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Connecticut Advance Directive Form

A Connecticut advance directive is a form that allows a resident of the State of Connecticut to bestow broad legal powers related to their personal medical decisions upon another individual or organization. This can be useful when someone becomes unable to actively participate in determining their treatment due to serious illness, injury, or other disability. In this case, the designated agent is legally authorized to work with the principal’s healthcare providers to determine the best course of action.

Signing Requirements (§ 19a-575) – Two (2) witnesses.
The witnesses cannot be:

(a) The attending physician or any other physician;
(b) An employee of the attending physician or health-care facility in which the declarant is a patient;
(c) A person who has a claim against any portion of the estate of the declarant at his or her death at the time the declaration is signed; or
(d) A person who knows or believes that he or she is entitled to any portion of the estate of the declarant upon the declarant’s death either as a beneficiary of a will in existence at the time the declaration is signed or as an heir at law.

Statutory Form

DOCUMENT CONCERNING HEALTH CARE AND WITHHOLDING OR
WITHDRAWAL OF LIFE SUPPORT SYSTEMS.

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 or advanced practice registered nurse as to my own medical care, I wish this statement to stand as a testament of my wishes.

I, [NAME] (Name), request that, if my condition is deemed terminal or if it is determined that I will 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 or advanced practice registered nurse, 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. The life support systems which I do not want include, but are not limited to:

  • Artificial respiration
  • Cardiopulmonary resuscitation
  • Artificial means of providing nutrition and hydration

If I am pregnant:

◻ (1) I intend to accept life support systems if my doctor believes that doing so would allow my fetus to reach a live birth.
◻ (2) I intend this document to apply without modifications.
◻ (3) I intend this document to apply as follows: [INSTRUCTIONS]

______________________________________
(Signature)
[DAY] day of [MONTH], 20[XX]

This document was signed in our presence, by the above-named [NAME] (Name) 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 the document was signed.

______________________________________
(Witness)

[ADDRESS, CITY, STATE, ZIP CODE]
(Address)

______________________________________
(Witness)

[ADDRESS, CITY, STATE, ZIP CODE]
(Address)