Connecticut Living Will
This Living Will is designed to comply with the Connecticut Public Act No. 91-283, section 19a-575 of the Connecticut General Statutes. It allows you, the declarant, to make known your wishes regarding life-sustaining treatment and other specific medical care if you are unable to communicate these decisions yourself.
Please provide the following information:
Declarant's Information
- Full Name: __________________________________________________
- Address: ____________________________________________________
- City, State, ZIP: ____________________________________________
- Date of Birth: _______________________________________________
Living Will Declarations
I, _________________________[your name], being of sound mind, willfully, and voluntarily make known my desire that my dying should not be artificially prolonged under the circumstances set forth below. I declare that:
- If I am in a terminal condition, I do not want my life to be prolonged by life-sustaining treatment. I wish to die naturally and only receive treatment if it eases my pain and suffering.
- In the event I am found to be in a persistent vegetative state or permanently unconscious, I direct that life-sustaining treatment be withheld or withdrawn.
- I recognize the rights of my family and physician to consider my comfort and relief from pain as high priorities in my care.
- I give permission for my primary physician to consult with my family about my care in situations where I am unable to communicate my desires directly. It is my intention that my family's understanding of my wishes should guide the implementation of this document.
- This Living Will is subject to revocation at any time by me, without regard to my mental state or ability to communicate. Any revocation shall be in writing or by destroying this document.
Signatures
This Living Will shall be valid upon the signature of the declarant and the required witnesses.
__________________________
[Declarant's Signature]
Date: _____________________
Witness #1 Signature: __________________________
Print Name: ____________________________________
Address: ________________________________________
Date: ___________________________________________
Witness #2 Signature: __________________________
Print Name: ____________________________________
Address: ________________________________________
Date: ___________________________________________
Note: The witnesses to this Living Will should not be related to the declarant by blood or marriage, should not be entitled to any portion of the declarant’s estate, should not be responsible for the declarant’s medical expenses, and should not be directly involved in providing health care to the declarant.