Connecticut Living Will Template
This Living Will is designed in accordance with the Connecticut Public Health Code, specifically the Connecticut Living Will and Health Care Instructions Act. It allows you to direct the kind of medical care you wish to receive when you are no longer able to make decisions for yourself.
Personal Information
Name: _________________
Address: _______________________
Date of Birth: _______________
Social Security Number: ____________
Appointment of Health Care Agent
I, _______________ (your full name), appoint the following person as my Health Care Agent to make health care decisions for me if I am unable to communicate my wishes.
Agent's Name: _______________________
Relationship to me: ___________________
Contact Number: ______________________
Alternate Contact Number: ______________
General Instructions for Health Care
I direct that my Health Care Agent make decisions that are consistent with my wishes as stated in this document. If my wishes are unknown, I direct my agent to make decisions in my best interests, considering the benefits, burdens, and risks of my current health condition and treatment options.
Specific Instructions
My desires regarding life-sustaining treatment, including artificially administered nutrition and hydration, are as follows:
- If I am in a coma or persistent vegetative state from which I am not expected to recover, I do/do not (circle one) want my life to be prolonged by life-sustaining treatment, excluding pain relief.
- If I am terminally ill, I do/do not (circle one) want treatments to extend my life. This includes, but is not limited to, mechanical ventilation, surgery, dialysis, chemotherapy, and antibiotics.
Organ Donation
I do/do not (circle one) wish to donate my organs, tissues, or parts upon my death, for the purpose of transplantation, therapy, research, or education. Specific instructions regarding organ donation, if any:
______________________________________________________________________
Signature
This Living Will is effective immediately and will remain in effect until I revoke it. I understand the full import of this document.
Signed: ________________
Date: ________________
Witnesses
I declare that the person who signed this document is personally known to me and appears to be of sound mind and under no duress, fraud, or undue influence. I am not the appointed Health Care Agent or alternate agent, nor am I a health care provider or an employee of a health care provider who is treating the declarant.
Name: _______________________
Signature: ___________________
Date: _________________
Address: _____________________
Name: _______________________
Signature: ___________________
Date: _________________
Address: _____________________