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Connecticut Commissioner of the Superior Court Notary Public My commission expires: _____________________________ (Print or type name of all persons signing under all signatures). -3- _____ _________________________________ (Witness Signature) _________________________________ (Witness Signature) Subscribed and sworn to before me this _____________ day of ______________ 20______ mind, able to understand the nature and consequences of said document, and under no improper influence, and we make this affidavit at the author's request this _____________ day of ______________ 20_thor's presence, at the author's request, and in the presence of each other; that at the time of the execution of said document the author appeared to us to be eighteen years of age or older, of sound the author subscribed, published and declared the same to be the author's instructions, appointments and designation in our presence; that we thereafter subscribed the document as witnesses in the auuctions, the appointments of a health care agent and an attorney- in-fact, the designation of a conservator for future incapacity and a document of anatomical gift by the author of this document; that________________ STATE OF CONNECTICUT ) ) COUNTY OF _______________________ ) ss .... We, the subscribing witnesses, being duly sworn, say that we witnessed the execution of these health care instr_____ Address: ______________________________________ _____________________________________________ (Witness Signature) Print Name: ___________________________________ Address: ______________________nt in the author's presence and at the author's request and in the presence of each other. _____________________________________________ (Witness Signature) Print Name: ______________________________ able to understand the nature and consequences of health care decisions at the time the document was signed. The author appeared to be under no improper influence. We have -2- subscribed this docume_________ This document was signed in our presence, by _______________________________________ (Name), the author of this document, who appeared to be eighteen years of age or older, of sound mind and document may rely upon it unless such party has received actual notice of my revocation of it. ______________________________________________ (Signature) (Date) ___________________________________________________________________ These requests, appointments, and designations are made after careful reflection, while I am of sound mind. Any party receiving a duly executed copy or facsimile of thisa) of section 19a-279f of the general statutes ______ (2) .... these limited purposes ________________________________ _______________________________________________________ _______________________________________________________________________________ _______________________________________________________ to be donated for: (check one) ______ (1) .... any of the purposes stated in subsection (tomical gift, if medically acceptable, to take effect upon my death. I give: (check one) ______ (1) any needed organs or parts ______ (2) only the following organs or parts _________________________ _g or unable to serve as my conservator, I designate ____________________________________________________________ No bond shall be required of either of them in any jurisdiction. I hereby make this ana need to be appointed, I designate ____________________________________________________________ be appointed my conservator. If ____________________________________________________________ is unwillin, I appoint ____________________________________________________________ to be my alternative health care agent and my attorney- in-fact for health care decisions. If a conservator of my person shouldmaintaining physical comfort. If ____________________________________________________________is unwilling or unable to serve as my health care agent and my attorney- in- fact for health care decisionsnt as long as such action is consistent with my wishes concerning the withholding or removal of life support systems; and -1- (4) Consent to any medical treatment designed solely for the purpose of g the withholding or removal of life support systems; (2) Take whatever actions are necessary to ensure that any wishes are given effect; (3) Consent, refuse or withdraw consent to any medical treatmeo reach and communicate an informed decision regarding treatment, my health care agent and attorney- in- fact for health care decisions is authorized to: (1) Convey to my physician my wishes concerninnd my attorney- in- fact for health care decisions. If my attending physician determines that I am unable to understand and appreciate the nature and consequences of health care decisions and unable t I do not intend any direct taking of my life, but only that my dying not be unreasonably prolonged. I appoint ____________________________________________________________ to be my health care agent ae not limited to: Artificial respiration, cardiopulmonary resuscitation and artificial means of providing nutrition and hydration. I do want sufficient pain medication to maintain my physical comfort.s an irreversible condition in which I am at no time aware of myself or the environment and show no behavioral response to the environment. The life support systems which I do not want include, but ar, will, in the opinion of my attending physician, result in death within a relatively short time. By permanently unconscious I mean that I am in a permanent coma or persistent vegetative state which ie and not be kept alive through life support systems. By terminal condition, I mean that I have an incurable or irreversible medical condition which, without the administration of life support systems_________________________________________________, the author of this document, request that, if my condition is deemed terminal or if I am determined to be permanently unconscious, I be allowed to diician, you may rely on any decision made by my health care agent, attorney- in- fact for health care decisions or conservator of my person, if I am unable to make a decision for myself. I, ___________ntment of my health care agent and my attorney- in- fact for health care decisions, the designation of my conservator of the person for future incapacity and my document of anatomical gift. As my phys OF ANATOMICAL GIFT To any physician who is treating me: These are my health care instructions including those concerning the withholding or withdrawal of life support systems, together with the appoiCTIONS. MY APPOINTMENT OF A HEALTH CARE AGENT, MY APPOINTMENT OF AN ATTORNEY-IN-FACT FOR HEALTH CARE DECISIONS, THE DESIGNATION OF MY CONSERVATOR OF THE PERSON FOR MY FUTURE INCAPACITY AND MY DOCUMENTprofessional. [_] The purchase and use of these forms is subject to the Disclaimers and Terms of Use found at findlegalforms.com -2- Power of Attorney for Health Care THESE ARE MY HEALTH CARE INSTRUticular situation. You should also consult an attorney whenever a document is negotia ted with another party. Any possible tax consequences arising out of this document should be discussed with a tax be a starting point for you and should not be used without consulting with an attorney first. Before using or signing this document you should have an attorney review it to make sure it fits your paro their legal effect or completeness. [_]These forms are not intended and are not a substitute for legal and/or tax advice. Laws vary from time to time and from state to state. These forms should onlyfollowing form: (Form included below) [_] These forms are provided "as is" and no implied or express warranties have been made or are provided as to their suitability for any specific purpose or as tconservator of the person for future incapacity and a document of anatomical gift. Any such document shall be signed and dated by the maker with at least two witnesses and may be in the substantially r older may execute a document which contains health care instructions, the appointment of a health care agent, the appointment of an attorney-in- fact for health care decisions, the designation of a ns, appointment of health care agent, attorney-in-fact for health care decisions, designation of conservator of the person for future incapacity and anatomical gift. Any person eighteen years of age on" means the physician selected by, or assigned to, the patient and who has primary responsibility for the treatment and care of the patient. Sec. 19a-575a. Form of document re health care instructiotient; (B) an adult son or daughter of the patient; (C) either parent of the patient; (D) an adult brother or sister of the patient; and (E) a grandparent of the patient; -1- (9) "Attending physiciacare, including the withholding or withdrawal of life support systems; (8) "Next of kin" means any member of the following classes of persons, in the order of priority listed: (A) The spouse of the paicate an informed decision regarding the treatment; (7) "Living will" means a written statement in compliance with section 19a-575a containing a declarant's wishes concerning any aspect of his health Incapacitated" means being unable to understand and appreciate the nature and consequences of health care decisions, including the benefits and disadvantages of such treatment, and to reach and commune environment; (5) "Health care agent" means an adult person to whom authority to convey health care decisions is delegated in a written document by another adult person, known as the principal; (6) "udes permanent coma and persistent vegetative state and means an irreversible condition in which the individual is at no time aware of himself or the environment and shows no behavioral response to thcondition which, without the administration of a life support system, will result in death within a relatively short time, in the opinion of the attending physician; (4) "Permanently unconscious" incltreatment including surgery, treatment, medication and the utilization of artificial technology to sustain life; (3) "Terminal condition" means the final stage of an incurable or irreversible medical , but are not limited to, mechanical or electronic devices including artificial means of providing nutrition or hydration; (2) "Beneficial medical treatment" includes the use of medically appropriate hen applied to an individual, would serve only to postpone the moment of death or maintain the individual in a state of permanent unconsciousness. In these circumstances, such procedures shall includeonnecticut Statutes. Sec. 19a-570. Definitions. For purposes of this section and sections 19a-571 to 19a-580c, inclusive: (1) "Life support system" means any medical procedure or intervention which, wlth Care Directive Form. This Connecticut Advance Health Care Directive is based Chapter 368 Section 19a-570 et. Seq. of the Connecticut Statutes. The following are useful excerpts from the relevant CInformation and Instructions Connecticut Advance Health Care Directive This package contains (1) Information and Instructions for Connecticut Advance Health Care Directive; (2) Connecticut Advance Hea Connecticut