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Connecticut Living Will Form|Removal of Life Support System

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The Connecticut Living Will is a legal document that is provided to the Principal afford them the opportunity to create a document that, while they are of sound mind, that will stand as their choices for their end of life medical treatment as well as any decisions for when removal from life support should occur. This document allows the Principal to clearly state what their desires are if they are in an end of life scenario and what actions they would prefer that their healthcare team should do for them in this situation. This document may be revoked at any time as long as the Principal is of sound mind to do so.

Definition –  § 19a-570

Laws – Chapter 368w (Removal of Life Support Systems)

How to Write

Step 1 -Naming the Principal – In the first line of the document, enter the Principal’s full legal name

Step 2 – Principal’s Instructions – The Principal must review the statements as provided. If in agreement with these statements, initial the selections you would like provided or withheld as follows:

  • Cardiopulmonary Resuscitation
  • Artificial Respiration (including a respirator)
  • Artificial means of providing nutrition and hydration
  • If you have other provisions you would like to have provided or withheld, write them in and specify your wishes on the appropriate lines to the right. If you require more room, add a continuation sheet and attach it to the document

Step 3 – Other Specific Requests – If you have other requests that you would like recognized and implemented, write them into the lines provided. If more room is required, add a continuation sheet and attach it to the document

  • Read the statement regarding the provision of pain relief medications
  • Date the Principal’s signature in mm/dd/yyyy format
  • Enter the Principal’s signature or mark to the right if the date entered

Step 4 – Witness’ Signatures – The witnesses must carefully review the statement prior to submitting their signatures. Once the statement has been reviewed by each witness, enter the following:

Witness 1 – 

  • Witness Signature
  • Physical Address
  • City, State, Zip Code

Witness 2 – 

  • Witness Signature
  • Physical Address
  • City, State, Zip Code

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