Connecticut Living Will Template
This Living Will is created in accordance with the laws of the State of Connecticut. It allows you to express your wishes regarding medical treatment in the event you become unable to communicate your 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. I understand that this Living Will reflects my wishes regarding medical treatment in the event that I am unable to communicate my preferences due to a terminal condition or irreversible coma.
Medical Treatment Preferences
In the event that I am diagnosed with a terminal condition or am in an irreversible coma, I wish to make the following preferences known:
- Do not resuscitate me if my heart stops or if I stop breathing.
- Do not provide life-sustaining treatments that would only prolong the dying process.
- Provide comfort care to alleviate pain and suffering.
Appointment of Health Care Representative
If I am unable to make my own health care decisions, I appoint the following person as my health care representative:
- Name: ________________________________
- Relationship: _________________________
- Phone Number: ________________________
Signatures
This Living Will must be signed by me in the presence of two witnesses or a notary public.
Signature: ________________________________
Date: ____________________________________
Witnesses
We, the undersigned witnesses, affirm that the declarant signed this Living Will in our presence and that we are not related to the declarant by blood or marriage, nor are we entitled to any portion of the declarant’s estate.
- Witness 1 Name: ________________________
- Witness 1 Signature: _____________________
- Date: __________________________________
- Witness 2 Name: ________________________
- Witness 2 Signature: _____________________
- Date: __________________________________