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Form #708

Document Concerning Withholding or Withdrawal of Life Support Systems

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Connecticut - Document Concerning Withholding or Withdrawal of Life Support Systems - free to use

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Connecticut. 

DOCUMENT CONCERNING 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 as to my own medical care, I wish this statement to stand as a testament of my wishes.

"I, _________(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, 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

(Cross out and initial life support systems you want administered)

I do not intend any direct taking of my life, but only that my dying not be unreasonably prolonged."

Other specific requests:

"This request is made, after careful reflection, while I am of sound mind."

_________(Signature)

_________(Date)

This document was signed in our presence, by the above-named _________(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)

_________(Witness)

_________(Address)



 
Contributed by
Legal Concepts LTD
 
Name of Firm Legal Concepts LTD
Total Forms Contributed 63
 

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Terms Of Use

Submissions to this site, including any legal or business forms, posts, responses to questions or other communications by contributors are not intended as and should not be construed as legal advice. You are strongly encouraged to consult competent legal council before engaging in any action based upon content contained on this site.

These downloadable forms are only for personal use. Retransmission, redistribution, or any other commercial use is prohibited. This includes reposting forms from this site to another site offering free legal or other document forms for download.

Please note that the donator may have included different usage terms regarding this form, and you agree to abide by these terms. It is highly recommended that you have a licensed attorney review any legal documents for which you are searching in order to make sure that your needs are being properly and completely satisfied.

Your use of this site constitutes your acceptance of our terms of use and your agreement to hold this site, its officers, employees and any contributors to this site harmless for any damage you might incur from your use of any submissions contained on this site. If you do not agree to the above terms, please do not proceed.

These forms are provided to assist business owners and others in understanding important points to consider in different transactions. They are offered with the understanding that no legal advice, accounting, or other professional service is being offered by these documents or on this website. Laws vary in the different states. Agreements acceptable in one state may not be enforced the same way under the laws of another state. Also, agreements should relate specifically to the particular facts of each situation. Therefore, it is important to consult legal counsel whenever utilizing these forms. The Forms are not a substitute for legal advice YourFreeLegalForms.com is not engaged in recommending or referring members on the site or making claims about the competence, character or qualifications of its participating members.
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Keywords: Connecticut, will, wills, legal forms, life support

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