Publications

If the time comes when I am incapacitated to the point when I can 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, ____________________________(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 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 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 is an irreversible condition in which I am at no time aware of myself or the environment and show no behavioral response to the environment.

Listed below are my instructions regarding particular types of life support systems. This list is not all-inclusive. My general statement that I not be kept alive through life support system provided to me is limited only where I have indicated that I desire a particular treatment to be provided.

Provide Withhold

Cardiopulmonary Resuscitation ________ ________

Artificial Respiration (including a respirator) ________ _________

Artificial means of providing nutrition and hydration ________ ________

_________________________________________________ ________ ________

_________________________________________________ ________ ________

Other specific requests: ________________________________________________

__________________________________________________________________

I do not intend any direct taking of my life, but only that my dying not be unreasonably prolonged.

This request is made, after careful reflection, while I am of sound mind.

Signature _____________________________ Date__________________________

This document was signed in our presence, by the above-named __________________ (NAME)
who appeared to be eighteen years of age 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 ___________________________________

Address ___________________________________________________________

Witness ___________________________________

Address ___________________________________________________________

(NOTE: THIS FORM IS OPTIONAL)

STATE OF CONNECTICUT )

: ss. (Town)

COUNTY OF ___________ )

We, the undersigned, being duly sworn, depose and say:

That on this date, the within named __________________________, signed the foregoing living will in our presence as witnesses; that we thereupon subscribed our names thereto as witnesses in (his/her) presence and at (his/her) request, and in the presence of each other; that at the time of the execution of said living will the said ________________________ appeared to be more than eighteen years of age and of sound mind and memory, and to the best of our judgment not under any improper restraint or influence or in any respect incompetent to make a living will; and that we make this affidavit at (his/her) request this _____ day of __________ 200__.

______________________________________

______________________________________

Subscribed and sworn to before me, on this _____ day _________ of 200__.

__________________________________

Notary Public

Commissioner of the Superior Court