Connecticut Living Will Template
This Connecticut Living Will serves as a directive pursuant to the Connecticut Public Health Code concerning the use or refusal of life-sustaining treatment by the declarant if in a terminal condition or permanently unconscious. This document reflects the wishes of the declarant regarding medical treatment preferences in such situations.
Declarant Information:
- Full Name: ___________________________________________
- Date of Birth: ________________________________________
- Social Security Number: _______________________________
- Address: ______________________________________________
- City: ________________________ State: CT Zip: __________
I, _________________ [Full Name], being of sound mind and not under undue influence or duress, hereby declare the following:
- Appointment of Health Care Representative: I designate the following individual as my Health Care Representative to make health care decisions for me if I become unable to make or communicate my own decisions:
- Name: _______________________________________________
- Relationship: ________________________________________
- Phone Number: _______________________________________
- Alternate Phone Number: ______________________________
- Instructions for Health Care:
In the event that I am unable to make my own health care decisions, I direct that my health care providers and my Health Care Representative follow these instructions:
- Life-Sustaining Treatment: ____________________________________________
- Pain Relief and Comfort Care: _________________________________________
- Other Specific Instructions: ___________________________________________
- Organ Donation:
I express my wishes regarding organ and tissue donation as follows:
- ____ I do wish to donate only the following organs/tissues: ________________
- ____ I do wish to donate any needed organs/tissues.
- ____ I do not wish to donate any organs/tissues.
- Signature and Confirmation:
This Living Will is made according to and shall be governed by the laws of the State of Connecticut. I understand the full import of this declaration, and I am emotionally and mentally competent to make this declaration.
- Signature: ________________________________ Date: ________________
- Print Name: ___________________________________________________
Witness Declaration:
I declare that the person signing 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 person appointed as health care representative or alternate in this document, nor am I a health care provider or an employee of a health care provider treating the declarant. I am not related to the declarant by blood, marriage, or adoption, and, to the best of my knowledge, I am not entitled to any part of the estate of the declarant upon the declarant's death under a will now existing or by operation of law.
- Witness 1 Signature: __________________________________ Date: ___________
- Witness 1 Print Name: ________________________________
- Witness 2 Signature: __________________________________ Date: ___________
- Witness 2 Print Name: ________________________________