THIS PAGE IS MEANT AS A GUIDELINE
ALWAYS CONSULT YOUR ATTORNEY BEFORE CREATING A LIVING WILL
KNOW ALL MEN BY THESE PRESENTS, that I, _______________ presently residing at ___________________________________________ , hereby willfully and voluntarily make known my wish that my dying shall not be artificially prolonged under the circumstances set forth below and do further declare that:
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 , __________________________ request that, if my condition is deemed terminal, by terminal I mean that I am in the final stage of an incurable or irreversible medical condition which, in the opinion of the attending physician, confirmed by a second physician's opinion, will result in death within a relatively short time or if I am determined to be permanently unconscious. 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. If either of said situations exist then I be allowed to die and not be kept alive through life support systems. By life support systems, I mean any mechanical or electronic device, excluding the provision of nutrition and hydration, utilized by any physician or licensed medical facility in order to replace, assist or supplement the function of any human vital organ or combination of organs and which prolongs the dying process. However, the attending physician shall obtain the informed consent of NAME PERSON, or my next of kin, if known, or legal guardian, if any.
I do not, however, intend any direct taking of my life, but only that my dying not be unreasonably prolonged.
Nothing herein shall be interpreted or presumed to prohibit comfort care, pain alleviation and nutrition and hydration. All of the same shall be provided.
If the attending physician does not deem that I am in a terminal condition, beneficial medical treatment and nutrition and hydration must be provided.
I direct that my wishes not be altered in any way by any guardian appointed over me or any court of competent jurisdiction.
This declaration made at___________, Connecticut, this________ day of_______, 199__
________________________
We, the undersigned witnesses, declare that we were present at the time that__________________________ executed this Living Will Declaration, that he/she did so freely and voluntarily with full knowledge of its meaning and consequences, and that at the time of its execution he/she appeared to be of sound mind and competent in every respect to make this Declaration.
______________________________
______________________________
Subscribed and sworn to before me this________day of________, 199__.
______________________________
Notary Public, my commission expires
Commissioner of the Superior Court