Connecticut Living Will Template
This Living Will is made in accordance with the laws of the State of Connecticut. It expresses my wishes regarding medical treatment in the event that I become unable to communicate my preferences.
Personal Information:
- Name: __________________________
- Date of Birth: ___________________
- Address: _________________________
- City, State, Zip: ________________
Declaration:
I, the undersigned, being of sound mind, willfully and voluntarily make this declaration to be followed if I become terminally ill or permanently unconscious, and I am unable to communicate my wishes regarding medical treatment.
My wishes are as follows:
- If I am in a terminal condition, I do not want life-sustaining treatment, including but not limited to:
- Mechanical ventilation
- Cardiopulmonary resuscitation (CPR)
- Artificial nutrition and hydration
- If I am in a persistent vegetative state, I do not wish to receive life-sustaining treatment.
- If I am able to receive comfort care, I wish to have measures taken to alleviate pain and provide comfort, even if such measures may hasten my death.
Appointment of Health Care Representative:
If applicable, I appoint the following person as my health care representative to make decisions on my behalf if I am unable to do so:
- Name: __________________________
- Phone Number: __________________
- Address: ________________________
This Living Will reflects my wishes and is intended to guide my health care providers and loved ones in making decisions that align with my values and preferences.
Signature:
______________________________
Date: __________________________
Witnesses:
- Witness 1: ______________________
- Witness 2: ______________________