THIS PAGE IS MEANT AS A GUIDELINE

ALWAYS CONSULT YOUR ATTORNEY BEFORE CREATING A LIVING WILL

How to Use the Connecticut Will to Live form
--Suggestions and Requirements:

1. This document allows you to designate (name) a health care agent who will make health care decisions for you whenever you are unable to make them for yourself. It also allows you to give instructions concerning medical treatment decisions that the health care agent must follow.

2. Your health care agent must be an adult. Your health care agent must NOT be: (1) your treating physician, (2) an employee, operator, or administrator of your hospital, nursing home, or other health care facility, or (3) a person who at the time of appointment is a patient or resident of one of those facilities. However, any of these may be named your health care agent if he or she is related to you by blood, marriage or adoption.

3. It is helpful to designate successor health care agents(s) to take over if your first choice is unable to serve. There is space on the form for you to designate two successor health care agents.

4. You must do the following to properly designate a health care agent through this document:
Sign and date this document in the presence of two witnesses who are each at least 18 years old. (If you are unable to sign and date the document yourself, you may direct someone to do it for you in your presence.) The two witnesses must sign the document in your presence and in each other's presence.

5. The witnesses must be adults. Neither witness can be the appointed health care agent nor an alternate agent. For persons who reside in facilities operated or licensed by the Department of Mental Health, at least one witness must be a physician or clinical psychologist with specialized training in treating mental illness. For persons who reside in facilities operated or licensed by the Department of Mental Retardation at least one witness must be an individual who is not affiliated with the facility and at least one witness must be a physician or a clinical psychologist with specialized training in developmental disabilities.

6. Your health care agent's authority takes effect only when this document has been given to your attending physician and your attending physician has determined that you no longer have the capacity to make and communicate your own health care decisions.

7. An attending physician or health care provider who is unable to comply with the wishes of the patient must, as promptly as practicable, take all reasonable steps to transfer care of the patient to a physician or health care provider who is willing to comply with the wishes of the patient.

8. You may revoke this document at any time and in any manner regardless of your mental or physical condition. When you revoke it, your attending physician will make the revocation part of your medical record.

9. You should tell your doctor about this document. You should also ask your doctor to keep a copy of this document as a part of your medical health record. Give copies of the signed original to your health care agent, family members, and anyone else you think appropriate. Keep the original document in a safe place that will be easily accessible to others in case of an emergency and tell someone where it is.

10. This type of document has been authorized by the Connecticut Removal of Life Support Systems Act, Conn. Gen. Stat. 19a-570 to-575.

11. If you have any questions about this document or want assistance, in filling it out, please consult an attomey.

For additional copies of the Will to Live, please send a self-addressed, stamped business envelope to:

Will to Live, Project Suite 500, 419 Seventh St., N.W. Washington, D.C. 20004

PRO-LIFE COUNCIL 190 MAIN STREET EAST HAVEN, CONNECTICUT, 06512

FOR SIMILAR INFORMATION ON OTHER STATES,
WRITE TO THE ABOVE "WILL TO LIVE PROJECT"

Click Here For Will To Live

form prepared 1996

Connecticut Health Care Agent
Will To Live Form

I,________________________________________________(your name)

Address _____________________________________________________

_____________________________________________________________

(your address)

Telephone _____________________________________________________

(your telephone number(s)) designate ________________________________________________(surrogate's name)

Address _____________________________________________________

_____________________________________________________________

(surrogate's address)

Telephone _____________________________________________________

(surrogate's telephone number(s)) as my health care agent to make any health care decisions for me as authorized in this document consistent with the instructions below.
If the person I designate above refuses or is not able to act for me, I designate the following persons (each to act alone and successively, in the order named):

A. _______________________________________________________(successor agent's name)

Address ____________________________________________________

_____________________________________________________________

(successor agent's address)

Telephone _____________________________________________________

(successor agent's telephone number(s)) B. _______________________________________________________(second successor agent's name)

Address ____________________________________________________

_____________________________________________________________

(second successor agent's address)

Telephone _____________________________________________________

(second successor agent's telephone number(s))

as my health care agent(s) to make any health care decisions for me as authorized in this document consistent with the instructions below.
This designation shall become effective only when I become incapable of making and communicating my own health care decisions.
Any prior designation is revoked.

GENERAL PRESUMPTION FOR LIFE I direct my health care provider(s) and health care agent(s) to make health care decisions consistent with my general desire for the use of medical treatment that would preserve my life, as well as for the use of medical treatment that can cure, improve, or reduce or prevent deterioration in, any physical or mental condition.
Food and water are not medical treatment, but basic necessities. I direct my health care provider(s) and health care agent to provide me with food and fluids orally, intravenously, by tube, or by other means to the full extent necessary both to preserve my life and to assure me the optimal health possible.
I direct that medication to alleviate my pain be provided, as long as the medication is not used in order to cause my death.
I direct that the following be provided:
* the administration of medication;
* cardiopulmonary resuscitation (CPR); and
* the performance of all other medical procedures, techniques, and technologies, including surgery,
- all to the full extent necessary to correct, reverse, or alleviate life-threatening or health-impairing conditions, or complications arising from those conditions.
I also direct that I be provided basic nursing care and procedures to provide comfort care.
I reject, however, any treatments that use an unborn or newborn child, or any tissue or organ of an unborn or newborn child, who has been subject to an induced abortion. This rejection does not apply to the use of tissues or organs obtained in the course of the removal of an ectopic pregnancy.
I also reject any treatments that use an organ or tissue of another person obtained in a manner that causes, contributes to, or hastens that person's death.
The instructions in this document are intended to be followed even if suicide is alleged to be attempted at some point after it is signed.
I request and direct that medical treatment and care be provided to me to preserve my life without discrimination based on my age or physical or mental disability or the "quality" of my life. I reject any action or omission that is intended to cause or hasten my death.
I direct my health care provider(s) and health care agent to follow the above policy, even if I am judged to be incompetent.
During the time I am incompetent, my agent, as named above, is authorized to make medical decisions on my behalf, consistent with the above policy, after consultation with my health care provider(s), utilizing the most current diagnoses and/or prognosis of my medical condition, in the following situations with the written special conditions.

WHEN MY DEATH IS IMMINENT

A. If I have an incurable terminal illness or injury, and I will die imminently - meaning that a reasonably prudent physician, knowledgeable about the case and the treatment possibilities with respect to the medical conditions involved, would judge that I will live only a week or less even if lifesaving treatment or care is provided to me -- the following may be withheld or withdrawn:

(Be as specific as possible: SEE SUGGESTIONS.):_____________________

____________________________________________________________________

(Cross off any remaining blank lines.)

WHEN I AM TERMINALLY ILL

B. Final Stage of Terminal Condition. If I have an incurable terminal illness or injury and even though death is not imminent I am in the final stage of that terminal condition - meaning that a reasonably prudent physician, knowledgeable about the case and the treatment possibilities with respect to the medical conditions involved, would judge that I will live only three months or less, even if lifesaving treatment or care is provided to me - the following may be withheld or withdrawn:

(Be as specific as possible: SEE SUGGESTIONS.):_____________________

____________________________________________________________________

(Cross off any remaining blank lines.)

C. OTHER SPECIAL CONDIIIONS: (Be as specific as possible: SEE SUGGESTIONS.):

____________________________________________________________________

(Cross off any remaining blank lines.)

IF I AM PREGNANT

D. Special Instructions for Pregnancy. If I am pregnant, I direct my health care provider(s) and health care agent(s) to use all lifesaving procedures for myself with none of the above special conditions applying if there is a chance that prolonging my life might allow my child to be born alive. I also direct that lifesaving procedures be used even if I am legally determined to be brain dead if there is a chance that doing so might allow my child to be born alive. Except as I specify by writing my signature in the box below, no one is authorized to consent to any procedure for me that would result in the death of my unborn child.

If I am pregnant, and I am not in the final stage of a terminal condition as defined above, medical procedures required to prevent my death are authorized even if they may result in the death of my unborn child provided every possible effort is made to preserve both my life and the life of my unborn child.

______________________________________
(Signature of Principal)

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

Signed this ___________________ day of ________________________________, 19______________

Signature __________________________________

Address ____________________________________

____________________________________________

This document was signed in my 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 of the consequences of health care decisions at the time the document was signed.

Signature of First Witness________________________________

Address___________________________________________________

Signature of Second Witness_______________________________

Address___________________________________________________

Form prepared 1996

ALWAYS CONSULT YOUR ATTORNEY BEFORE CREATING A LIVING WILL

Click Here For Will To Live

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