Fillable Living Will Form (Page 7 of 10) in pdf

APPOINTMENT OF HEALTH CARE AGENT AND

ATTORNEY-IN-FACT FOR HEALTH CARE DECISIONS

I appoint ______________________________________ to be my health care agent and my attorney-in-fact for health care

decisions. If my attending physician determines that I am unable to understand and appreciate the nature and consequences of

health care decisions and unable to reach and communicate an informed decision regarding treatment,

_______________________________ is authorized;

As My Health Care Agent to:

1. Convey to my physician my wishes concerning the withholding or removal of life support systems;

2. Take whatever actions are necessary to ensure that any wishes are given effect;

As My Attorney-In-Fact to:

1. Act in my name, place and stead in any way which I myself could do, if I were personally present, with respect to

health care decisions as defined in the Connecticut Statutory Short Form Power of Attorney Act to the extent that I

am permitted by law to act through an agent;

2. Consent, refuse or withdraw consent to any medical treatment other than that designed solely for the purpose of

maintaining physical comfort, withdrawal of life support systems, or withdrawal of nutrition or hydration.

If ________________________ is unwilling or unable to serve as my health care agent and my attorney-in-fact for health

care decisions, I appoint ____________________________________ to be my alternative health care agent and my attorney-

in-fact for health care decisions.

DOCUMENT OF ANATOMICAL GIFT

I make no anatomical gift at this time.

_______ (Initial here)

I hereby make this anatomical gift,

_______ (Initial here)

if medically acceptable, to take effect upon my death

I give: (check one)

____________________ (1) any needed organs or parts

____________________ (2) only the following organs or parts

_________________________________________________________________________________________

to be donated for: (check one)

____________________ (1) any of the purposes stated in subsection (a) of section 19a-279f of the CT general statutes

____________________ (2) these limited purposes _______________________________________.

THIS IS A SAMPLE AND OFFERED SOLELY FOR THE ASSISTANCE OF ATTORNEYS WHO WILL BE RESPONSIBLE FOR THE

ULTIMATE SUBSTANCE AND WORDING OF THE DOCUMENT. THE USE OF THIS SAMPLE BY PARTIES OTHER THAN ATTORNEYS

IS NOT AUTHORIZED

Living Will Form Page 7