Form For Advance Directives

August 7, 2000 Published Work

ADVANCE DIRECTIVES OF ____________________

To Any Physician Who Is Treating Me, this document contains the following:

1. My Living Will or Health Care Instructions
2. My Appointment Of A Health Care Agent
3. My Appointment Of An Attorney-in-Fact For Health Care Decisions
4. The Designation Of My Conservator Of The Person For My Future Incapacity
5. My Document Of Anatomical Gift

As my physician, you may rely on any information provided by my health care agent and decisions made by my attorney-in-fact for health care decisions or conservator of my person, if I am unable to make a decision for myself.

LIVING WILL or HEALTH CARE INSTRUCTIONS

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, ______________________, 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 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.

Specific Instructions

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 systems 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 want sufficient pain medication to maintain my physical comfort. I do not intend any direct taking of my life, but only that my dying not be unreasonably prolonged.

APPOINTMENT OF HEALTH CARE AGENT AND ATTORNEY-IN-FACT FOR HEALTH CARE DECISIONS

I appoint ______________________________to be my health care agent and 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 to reach and communicate an informed decision regarding treatment, ____________________________ is authorized:

As My Health Care Agent to:

(1)Convey to my physician my wishes concerning the withholding or removal of life support systems;

(2) Take whatever actions are necessary to ensure that any wishes are given effect;

As my Attorney-ln-Fact to:

(1) Act in my name, place and stead in any way which I myself could do, if I were personally present, with respect to health care decisions as defined in the Connecticut Statutory Short Form Power of Attorney Act to the extent that I am permitted by law to act through an agent;

(2) Consent, refuse or withdraw consent to any medical treatment other than that designed solely for the purpose of maintaining physical comfort, withdrawal of life support systems, or withdrawal of nutrition or hydration.

If ___________________________ is unwilling or unable to serve as my health care agent and my attorney-in-fact for health care decisions, I appoint ____________________________ to be my alternative health care agent and my attorney-in-fact for health care decisions.

DOCUMENT OF ANATOMICAL GIFT

I make no anatomical gift at this time. ________ (Initial here). I hereby make this anatomical gift, if medically acceptable, to take effect upon my death. ________ (Initial here).

I give: (check one)

__________ (1) any needed organs or parts

__________ (2) only the following organs or parts

________________________________________________________

________________________________________________________

to be donated for: (check one)

__________ (1) any of the purposes stated in subsection (a) of section 19a-279f of the general statutes

__________ (2) these limited purposes ______________________________________.

DESIGNATION OF A CONSERVATOR OF THE PERSON

If a conservator of my person should need to be appointed, I designate ___________________________ be appointed my conservator. If _________________________ is unwilling or unable to serve as my conservator, I designate ________________________________. No bond shall be required of either of them in any jurisdiction.

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 this document may rely upon it unless such party has received actual notice of my revocation of it.

Date _____________,200__ x_______________________________________________L.S.

STATE OF CONNECTICUT )

: ss. ___________________________________________

COUNTY OF ____________ )

Personally appeared ______________________________, signer of the foregoing instrument, and acknowledged the same to be his/her free act and deed, before me, this ______ day of __________, 200___.




______________________________________________
Commissioner of the Superior Court
Notary Public
My Commission expires:_______________

WITNESSES' STATEMENTS

This document was signed in our presence by ___________________________ the author of this document, 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 this document was signed. The author appeared to be under no improper influence. We have subscribed this document in the author's presence and at the author's request and in the presence of each other.

x______________________________ x________________________________
(Witness) (Witness)

_______________________________ _________________________________
(Number and Street) (Number and Street)

_______________________________ _________________________________
(City, State and Zip Code) (City, State and Zip Code)

(NOTE: This Form is Optional)

WITNESSES' AFFIDAVITS

STATE OF CONNECTICUT )
: ss. ________________________________
COUNTY OF ___________ )

We, the subscribing witnesses, being duly sworn, say that we witnessed the execution of these health care instructions, 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 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 author'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 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 __________ 200__.

x__________________________________ x_________________________________
(Witness) (Witness)

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




__________________________________
Commissioner of the Superior Court
Notary Public
My Commission expires:______________

(Print or type name of all persons signing under all signatures).