETHICS AND POLICY Graduate School of Public Affairs University of Colorado at Denver 1200 Larimer Street, Campus Box 133 Denver, Colorado 80204 (303) 556-4837 Marshall Kaplan, Dean Donald W. Hoagland, Director Principal Investigators: Fredrick R. Abrams, M.D., Associate Director Elizabeth D. Gee, Ed.D., Senior Research Associate Project Staff Shirley Boeke Russell A. Cargo, M.A., M.S.B.A. Carol Jacobson, M.P.A. Estelle Kennelly Margaret Noble c. William Reiquam, M.D. Deborah Trantin Eileen Tynan, Ph.D. The Center was formed in 1987 to address ethical and policy issues facing Colorado and the nation. The Center serves as a forum for information exchange, offers educational programs, assists in development of health policy, conducts applied research, and assists health care providers with bedside ethical problems. The Center for Health Ethics and Policy is supported in part by grants from the Rose Medical Center Foundation and The Colorado Trust. This project was also supported by a grant from Mr. Bill Gossard.

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[ [ [ [ [ [ E I I I E E I [ [ [ [ Table of Contents INTRODUCTION SURVEY METHOD Classification of Physicians Classification of Questions 1. 2. 3 Familiarity with Living Will and Durable Powers of Attorney Statutes Decisions to Withhold or Withdraw LifeSustaining Treatment Active Euthanasia and Assisted Suicide SURVEY FINDINGS 1. 2. 3. 4. 5. 6. A significant minority of Colorado physicians is not familiar with the Colorado living will, and a large majority is not familiar with the durable powers of attorney. Many Colorado doctors do not discuss advance directives with patients. Most Colorado physicians do not personally have a living will nor have they appointed a personal attorney-in-fact under the durable powers of attorney statute. When available, advance directives are used in making decisions to withhold or withdraw lifesustaining treatment for patients who do not have the capacity to choose, but their use is not widespread. An overwhelming majority of Colorado physicians consults with someone when making lifesustaining treatment decisions for patients who do not have the capacity to choose. A strong majority of physicians expressly believes that the Colorado living will statute should permit patients to refuse medical intervention that provides food and fluid. An overwhelming majority of Colorado physicians does not believe they are obligated to prolong life regardless of its quality. Page 1 4 5 5 5 6 8 9 10 11 11 12 14 15

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[ [ [ E [ [ E E E E I E [ I [ [ [ [ [ 7. 8. 9. A majority of Colorado doctors has attended patients for whom they believed active euthanasia would be justifiable, if legal. A significant minority of Colorado doctors would have been willing to administer a lethal dose to such patients, but for legal prohibitions. Some Colorado physicians have assisted their patients in stockpiling lethal doses of medication while aware that they might be used to commit suicide. For permanently comatose patients, doctors are more willing to discontinue antibiotic treatment than nutrition. POLICY ISSUES AND RAMIFICATIONS RECOMMENDATIONS ENDNOTES APPENDIX A APPENDIX B APPENDIX C APPENDIX D TABLES Table 1: Parties with whom Doctors Consult When a Living Will is Used Table 2: Parties with whom Doctors Consult When There is no Living Will Table 3: Treatments for which Doctors Believe an Order to Withhold or Withdraw be Properly Written ( ii) 15 17 18 20 23 28 29 30 33 40 13 13 18

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t E [ E E E E E E E I E E E I E [ [ [ WITHHOLDING AND WITHDRAWING LIFE-SUSTAINING TREATMENT: A SURVEY OF OPINIONS AND EXPERIENCES OF COLORADO PHYSICIANS INTRODUCTION For the majority of Americans, the state of biomedical knowledge and technology has never been better. The availability of new and vast medical resources has enabled physicians to offer patients a high standard of medical care. Yet for critically ill patients, their families, and their doctors, the miracles of medical science have created complex ethical questions. Today, life-sustaining technology may be used to prolong life that is so poor in quality as to seem not worth living. As such, judgments about terminating critical life-support treatment have profound personal and social ramifications. Choices to use or forgo lifesustaining interventions carry with them grave implications for patients and family members. Such decisions may determine when a patient will live or die, what will be the patient's quality of life, and what emotional, physical and financial burdens will be thrust upon family members. The public also has an interest in critical health decisions. Society provides access to care, guards patients' rights, and protects individuals who, because of their vulnerability, are not able to participate in decisions about their own lives. The special nature of life-sustaining treatment poses unique considerations for physicians. The doctor's role in making choices to withhold treatment or withdraw existing life-supports 1

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[ E [ [ [ E E E [ [ I E [ I I E E [ [ cannot be separated from the interests of patients, their loved ones, or society. Once life-and-death decisions were of a more simple order for physicians but today doctors must evaluate the new profusion of treatment options in the full light of burgeoning law, institutional mandate, cost constraints, and public policy. Additionally, physicians making critical health decisions must do so recognizing the increasing complexity of ethical issues that necessarily arise when medical practice becomes more capable of hastening birth or prolonging dying. Much misunderstanding surrounds the range of options available to patients for expressing their treatment preferences. Legal, economic, and ethical justifications for euthanasia1 and for forgoing various medical interventions often are not clearcut. Often blurred are ground rules indicating when, if ever, deliberately ending patients' lives or assisting patients to end their own lives is warranted or permitted. Colorado citizens, as health care providers, purchasers, prospective patients, and policy makers are deeply concerned about how life-sustaining treatment decisions are made. In order for them to face these hard questions squarely, they must understand the role of the physician in making critical care decisions. Policy makers particularly need to know how doctors perceive and respond to these dilemmas. The Center for Health Ethics and Policy at the Graduate School of Public Affairs, University of Colorado at Denver, has completed a survey of Colorado physicians which identifies their 2

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I I I I I I I I I I I E I E I I [ [ I opinions about life-sustaining treatment. By undertaking this project, the Center hopes to initiate rigorous public/private sector dialogue in Colorado about these opinions and this critical subject. This report first reviews the methodology used to develop and analyze the survey data. The findings of the study are next presented and discussed. Finally, broad-ranging implications and issues raised by the survey are considered, and recommendations are proposed which are intended to promote future discussion and debate. 3

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I I I I I I I I I I I I I I I I E t I SURVEY METHOD In January, 1988, the Center for Health Ethics and Policy mailed a questionnaire to all licensed physicians, numbering 7,095, currently listed with the Board of Medical Examiners as living in Colorado.2 Physicians were asked about their opinions and experiences regarding life-sustaining treatment. The questionnaire followed a forced-choice format, although some open-ended questions were included. Demographic information on religious affiliation and date of medical school graduation (see Appendix A), age, specialty (see Appendix B), and county of residence was also collected. This survey is typical of any mail survey in that the sample response is not random; rather, it is self-selected or selfinitiated which qualifies generalizing results to the entire Colorado physician population. Because of the number of respondents, the strong similarities that exist between physicians characteristics as reported in the Center survey and a profile of Colorado physicians published by the Colorado State Department of Health (see Appendix B),3 and the results of a limited number of comparable surveys initiated elsewhere in the country,4 the Center's findings likely can be extrapolated with reasonable confidence levels to all Colorado physicians. The reader should keep in mind that findings about physicians' conduct presented in this study represent the perceptions of physicians themselves rather than the observations of others about their conduct. 4

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I I I I I I I I I I I I I I I I E t 1Classification of Physicians The surveyed physicians were categorized into two groups: All Doctors and Primary Care Doctors. The term All Doctors refers to all Colorado physicians who responded to the survey. For purpose of this study, the term Primary Care Doctors refers only to family practitioners and internists. The Primary Care Doctors were separated out for comparison with All Doctors because they play an important continuing role with the patient. Classification of Questions Colorado physicians were questioned about their opinions and experiences regarding three broad areas of concern. 1. Familiarity with Living Will and Durable Powers of Attorney Statutes These questions address the physician's familiarity with the Colorado living will and durable powers of attorney statutes (see Appendices c and D).5 Colorado's statutory living will is a statement written by a competent adult directing the future withholding or withdrawing of lifesustaining procedures if the individual develops "a terminal condition and either is unconscious or otherwise incompetent to decide whether or not any medical procedure or intervention should be accepted or rejected."6 The law protects the doctor from legal liability if conditions specified in the directive are fulfilled7 and the doctor complies with the statutory procedures for certification of 5

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I I I I I I I I I I I I I I I I E [ E 2 terminal conditions together with the notice requirements if applicable under the circumstances. In situations where patients are able to competently communicate their wishes to the physicians, the living will has no force. If conditions of the living will and the statute are met and the physician is unwilling to withdraw life support, the doctor must transfer the patient to another doctor who is willing to comply or risk being subject to disciplinary action for unprofessional conduct8 A durable power of attorney for health care is a proxy directive executed while the individual is competent that takes effect when the patient is incapable of making decisions or expressing opinions. Individuals may appoint other persons to make medical care decisions on their behalf should they lose decision-making capacity, provided that the durable power of attorney expressly authorizes the principal to make such medical care decisions. Decisions made by the individual empowered by the durable power of attorney are equivalent to those actually made by the patient. Decisions to Withhold or Withdraw Life-Sustaining Treatment This series of questions addresses physicians' involvement in forgoing the use of life-support systems. Doctors have always had to judge when to withhold or withdraw treatments that are futile. Sometimes decisions to terminate life-support must be made when the patient does not have decision-making capability. As discussed above, 6

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E [ [ [ [ [ E E [ [ r .. .. occasionally in such situations the physician may be guided by advance directives; more typically, there is no legal instrument that expresses the patient's desires. The surveyed physicians were questioned about their involvement with choices to forgo life-support and about individuals with whom they consult at the time of such decisions. Doctors were asked whether or not they believe an order to withdraw or withhold life-support may be properly written for specific treatments -dialysis (mechanical process used to cleanse the blood in the case of kidney failure), respirator (machine that provides oxygen and forces breathing), nasogastric tube (feeding tube from the nose into the stomach), gastrostomy (feeding tube surgically introduced through the abdominal wall into the stomach), and intravenous feeding (fluids introduced through the veins). Physicians' opinions also were sought regarding the withholding or withdrawing of food and fluids. They were asked if nourishment should be given patients in permanent coma Additionally, the survey questionnaire asked doctors their views about the failure of the Colorado living will statute to provide for the forgoing of nourishment. The Colorado living will stipulates that "life-sustaining procedures" which may be refused "shall not include any medical procedure or intervention to nourish the qualified patient ... ".9 In other words, the statute has been 7

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I I I I I E I I I I I E E E I E [ t [ 3 integrated to say that an individual cannot use the living will to direct the withdrawal or withholding of food and fluids. Physicians were asked whether or not the Colorado living will statute should be changed to allow patients to refuse food or fluid. Active Euthanasia and Assisted Suicide The survey posed a series of questions to physicians regarding actions which, in fact, accelerate the patient's death. Colorado doctors were asked whether they had encountered patients for whom active euthanasia, or "mercy killing", would be appropriate and whether they would personally have been willing to administer lethal doses of medication in situations where they believed active euthanasia was warranted if legal. Current law prohibits assisting suicide. They were also asked if they had assisted patients to stockpile lethal doses of medication while aware they might be used to commit suicide. Certain powerful medications are dispensed in small amounts because of the danger of overdose leading to death. Despite precautions, some patients, over a period of time, have "stockpiled", or accumulated large amounts of drugs, in order to administer a lethal dose to themselves. Physicians were also asked how they weigh quality of life relative to prolonging life and about their experiences in administering treatment that shortened patient life. 8

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I I I I I I I I I I I E I I I E [ t E SURVEY FINDINGS Of the 7,095 Colorado physicians who were mailed survey questionnaires, 31.3 percent, or 2,218, responded. Primary Care Doctors accounted for 846 or 39.2 percent of all responses. Seventy percent (69.6) of All Doctors and 71.3 percent of Primary Care Doctors are in private practice or working in non-hospital settings, such as clinics, where they deal with patients directly and on a fee-for-service basis. Other common specialties among the respondents were pediatrics (8.5 percent), psychiatry (7.8 percent), general surgery (8.1 percent), and obstetrics and gynecology (6.4 percent). Combined with Primary Care Doctors responses, these practice types account for 70.0 percent of survey respondents. Of all replies, 90.4 percent identified with a specific religion, including Protestant (54.3 percent), Catholic (17.7 percent), and Jewish (13.4 percent). Although the responses were analyzed by religious affiliation, with the exception noted in the text, no substantial differences were identified. Future analyses will examine the survey data in light of additional variables. 9

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I I I I I I I E I E I I E E E [ E [ E The principal findings of this study are as follows: 1. A significant minority of Colorado physicians is not familiar with the Colorado living will, and a large majority is not familiar with durable powers of attorney. Many Colorado doctors do not discuss advance directives with patients. Many Colorado doctors responding to the survey are not knowledgeable about advance directives. Twenty-four percent (23.5) of All Doctors and 17.2 percent of Primary Care Doctors were unfamiliar with the Colorado living will. Substantially more physicians were not knowledgeable about the durable powers of attorney: that is, 73.5 percent of All Doctors and 68.1 percent of Primary Care Doctors lacked familiarity with the durable powers of attorney statute. Slightly more Primary Care Doctors than All Doctors had discussed advance directives with their patients, although both physician groups indicated that such conversations were not numerous. Forty-one percent (40.7) of All Doctors and 64.8 percent of Primary Care Doctors had discussed living wills or durable powers of attorneys with some patients. Nevertheless, 74.1 percent of All Doctors and 69.6 percent of Primary Care Doctors who had such discussions noted that the number of such discussions was negligible in relation to the total number of patients in their practice. 10

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I I I I I I I I I I I I I I I I I I I 2 3 Most Colorado physicians do not personally have a living will nor have they appointed a personal attorney-in-fact under the durable powers of attorney statute. Few Colorado doctors have executed advance directives on their own behalf. Proportionately more physicians have prepared living wills than have appointed an attorney-in-fact (someone authorized to act in their name). Eighty-six percent (86.1) of All Doctors replying to the survey and 86.6 percent of Primary Care Doctors do not personally have a living will. Ninety-four percent (94.4) of All Doctors and 93.6 percent of Primary Care Doctors have not personally appointed an attorney-in-fact under the Colorado durable powers of attorney statute. When available, advance directives are used in making decisions to withhold or withdraw life-sustaining treatment for patients who do not have the capacity to choose, but their use is not widespread. Not many doctors who responded to the survey have encountered incompetent patients for whom either a living will or a durable power of attorney was used. Slightly more Primary Care Doctors than All Doctors report to have been involved in implementing such legal directives. Twentythree percent (23.1) of All Doctors and 35.9 percent of Primary Care Doctors responding to the survey have had at least one patient who lacked the capacity to choose and on 11

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I I I I I I I I I I I I I I I I I E I 4 whose behalf a living will or durable power of attorney was used. An overwhelming majority of Colorado physicians consults with someone when making life-sustaining treatment decisions for patients who do not have the capacity to choose. Irrespective of whether or not a living will was used, the vast majority of All Doctors and Primary Care Doctors responding to the survey consulted with someone when making decisions to terminate life-supports for patients who lacked decision-making capability. Ninety-four percent (94.4) of All Doctors and 97.0 percent of Primary Care Doctors seek advice from professionals and family members if there is a living will. Ninety-seven percent (96.9) of All Doctors and 98.7 percent of Primary Care Doctors seek consultation with these individuals when there is no living will. Responses from All Doctors and Primary Care Doctors indicate they consult with parents, family members, physicians, clergy, ethics committees, and attorneys shown in Tables 1 and 2 (see following) when making decisions to discontinue life-supports for individuals who are unable to make choices. 12

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I I I I I I I I I I I I I I I I I I Table 1 Parties with whom Doctors Consult When a Living Will is Used Consultant All Doctors Primary Care Doctors Family Members Parent (for minor patient) Another Physician Hospital or Other Attorney Clergy Ethics Committee Other 93.8% 80.3 67.8 24.3 20.5 31.1 3.2 * * Table 2 Parties with whom Doctors Consult When There is no Living Will Consultant All Doctors Primary Family Member 94.9% Parent (for minor patient) 82.4 Another Physician 73.5 Hospital or Other Attorney 29.5 Clergy 22.9 Ethics Committee 37.1 Other 3.1 13 97.7% 75.0 65.2 17.7 18.1 23.5 3.8 Care Doctors 98.4% 77.5 72.7 21.9 21.4 30.5 3.5

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I I I I I I I I I I I E I E I E E E 5 In general, All Doctors proportionately consult more with family members, parents, and other physicians than with clergy, ethics committees or attorneys. With the exception of parent consultations, Primary Care Doctors appear to seek advice of these parties less often than All Doctors. A strong majority of physicians believes that the Colorado living will statute should expressly permit patients to refuse medical intervention that provides food and fluid. All Doctors and Primary Care Doctors responded similarly to questions about the need for the Colorado living will statute to allow patients to refuse food and fluid. A majority of All Doctors and of Primary Care Doctors disagreed with the Colorado living will statutory language which defines the life-sustaining procedures that may be refused as not including medical interventions to nourish the patient. Many would like to see the statute changed to allow patients the option of expressly refusing nutrition and hydration through an advance directive. Eighty-eight percent (88.1) of All Doctors and 89.1 percent of Primary Care Doctors indicated that the law should be changed to allow the patient to decline food or fluid. Eighty-five percent (85.1) of All Doctors and 85.2 percent of Primary Care Doctors said they believe that the Colorado living will statute, which denies the patient the option to refuse food and fluid, is unsatisfactory. 14

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I I I I I I I I I I I I I I I I I t I 6 7 An overwhelming majority of Colorado physicians does not believe they are obligated to prolong life regardless of its quality. Almost all physicians responding to the survey indicated that it is not incumbent upon doctors to prolong life regardless of its quality. Responses from All Doctors and Primary Care Doctors relevant to this finding were substantially similar. Ninety-five percent (95.3) of All Doctors and 94.5 percent of Primary Care Doctors believe they are not duty bound to sustain life regardless of quality. Ninety percent (89.9) of All Doctors and 91.7 percent of Primary Care Doctors agreed that expected quality of life should be a consideration when deciding whether or not someone is to be treated with critical care technology. A majority of Colorado doctors has attended patients for whom they believe active euthanasia would be justifiable, if legal. A majority of Colorado doctors who have encountered such patients would have been willing to administer a lethal dose, but for legal prohibitions. More than half of survey respondents have cared for patients they believed to be candidates for active euthanasia. When asked if they would agree to administer, if it were legal, a lethal dose of medication to such 15

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I I I I I I I I I I I I I I I I I I I patients, a slight majority of these respondents who have encountered such patients reported that they would be willing to do so. Sixty percent (60.0) of All Doctors and 60.7 percent of Primary Care Doctors responding to the survey have attended patients for whom they believed active euthanasia to be justifiable if it were legal. Fifty-nine percent (58.9) of All Doctors and 55.7 percent of Primary Care Doctors who have encountered such patients indicated that they would have personally been willing to administer a lethal drug if such measures were allowed by law. Responses to this question differ by religious affiliation. Responses from Catholic doctors, more than Protestant or Jewish physicians, suggested hesitation to justify or engage in active euthanasia. Sixty-one percent (60.9) of Protestants, 66.8 percent of Jewish, and 44.0 percent of Catholic physicians have cared for patients for whom they believed legal active euthanasia to be justifiable. Fifty-eight percent (57.6) of Protestant, 61.8 percent of Jewish, and 47.5 percent of Catholic doctors acknowledged that they would administer a lethal dose to such patients if it were legal. A smaller percentage of physicians have administered pain medication, aware that while shortening a patient's life was not intended, the effect of the medication was to 16

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I I E I I I I I I I I I I I I I E I 8 do so. Responses from Primary Care Doctors indicated that they gave pain medications in such situations more often than All Doctors. Thirty-seven percent (36.7) of All Doctors and 43.3 percent of Primary Care Doctors have administered pain medication while aware that to do so would hasten the patient's death. Religious affiliation appeared only as a slight possible influencing factor in such decisions. Thirty-five percent (35.4) of Protestant, 42.3 percent of Jewish, and 33.1 percent of Catholic physicians have given pain medication that resulted in shortening a patient's life. Some Colorado physicians have assisted their patients in stockpiling lethal doses of medication while aware that they might be used to commit suicide. A relatively few Colorado doctors admit to helping patients stockpile lethal doses of medication, knowing that the drugs might be used to commit suicide. Four percent (4.3) of All Doctors and 4.7 percent of Primary Care Doctors acknowledge providing such aid to their patients. 17

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I I I I I I I I I I I I I I I E E I E 9 For permanently comatose patients, doctors are more willing to discontinue antibiotic treatment than nutrition. A relatively small proportion of respondents reported that doctors ought to sustain patients who are in a permanent coma or persistent vegetative state by antibiotics when necessary to treat infection. A larger percentage indicated that patients in such conditions ought to be maintained by tube or intravenous feeding. Fourteen percent (13.6) of All Doctors and 12.8 percent of Primary Care Doctors responding to the survey indicated that antibiotics should be given patients in permanent coma. Thirty percent (29.9) of All Doctors and 30.3 percent of Primary Care Doctors said comatose patients should be sustained by tube or intravenous feeding. All Doctors and Primary Care Doctors also believe orders to withhold or withdraw treatment may more appropriately apply to dialysis and respirator life-supports than to nasogastric, gastrostomy, and intravenous feeding interventions (see Table 3). 18

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I I I I I E I I I I I I! li I E I Table 3 for which Doctors Believe an Order to Withhold or Withdraw may be Properly Written10 (Percentage of physicians who believe such an order may be properly written) Type of Treatment All Doctors Primary Care Doctors Respirator 98.1% 98.5% Dialysis 88.8 89.9 Gastrostomy 79.9 82.5 Intravenous Feeding 76.9 79.1 Nasogastric Tube 75.5 78.2 Previously presented data suggests that a strong majority of physicians believe that the Colorado living will statute should allow patients to refuse food and fluid. Yet some physicians responding to the survey reported that they believe an order to withdraw life support may be more appropriately applied to respirators and kidney machines than to gastrostomy tubes, intravenous feedings and nasogastric tubes. 19

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I I I I E I I I I I I E E E I E E [ E POLICY ISSUES AND RAMIFICATIONS Many concerns were raised by the physicians' response to the Center's survey. Some issues relate to the relationship between health care professionals and patients, others concern ground rules associated with the use of life-sustaining technology. Several important public policy concerns were suggested by the study, some of which are summarized below. Absence of Familiarity with Advance Directives The survey suggests that not all physicians have familiarity with advance directive statutes. Just as clearly, the survey indicates that many physicians do not discuss these legal options with patients. Given the sanction of certain kinds of advance directives by Colorado citizens through their legislature, it is incumbent upon those who treat and counsel patients to make them aware of their options. To fail to do so is to deny patients legitimate opportunities to make choices about their life and, indeed, their death. 20

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I I I I I I I I I I I I Need for Clarification and Reevaluation of Current Law A relatively large percentage of physicians question the distinction in current law concerning advance directives that permits doctors to withdraw some types of life-sustaining treatment but does not allow them to withdraw nutrition. Many physicians appear to experience unease about decision-making in such cases in the absence of a firm legal footing. At a minimum, given the importance of the subject and the intricate relationship it has to issues of individual and societal rights, Colorado citizens should instruct their legislature to provide clearer instruction regarding interventions that are permitted when an advance directive is or is not used. Need for Discussion Concerning Basic Changes in Laws Governing Active Euthanasia A substantial number of physician respondents have been involved in withholding or withdrawing life-sustaining treatment. Moreover, a large percentage of doctors has had patients for whom they think active euthanasia would have been appropriate were it legal. A large percentage of them would have been willing to practice active euthanasia if the law permitted it. Given these facts, Colorado citizens should re-evaluate the law and its I consistency with their own perceptions of right and wrong. Is the significant number of physicians who are tolerant of active I IIIII I euthanasia indicative of changing community mores? If not, we must clearly address the uncertainty about current laws; if so, we should emphatically begin the process of evaluating or changing current laws. 21

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I E E E I E I I I E I I E I I I E E E We cannot and should not sweep the Center's findings under the rug. A society that is confident of itself should find a way to openly and squarely face what have become legitimate public policy issues. and value life. How we die tells us something about how we live Ground rules governing the relationship between health care professionals and the terminally ill raise questions about the relationship of individual and societal interests and rights. They also raise questions about personal and professional values and responsibilities. Current laws do not reflect the perceptions and possibly the actions of relatively large numbers of physicians. This alone suggests the need for a state-wide dialogue. Absence of Sustained Ground Rules Governing the Dying Process Doctors consult with different professionals and nonprofessionals about the dying process and about forgoing lifesupports. Most appear to follow varied personal, professional, and institutional ground rules when considering life and death choices. While it is unlikely that society will ever clearly define and apply uniform principles to the treatment of the terminally ill and permanently comatose, we can and should develop generally predictable and acceptable decision-making processes. These procedures should acknowledge patient rights, economic constraints, public policy complexities, existing statutes, judicial rulings, the responsibilities of health care professionals, and community mores. 22

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I I E I I I I I I I I I I I I I I E [ RECOMMENDATIONS No absolute wisdom exists concerning the care and treatment of the dying. For theological or empirically-based reasons many people feel strongly that any enlargement of current options for shortening the dying process would threaten values they hold dear. Critics view advance directives as a threat to society's interest in preserving life. Supporters feel equally strongly that patients deserve to make decisions not only about their own lives, but about their own deaths. To these individuals, patient autonomy is an overriding concern. Further, they claim that it is often more humane to facilitate dying than to permit or cause a lingering death, a process that may offer a person a minimal existence and impose emotional and financial burdens on loved ones. The debate over euthanasia has intensified as the use of costly life-extending technology has become more commonplace. What is society's obligation to keep permanently comatose and terminally ill patients alive against their wishes or the wishes of others close to them? By sanctioning any form of euthanasia are we proceeding down a slippery slope that endangers the balance between the rights of the individual and the community? Are we giving health care professionals enough or too much authority and responsibility over life and death decisions? Conversely, can we justify expensive life-saving care for terminally ill or permanently comatose patients? Can we develop 23

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I I I I I I I I I I I E I I I E E E I equitable policy equations that will enhance the quality of life and health care for Coloradans while respecting their values? These are difficult questions and issues with no easy answers. Given the results of the Center's survey, the following public and private sector initiatives should be forthcoming: 1. The Governor and the Legislature Should Create a Bi-partisan Representative Commission to Review the Study's Findings and its Implications. The commission should be composed of a cross-section of Colorado's public private sector and community leadership. It should include among its members clergy, lawyers, medical professionals, ethicists, economists, public policy scholars, decision-makers, and lay citizens. Great care should be taken to ensure that all divergent views are represented. The commission should examine Colorado law concerning advance directives, the forgoing of life-sustaining treatment and euthanasia in general. It should recommend amendments to current statutes that remove shortcomings, ambiguities, and inconsistencies. The Commission should go further: it should initiate a state-wide public dialogue exploring legal, ethical, and economic ground rules which might be developed to help patients and physicians face difficult choices about life-sustaining medical care. The 24

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I I I I I I I I I I I I I I I I I E I 2 3 commission should propose predictable, sensitive, and acceptable procedures for health care professionals to follow in making life and death decisions. Medical Schools, Law Schools, and Other Relevant Professional Schools Should Take the Lead in Training Students in Current Colorado Law Regarding Advance Directives and Euthanasia. Internship instruction and course work in state law, court decisions, and consent documents relevant to lifesustaining treatment deliberations should be mandatory in Colorado medical and professional schools. Knowledge of the law and recognizing the duty to counsel patients about critical treatment options should become part and parcel of professional responsibilities. Relevant Professional Organizations Should Offer Their Membership Continuous Refresher Courses Regarding Advance Directives, Euthanasia and Withholding and Withdrawing of Life-sustaining Treatment. Continuing education providers should allow ample opportunities for learning about legal directives that have a bearing upon life-support choices. Such instruction should be mandatory for those professionals involved with such decisions. 25

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I I I I I I I I I E I I I I I I I I I 4. State and County Health Departments Should Take the Initiative in Beginning Education Programs to Inform Colorado Citizens About Advance Directives and About the Legal and Ethical Ramifications of Withholding and Withdrawing Life-sustaining Treatment. A large number of citizens in the state are probably not aware of the Colorado living will and durable powers of attorney statutes. They are even less likely to know what decisions doctors and health care personnel can legally make about their treatment should they become terminally ill or lose decision-making capability. They also are unaware of the degree to which they themselves, or people chosen by them, can influence such decisions. The state has a responsibility to take the lead in ensuring that Colorado citizens are informed about the dying process and how it might affect them, their families, and their communities. * * We end this report as we began it. Through this study, we have introduced sensitive issues that are controversial and often hard to discuss in a public forum. Yet our survey indicates that critical issues related to death and dying must be openly considered. The strength of a civilized and democratic society is directly related to a public willingness to discuss the difficult and to a public capacity to secure consensus on the 26

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I I I I I I I I I I I E I I I E I E I important. The treatment and care of the dying are difficult subjects to contemplate, but we believe they must be placed on the public agenda. We hope we have done so. 27

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I I I I I I I I I I I I I I I t I l. 2 3 4 5. ENDNOTES Although we recognize absence of precise distinctions between the words "active" and "passive euthanasia," we use the term "euthanasia" generally to refer to medical practices that assist a patient to die more quickly than would be the case without such action. A copy of the questionnaire may be obtained from the Center for Health Ethics and Policy, Graduate School of Public Affairs, University of Colorado at Denver, 1200 Larimer Street, Campus Box 133, Denver, Colorado 80204. Colorado Department of Health, "Physicians in Colorado, 1983" (1985). For example, "Making Difficult Health Care Decisions", Vol. I -The National Study -A Survey Conducted for the Loran Commission. Louis Harris and Associates, Inc., June (1987). (Living Will), Colorado Medical Treatment Decision Act, C.R.S. S 15-18-101 et seq., (Durable Powers of Attorney) Powers of Attorney, C.R.S. S 15-14-501, et seq. 6. C.R.S. Sec. 15-18-104. 7. C.R.S. Sec. 15-18-110. 8. C.R.S. Sec. 15-18-113(5). 9. C.R.S. Sec. 15-18-103(7). 10. Due to inadequate sample size, the data were not crosstabulated according to medical specialty, with the exception of Primary Care Doctors. Nevertheless, it is interesting to note that pediatricians may be willing to discontinue antibiotic treatment more than food and fluids. Forty-three percent (43.2) of pediatricians responding to the survey reported that patients in a permanent coma or persistent vegetative state ought to be sustained by artificial feeding; fifteen percent (15.2) stated that pneumonia or sepsis should be treated. 28

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I I I I I I I I I I I I I I I I I I I APPENDIX A Respondent Physicians by Religious Affiliation Center for Health Ethics and Policy Survey (1988) Protestant Catholic Jewish Latter-Day Saint Moslem Other TOTAL * * 54.4% 17.6 13.4 0.9 0.1 13.6 100.0% Respondent Physicians by Year of Graduation Center for Health Ethics and Policy Survey (1988) 1930-39 1940-49 1950-59 1960-69 1970-79 1980-87 TOTAL 29 2.9% 8.3 16.2 22.0 31.3 19.3 100.0%

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I I I I I I I I I I I I I I I I I I I APPENDIX B Colorado Physicians by Specialty Comparison of Department of Health 1983 Survey and Center for Health Ethics and Policy Survey (as percentage of all respondents) Center for Health Ethics Colorado Department of and Policy Survey (1988) Health Survey (1983) Family Practice* 22.3% 18.1% Osteopathic Medicine 0.1 no data Anesthesiology 3.5 3.9 Internal Medicine 16.9 13.7 Ob/Gyn 6.4 6.2 Pediatrics 8.5 7. 3 Orthopedics 2.5 3.9 Ophthalmology 2.3 3.4 Cardiology 1.4 0.5 Urology 1.0 1.6 Radiology 2.8 4.2 otolaryngology 1.1 no data Neurology 1.8 1.1 Psychiatry 7.8 8. 3 Pathology 2.3 3.2 Gerontology 0.4 no data General Surgery 8.1 5.1 Oncology 1.1 no data Dermatology 1.0 1.5 Hematology 0.1 no data Retired 0.2 no data Occupational Medicine 0.9 0.7 Infectious Disease 0.1 no data Endocrinology 0.3 no data 30

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I I < I E E I I E E E Appendix B, continued Colorado Physicians by Specialty continued Center for Health Ethics and Policy Survey (1988) Colorado Department of Health Survey (1983) Neonatology 0.3 no data Preventive Medicine 0.6 0.2 Emergency Medicine 3.4 3.4 Pulmonary Medicine 1.4 7 No Specialty 1.2 no data Others** 13.0 TOTAL 100.0% 100.0% ** <35 35-44 45-54 55-64 Center for Health Ethics and Policy Survey Categories specialty designations between the two surveys were not always equivalent. In order to facilitate comparisons, some of the 1983 specialty categories were combined (e.g., radiology and diagnostic radiology), and paired with the 1988 survey categories. This percentage accounts for responses that did not correspond to specialty designation in the Center for Health Ethics and Policy Survey. * * Colorado Physicians by Age Comparison of Department of Health 1983 Survey and Center for Health Ethics and Policy Survey Center for Health Ethics and Policy Survey (1988) Colorado Department of Health Survey (1983) 19.5% 35.6 21.9 15.3 65TOTAL 17.2% 34.7 21.2 16.2 10.7 100.0% 7.7 100.0% 31

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I I I I I I I I I I I I I I I I I Appendix B, continued Adams Arapahoe Boulder Denver El Paso Jefferson Larimer Mesa Pueblo Other TOTAL Colorado Physicians by County of Residence Comparison of Department of Health 1983 Survey and Center for Health Ethics and Policy Survey Center for Health Ethics Colorado Department of and Policy Survey (1988) Health Survey (1983) 3.5% 4% 8.9 8 5.8 5 41.9 38 8.8 9 7.0 7 4.6 4 3.6 3 3.5 4 12.4 18 100.0% 100% 32

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I I I I I I I I I I I I I I E [ I APPENDIX C LIVING VILL DECLARATIONS FUTURE MEDICAL TREATMENT ARTICLE 18 Colorado Medical Treatment Decision Act law reYie,.s. For anicle. -The New Colorado Medical Treatment Decision Act-. SC'C'. I .a law. 1190 (1985). For anicle. -working With the New Medical Treatment Decis1un Will) Act ... see I :5 Colo. law. 64.5 ( 1986). 15. 15. 15-18-103. 15-18-104. 15-18-105. I S-18. I 5-107. Shon title. legislative declaration. Definitions. Declaration as to medical treatment. Inability of declarant to sign. Witnesses. Withdrawal withholding of liic-sust.1inmg procedures. 33 15-18-108. 15-18-109. 15-18-110. IS-18-111. IS-18-112. I 5-18-113. Determination Revocation ofdedaraun. Liability. 1 Determination of su,a.lc '' homicide effect of """1 .. .. tion on insurance:. Application ofaniclc. Penalties.

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I I I I I I I I I I I I I I I I I I I Appendix C, continued 433 Colorado Medical Treatment Decision Act 15-18-103 15-18-101. Short title. This article shall be known and may be cited as the "Colorado Medical Treatment Decision Act". Source: l. 85. p. 608. l. 15-18-102. ugislative declaration. (I) The general assembly hereby finds, determines. and declares that: (a) Colorado law has traditionally recognized the right of a competent adult to accept or reject medical or surgical treatment affecting his person; (b) Recent advances in medical science have made it possible to prolong dying through the use of anificial. extraordinary. extreme. or radical medical or surgical procedures; (c) The use of such medical or surgical procedures increasingly involves patients who are unconscious or otherwise incompetent to accept or reject medical or surgical treatment affecting their persons; (d) The traditional right to accept or reject medical or surgical treatment should be available to an adult while he is competent, notwithstanding the fact that such medical or surgical treatment may be offered or applied when he is suffering from a terminal condition and is either unconscious or other wise incompetent to decide whether such medical or surgical treatment should be accepted or rejected; (e) This anicle affirms the traditional right to accept or reject medical or surgical treatment affecting ones person. and creates a procedure by which a competent adult maymake such decisions in advance. before he becomes unconscious or otherwise incompetent to do so; (0 It is the legislative intent that nothing in this anicle shall have the effect of modifying or changing currently practiced medical ethics or protocol with respect to any patient in the absence of a declaration as provided for in section 15-18-104; (g) It is the legislative intent that nothing in this anicle shall require any person to execute a declaration. Source: l. 85, p. 608. 1. 15-18-103. Definitions. As used in this anicle, unless the context other wise requires: (I) ''Adult" means any person eighteen years of age or older. (2) "Attending physician" means the physician, whether selected by or assigned to a patient. who has primary responsibility for the treatment and care of said patient. (3) ''Coun" means the district coun of the county in which a declarant having a terminal condition is located at the time of commencement of a proceeding pursuant to this anicle or, in the city and county of Denver, the probate coun. (4) "Declarant" means a mentally competent adult who executes a decla ration. (5) "Declaration" means a written document voluntarily executed by a declarant in accordance with the requirements of section 15-18-104 34

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E I I I I I I I E I I 1-I I I I Appendix C, continued 15-18-104 Probate, Trusts, and Fiduciaries 434 (6) .. Hospital" means an institution holding a license or certificate of compliance as a hospital issued by the department of health of this state and includes hospitals operated by the federal government in Colorado. (7) ''Life-sustaining procedure" means any medical procedure or inter vention that. if administered to a qualified patient, would serve only to prolong the dying process. "Life-sustaining procedure" shall not include any medical procedure or intervention to nourish the qualified patient or consid ered necessary by the attending physician to provide comfort or alleviate pain. (8) ''Physician" means a person duly licensed under the provisions of article 36 of title 12. C.R.S. (9) .. Qualified patient" means a patient who has executed a declaration in accordance with this article and who has been certified by the attending physician and one other physician to be in a terminal condition. (10) "Terminal condition" means an inc{!rable or irreversible condition for which the administration of life-sustaining procedures will serve only to postpone the moment of death. Source: L. 85, p. 609, 1. 15-18-104. Declaration as to medical treatment. (I) Any competent adult may execute a declaration directing that life-sustaining procedures be with held or withdrawn if, at some future time, he is in a terminal condition and either unconscious or otherwise to decide whether any med ical procedure or intervention should be accepted or rejected. It shall be the responsibility of the declarant or someone acting for him to submit the declaration to the attending physician for entry in the declarant's medical record. (2) in the case of a declaration of a qualified patient known to the attend ing physician to be pregnant, a medical evaluation shall be made as to whether the fetus is viable and could with a reasonable degree of medical certainty develop to live birth with continued application of life-sustaining procedures. If such is the case, the declaration shall be given no force or effect. (3) A declaration executed before two witnesses by any competent adult shall be legally effective for the purposes of this article and "may, but need not be, in the following form: DECL\Ro\ TION AS TO :\IEDICAL OR Sl"RGICAL I, (name of declarant) being of sound mind and at least eighteen years of age, direct that my life shall not be artificially prolonged under the circum stances set forth below and hereby declare that: I. 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 responsible decisions concerning my person: then 35

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E I I I I I I I I E I I E [ Appendix C, continued 435 Colorado Medical Treatment Decision Act 15-18-105 I direct that life-sustaining procedures shall be withdrawn and withheld, it being understood that life-sustaining procedures shall not include any med ical procedure or intervention for nourishment or considered necessary by attending physician to provide comfort or alleviate pain. :!. I execute this declaration, as my free and voluntary act. this dayof 19_. --By ---=:--:,----Declarant The foregoing instrument was signed and declared by to be his declaration, in the presence of us, who: in h-.i-s -p-re_s_e_n-ce....... i-n-t...,h-e 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 instru ment. the declarant, according to our best knowledge and belief, was of sound mind and under no constraint or undue influence. Dated at Colorado, this __ day of 19 __ Name and Address Name and Address STATE OF COLORADO ) ) ss. 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 19 __ My commission expires: Notary Public Source: L. 85. p. 610, I. 15-18-105. Inability of declarant to sign. (l) In the event that the declarant is physically unable to sign the declaration, it may be signed by some other person in the declarant's presence and at his direction. Such other person shall be: (a) The attending physician or any other physician; or (b) An employee of the attending physician or health care facility in which the declarant is a patient: or (c) A person who has a claim against any portion of the estate of the declarant at his death at the time the declaration is signed; or (d) A person who knows or believes that he is entitled to any portion of the estate of the declarant upon his death either as a beneficiary of a will in existence at the time the declaration is signed or as an heir at law. Source: l. 85. p. 611, I. 36

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E I I I I I I I I I I I I I I I E I I Appendix C, continued 15-18-106 Probate, Trusts, and Fiduciaries 436 15-18-106. Witnesses. ( 1-) The declaration shall be signed by the declarant in the presence of two witnesses. Said witnesses shall not include any person specified in section 15-18-105. (2) If the declarant is a patient or resident of a health care facility, the witnesses shall not be patients of that facility. Source: L. 85. p. 611. 1. 15-18-107. \Vithdrawal-withholding of life-sustaining procedures. In the event that an attending physician is presented with an unrevoked declaration executed by a declarant whom the physician believes has a terminal condi tion, the attending physician shall cause the declarant to be examined by one other physician. If both physicians find that the declarant has a terminal condition, they shall certify such fact in writing and enter such in the quali fied patient's medical record of the hospital in which the withholding or withdrawal of life-sustaining procedures may occur, together with a copy of the declaration. If the attending physician has actual knowledge of the whereabouts of the qualified patient's spouse, any of his adult children, a parent. or attorney-in-fact under a durable power of attorney, the attending physician shall immediately make a reasonable effort to notify at least one of said persons, in the order named, that a certificate of terminal condition has been signed. If no action to challenge the validity of a declaration has been filed within forty-eight consecutive hours after the certification is made by the physicians, the attending physician shall then withdraw or withhold all life sustaining procedures pursuant to the terms of the declaration. Source: L. 85, p. 611, 1. 15-18-108. Determination of validity. (1) Any person who is the parent. adult child, spouse, or 'attorney-in-fact under a durable power of attorney of the qualified patient may challenge the validity of a declaration in the appropriate court of the county in which the qualified patient is located. Upon the filing of a petition to challenge the validity of a declaration and notification to the attending physician, a temporary restraining order shall be issued until a final determination as to validity is made. (2) (a) In proceedings pursuant to this section, the court shall appoint a guardian ad litem for the qualified patient, and the guardian ad litem shall take action as he deems necessary and prudent in the best interest of the qualified patient and shall present to the court a report of his actions. findings, conclusions, and recommendations. (b) (I) Unless the court for good cause shown provides for a different method or time of notice, the petitioner, at least five days prior to the hear ing, shall cause notice of the time and place of hearing to be given as follows: (A) To the qualified patient's guardian or conservator, if any, and the court-appointed guardian ad litem; and (B) -To the qualified patient's if the identity and whereabouts of the spouse are known, to the petitioner, or otherwise to an adult child or parent of the qualified patient. (II) Notice as required in this paragraph (b) shall be made in accordance with the Colorado rules of civil procedure. 37

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E E I I E E I I I I I I I I I I Appendix C, continued 437 Colorado Medical Treatment Decision Act 15-18-112 (c) The court may require such evidence, including independent medical evidence. as it deems necessary. (3) Upon a determination pf the validity of the declaration, the court shall enter any appropriate order. Source: l. 85. p. 612, 1. 15-18-109. Revocation of declaration. A declaration may be revoked by the declarant orally. in writing, or by burning, tearing, cancelling, obliterating. or destroying said declaration. Source: L. 85. p. 612, 1. 15-18-110. Liability. (I) With respect to any declaration which appears on its face to have been executed in accordance with the requirements of this article: (a) Any physician may act in compliance with such declaration in the absence of actual notice of revocation, fraud, misrepresentation. or improper execution; (b) No physician signing a certificate of terminal condition or withhold ing or withdrawing life-sustaining procedures in compliance with a declara tion shall be subject to civil liability, criminal penalty, or licensing sanctions therefor. (c) No hospital or person acting under the direction of a physician and participating in the withholding or withdrawal of life-sustaining procedures in compliance with a declaration shall be subject to civil liability, criminal penalty, or licensing sanctions therefor. Source: l. 85, p. 612, 1. Cross rtfertncts: For other circumstances under which physicians are not subject to civil or criminalliabi1ity. see 13-.21-108. 13-22-106. and 42-4-120.2 (J)(b). 15-18-111. Determination of suicide or homicideeffect of declaration on insurance. The withholding or withdrawal of life-sustaining procedures from a qualified patient pursuant to this article shall not, for any purpose, consti tute a suicide or a homicide. The existence of a declaration shall not affect, impair, or modify any contract of life insurance or annuity or be the basis for any delay in issuing or refusing to issue an annuity or policy of life insur ance or any increase of the premium therefor. No insurer or provider of health care shall require any person to execute a declaration as a condition of being insured for or receiving health care services; nor shall the failure to execute a declaration be the basis for any increased or additional premium for a contract or policy for medical or health insurance. Source: l. 85, p. 613, 1. 15-18-112. Application of article. (1) Nothing in this article shall be con strued as altering or amending the standards of the practice of medicine 38

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E I E I I E I I I I I I I I I I [ I Appendix C, continued 15-18-113 Probate, Trusts, and Fiduciaries 438 or establishing any presumption. absent a valid declaration, nor as condon ing, authorizing, or approving euthanasia or mercy killing, nor as permitting any affirmative or deliberate act or omission to end life, except to permit natural death as provided in this anicle. (2) In the event of any conflict between the provisions of this anicle. or a declaration executed under this anicle, and the provisions of section 15-14-501, the provisions of this anicle and the declaration shall prevail. Source: L. 85, p. 613, 1. 15-18-113. Penalties. (I) Any person who willfully conceals, defaces. damages, or destroys a declaration of another, without the knowledge and consent of the declarant, commits a class 1 misdemeanor and shall be pun ished as provided in section 18-1-106, C.R.S. (2) Any person who falsifies or forges a declaration. of another commits a class 4 felony and shall be punished as provided in section 18-1-105, C.R.S. (3) Any person who falsifies or forges a declaration of another, and the terms of the declaration are carried out, resulting in the death of the pur poned declarant, commits a class 2 felony and shall be punished as provided in section 18-1-105, C.R.S. (4) Any person who willfully-withholds information concerning the revo cation of the declaration of another commits a class I misdemeanor and shall be punished as provided in section 18-1-1 06, C. R.S. (5) An attending physician who refuses to comply with the terms of a declaration valid on its face shall transfer the care of the declarant to another physician who is willing to comply with the declaration. Refusal of an attend ing physician to comply with a declaration and failure to transfer the care of the declarant to another physician shall constitute unprofessional conduct as defined in section 12-36-117, C.R.S. Source: L 85, p. 613, 1. 39

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I I I I I I I I I I I I E I APPENDIX D DURABLE POVERS OF ATTORNEY POWERS OF ATTORNEY 15-14-501. When power or attorney not affected by disability. (I) When ever a principal designates another his attorney-in-fact or agent by a power of attorney in writing and the writing contains the words .. This power of attorney shall not be affected by disability of the principal:' or '"This power of attorney shall become effective upon the disability of the principal. .. or similar words showing the intent of the principal that the authority conferred shall be exercisable notwithstanding his disability. the authority of the attor ney-in-fact or agent is exercisable by him as provided in the power on behalf of the principal notwithstanding later disability or incapacity of" the principal at law or later uncertainty as to whether the principal is dead or alive. The authority of the attorney-in-fact or agent to act on behalf of the principal shall be set forth in the power and may relate to any act, power, duty, right. or obligation which the principal has or after acquires relating to the principal or any matter. transaction, or property. real or personal. tangible or intan gible. including by way of illustration but not limitation, the power to consent to or approve on behalf of the principal any medical or other professional care, counsel. treatment, or service of or to the principal by a licensed or professional person or institution engaged in the practice of. or pro viding, a healing an. The attorney-in-fact or agent, however. is subject to the same limitations imposed upon court-appointed guardians contained in section 15-14-312 (I) (a). All acts done by the attorney-in-fact or agent pur suant to the power during any period of disability or incompetence or uncer tainty as to whether the principal is dead or alive have the same effect and inure to the benefit of and bind the principal or his heirs, devisees. and personal representative as if the principal were alive. competent, and not disabled. If a guardian or conservator thereafter is appointed for the prin cipal. the attorney-in-fact or agent, during the continuance of the appoint ment, shall consult with the guardian on matters concerning the principal's personal care or account to the conservator on matters concerning the principars financial affairs. The conservator has the same power the prin cipal would have had if he were not disabled or incompetent to revoke. sus pend. or terminate all or any pan of the power of attorney or agency as it relates to financial matters. Subject to any limitation or restriction of the guardian's powers or duties set forth in the order of appointment and endorsed on the letters of guardianship. a guardian has the same power to re .. oke. suspend. or terminate all or any part of the power of attorney or agency as it relates to matters concerning the principal's personal care that the principal would have had if the principal were not disabled or incompe tent. (2) An affidavit. executed by the attorney-in-fact or agent, stating that he did not ha,e. at the time of doing an act pursuant to the power of attorney. actual knowlc:dge of the termination of the po,..-er of attorney by death IS. in the absence of fraud, conclusive proof of the non termination of the power at that time. If the exercise of the power requires execution and delivery of any instrument which is recordable. the affidavit when authenticated for record is likewise recordable. Source: R & RE, L. 73. p. 1633, I: C.R.S. 1963. 153-5-501; L. 77. P 836. 25: l. 83, p. 661, I. La For anick. -Estate Planning for Young laW)ers". see I-' Colo. la-.... SJ (1985). For arttcle. "The of Durable Powers of Attorney-. sec I.S Colo. law. S.SS I 198Sl. 40

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[ E E I I I I I I I I I I -E .. E I 0 I Appendix D, continued 15-14-502. Other powers of attorney not revoked until notice of death or disability. (f) The death, disability, or incompetence of any principal who has executed a power of auonaey in writing, other than a power as described by section 15-14-501, does not revoke or terminate the agency as to the attor ney-in-fact, agent, or other person who, without actual knowledge of the death, disability, or incompetence of the principal, acts in good faith under the power of attorney or agency. Any action so taken. unless otherwise invalid or unenforceable. binds the principal and his heirs, de-.isees, and personal representatives. (2) An affidavit, executed by the attorney-in-fact or agent, stating that he did not have, at the time of doing an act pursuant to the power of attorney, actual knowledge of the revocation or termination of the power of attorney by death, disability, or incompetence is, in the absence of fraud, conclusive proof of the nonrevocation or nontermination of the power at that time. If the exercise of the power requires execution and delivery of any instrument which is recordable, the affidavit when authenticated for record is likewise recordable. (3) This section shall not be construed to alter or affect any provision for revocation or termination contained in the power of attorney. (4) All powers of attorney executed for real estate and other purposes, pursuant to law, shall be deemed valid until revoked as provided in the terms ofthe power of attorney or as provided by law. Source: R & RE, L. 73, p. 1634, 1; C.R.S. 1963, 153-5-502; L 75, p. 603, 52; L 85, p. 566, 13. 41