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Connecticut ____________ Address: ______________________________________ 2 e) Print Name: ___________________________________ Address: ______________________________________ _____________________________________________ (Witness Signature) Print Name: _______________________or older, of sound mind and able to understand the nature and consequences of health care decisions at the time the document was signed. _____________________________________________ (Witness Signatur(Signature) (Date) _________________________________________ 1 This document was signed in our presence, by the above-named _________________________ (Name) who appeared to be eighteen years of age _ ____________________________________________________________________________ This request is made, after careful reflection, while I am of sound mind. ______________________________________________ _______________________________________________ ____________________________________________________________________________ ___________________________________________________________________________g of my life, but only that my dying not be unreasonably prolonged." Other specific requests: ____________________________________________________________________________ _____________________________ initial life support systems you want administered): · · · Artificial respiration Cardiopulmonary resuscitation Artificial means of providing nutrition and hydration I do not intend any direct takinwhich 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 are not limited to (Cross out andtending 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 is an irreversible condition in 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, will, in the opinion of my at______________________________ (Name), request that, if my condition is deemed terminal or if it is determined that I will be permanently unconscious, I be allowed to die and not be kept alive through no longer actively take part in decisions for my own life, and am unable to direct my physician as to my own medical care, I wish this statement to stand as a testament of my wishes. I, _____________to the Disclaimers and Terms of Use found at findlegalforms.com Document Concerning Withholding Or Withdrawal Of Life Support Systems If the time comes when I am incapacitated to the point when I cand when dealing with estate planning matters. Any possible tax consequences arising out of this document should be discussed with a tax professional. [_] The purchase and use of these forms is subject only be a starting point for you and should not be used or signed without consulting an attorney first to make sure it fits your particular situation. Advice from a local attorney is always recommendeas to 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 the following 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 ections as to specific life support systems which such person chooses to have administered. Such document shall be signed and dated by the maker with at least two witnesses and may be in substantiallyt and who has primary responsibility for the treatment and care of the patient. Sec. 19a-575. Form of document. Any person eighteen years of age or older may execute a document which shall contain dirdult brother or sister of the patient; and (E) a grandparent of the patient; Information & Instructions ­ Page 2 (9) "Attending physician" means the physician selected by, or assigned to, the patien any member of the following classes of persons, in the order of priority listed: (A) The spouse of the patient; (B) an adult son or daughter of the patient; (C) either parent of the patient; (D) an at in compliance with section 19a-575a containing a declarant's wishes concerning any aspect of his health care, including the withholding or withdrawal of life support systems; (8) "Next of kin" meanshealth care decisions, including the benefits and disadvantages of such treatment, and to reach and communicate an informed decision regarding the treatment; (7) "Living will" means a written statemenh care decisions is delegated in a written document by another adult person, known as the principal; (6) "Incapacitated" means being unable to understand and appreciate the nature and consequences of ch the individual is at no time aware of himself or the environment and shows no behavioral response to the environment; (5) "Health care agent" means an adult person to whom authority to convey healthin a relatively short time, in the opinion of the attending physician; (4) "Permanently unconscious" includes permanent coma and persistent vegetative state and means an irreversible condition in whiy to sustain life; (3) "Terminal condition" means the final stage of an incurable or irreversible medical condition which, without the administration of a life support system, will result in death witding nutrition or hydration; (2) "Beneficial medical treatment" includes the use of medically appropriate treatment including surgery, treatment, medication and the utilization of artificial technolog individual in a state of permanent unconsciousness. In these circumstances, such procedures shall include, but are not limited to, mechanical or electronic devices including artificial means of provi571 to 19a-580c, inclusive: (1) "Life support system" means any medical procedure or intervention which, when applied to an individual, would serve only to postpone the moment of death or maintain theticut Statutes. For your convenience, we have included useful excerpts from the Connecticut Statutes relating to Living Wills. Sec. 19a-570. Definitions. For purposes of this section and sections 19a- Will); (2) Connecticut Document Concerning Withholding Or Withdrawal Of Life Support Systems (Living Will). This Connecticut Living Will is based on Chapter 368 Section 19a-575 et. Seq. of the ConnecInformation and Instructions Connecticut Living Will This package contains (1) Information and Instruction for Connecticut Document Concerning Withholding Or Withdrawal Of Life Support Systems (Living Connecticut