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Connecticut _____________________________________ __________________________ Address: ______________________________________ _____________________________________________ (Witness Signature) Print Name: ___________________________________ Address: _nd able to understand the nature and consequences of health care decisions at the time the document was signed. _____________________________________________ (Witness Signature) Print Name: _________________________________________________ This document was signed in our presence, by _______________________________________ (Name) who appeared to be eighteen years of age or older, of sound mind a______ (Name) to be my alternative health care agent. This request is made, after careful reflection, while I am of sound mind. ______________________________________________ (Signature) (Date) ______whatever actions are necessary to ensure that my wishes are given effect. If this person is unwilling or unable to serve as my health care agent, I appoint ____________________________________________mmunicate an informed decision regarding treatment, my health care agent is authorized to: (1) Convey to my physician my wishes concerning the withholding or removal of life support systems. (2) Take _________ (Name) to be my health care agent. If my attending physician determines that I am unable to understand and appreciate the nature and consequences of health care decisions and to reach and cohese forms is subject to the Disclaimers and Terms of Use found at findlegalforms.com -3- Document Concerning The Appointment Of Health Care Agent I appoint _________________________________________ an attorney whenever a document is negotiated with another party. Any possible tax consequences arising out of this document should be discussed with a tax professional. [_] The purchase and use of tt 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 particular situation. You should also consulthese 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 only be a starting point for you and should no 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 to their legal effect or completeness. [_]Tre appointment of health care agent. (a) Any person eighteen years of age or older may execute a document that may, but need not be in substantially the following form: (Form included below) -2- [_]oyee is related to the principal by blood, marriage or adoption. (e) A physician shall not act as both agent for a principal and attending physician for the principal. Sec. 19a-577. Form of document gency which is financially responsible for a person's medical care may not be appointed as a health care agent for such person. This restriction shall not apply if such operator, administrator or emplgent by any person who, at the time of the appointment, is a patient or a resident of, or has applied for admission to, one of the forego ing facilities. An administrator or employee of a government a. (d) An operator, administrator, or employee of a hospital, residential care home, rest home with nursing supervision, or chronic and convalescent nursing home may not be appointed as a health care ane witness shall be an individual who is not affiliated with the facility and at least one witness shall be a physician or clinical psychologist with specialized training in developmental disabilitiesysician or clinical psychologist with specialized training in treating mental illness. (c) For persons who reside in facilities operated or licensed by the Department of Mental Retardation, at least oerated or licensed by the Department of Mental Health and Addiction Services, at least one witness shall be an individual who is not affiliated with the facility and at least one witness shall be a ph witnesses who shall also sign the document. The person appointed as agent shall not act as witness to the execution of such document or sign such document. (b) For persons who reside in facilities ophteen years of age or older may appoint a health care agent by executing a document in accordance with section 19a-575a or section 19a-577, signed and dated by such person in the presence of two adultthe physician selected by, or assigned to, the patient and who has primary responsibility for the treatment and care of the patient. Sec. 19a-576. Appointment of health care agent. (a) Any person eignt; (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; (9) "Attending physician" means luding the withholding or withdrawal of life support systems; -1- (8) "Next of kin" means any member of the following classes of persons, in the order of priority listed: (A) The spouse of the patieinformed 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 care, incated" 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 communicate an ment; (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) "Incapacitanent 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 the environ 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" includes perm 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 condition 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 treatmented 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 include, but areCare Form. 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, when appli is based on Chapter 368 Section 19a-570 et. Seq. of the Connecticut Statutes. The following are useful excerpts from the Connecticut Statutes relating to the Connecticut Power of Attorney for Health t (Power of Attorney for Health Care) ; (2) Connecticut Document Concerning The Appointment Of Health Care Agent (Power of Attorney for Health Care). This Connecticut Power of Attorney for Health CareInformation and Instructions Connecticut Power of Attorney for Health Care This package contains (1) Information and Instruction for Connecticut Document Concerning The Appointment Of Health Care Agen Connecticut