LIVING WILL or HEALTH CARE INSTRUCTIONS If the time comes when I am incapacitated to the poi nt when I can no longer actively take part in decisions for my own life and am unable to direct my physici PDF document - DocSlides

LIVING WILL or HEALTH CARE INSTRUCTIONS If the time comes when I am incapacitated to the poi nt when I can no longer actively take part in decisions for my own life and am unable to direct my physici PDF document - DocSlides

2014-12-05 137K 137 0 0

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I the author of this document request that if my condition is deemed terminal or if I am determined to 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 in ID: 21092

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LIVING WILL or HEALTH CARE INSTRUCTIONS If the time comes when I am incapacitated to the poi nt 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 statement of my wishes. I, ________________________________, the author of this document, request that, if my condition is deemed terminal or if I am determined to 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 incur able 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 veget ative state which is an irreversib le condition in which I am at no time aware of myself or the environment and show no behavioral response to the environment. Specific Instructions Listed below are my instructions regarding particular types of life support systems. This list is not all-inclusive. My general statement that I not be kept alive through life support systems provided to me is limited only where I have indicated that I desire a particular treat ment to be provided. Provide Withhold Cardiopulmonary Resuscitation __________ ____________ Artificial Respiration (including a respirator) _________ ____________ Artificial means of prov iding nutrition and hydration __________ ____________ _____________________ _________________ __________ ____________ _____________________ _________________ __________ ____________ Other specific requests: ______________ ___________________________________________ __________________________________________ _____________________ _____________ __________________________________________ _____________________ _____________ __________________________________________ _____________________ _____________ ________________________ __________________________________________ __________ __________________________________________ _____________________ _____________ ________________________ _________________________________________ ___________ __________________________________________ _____________________ _____________ __________________________________________ _____________________ _____________ I do want sufficient pain medicat ion to maintain my physical comfort. I do not intend any direct taking of my life, but only that my dying not be unreasonably prolonged. This request is made, after careful re flection, while I am of sound mind. ______ / ______ / ______ (Date) X___________ ___________________
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WITNESSES' STATEMENTS This document was signed in our presenc e by __________________________ ___ the author of this document, who appeared to be eighteen years of age or older, of sound mind and able to understand the nature and consequences of health care decisio ns at the time this document was signed. The author appeared to be under no improper influence. We have subscribed this document in the author's presence and at the aut hor's request and in the presence of each other. x_________________ _________ x___________________________ (Witness) (Wit ness) x_________________ _________ x___________________________ (Number and Street) (Number and Street) x_________________ _________ x___________________________ (City, State and Zip Code) (City, State and Zip Code)
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OPTIONAL FORM WITNESSES' AFFIDAVITS STATE OF CONNECTICUT ) ) ) :ss.__________________________ ) (Town) COUNTY OF _____________________ _______ ) We, the subscribing witnesses, being duly sworn, say that we witnessed the execution of this living will or health care instructions by the aut hor of this document; that the author subscribed, published and declared the same to be the author's instructi ons, appointments and designation in our presence; that we t hereafter subscribed the document as witnesses in the author's presence, at the author's request and in the pres ence of each other; that at the time of the execution of said document the author appeared to us to be eighteen years of age or older, of sound mind, able to understand the nature and consequences of said document, and under no improper influence, and we make this affidavit at the author's request this _____ day of _____________________, 20____. x_________________ ____________ x____________ ___________________ (Witness) (Witness) x_________________ ____________ x____________ ___________________ (Number and Street) (Num ber and Street) x_________________ ____________ x____________ ___________________ (City, State and Zip Code) (City, State and Zip Code) Subscribed and sworn to before me by ___________________and _______ _______________, the signing witnesses to the foregoing affidavit this ______ day of _________________, 20____. __________________ _______________ Commissioner of the Superio r Court Notary Public My Commission expires: _____________ (Print or type name of all pers ons signing under all signatures)

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