Connecticut Advance Directive Form (Medical POA + Living Will)

A Connecticut advance directive is a document that provides health care planning instructions so that in an unfortunate event, medical staff will have instructions for health care treatment. An advance directive includes allows a person to select someone else to make their medical decision needs on their behalf in addition to selecting their preferred treatment options (and lack thereof).

Spanish (Español) VersionAdobe PDF

What’s Included?

Laws

Signing Requirements (Sec. 19a-575, Sec. 19a-575a) – Two (2) witnesses.

State Definitions

  • Advance Health Care Directive (Sec. 19a-570(1)) – Means a writing executed in accordance with the provisions of this chapter, including, but not limited to, a living will, or an appointment of health care representative, or both;
  • Appointment of Health Care Representative (Sec. 19a-570(2)) – means a document executed in accordance with section 19a-575a or 19a-577 that appoints a health care representative to make health care decisions for the declarant in the event the declarant becomes incapacitated.
  • Living Will (Sec. 19a-570(1)) – Means a written statement in compliance with section 19a-575a, containing a declarant’s wishes concerning any aspect of his or her health care, including the withholding or withdrawal of life support systems.

Versions (4)


blankAARP Advance Directive

Download: Adobe PDF

 

 

 

 


blank

CT.gov Advance Directive

Download: Adobe PDF

 

 

 

 


blankYale – New Haven Advance Directive

Download: Adobe PDF

 

 

 

 


blankStamford Health Advance Directive

Download: Adobe PDF

 

 

 

 


How To Write

Download; Adobe PDF

Title

(1) Connecticut Declarant Name. The name of the potential Connecticut Patient issuing this directive as its Principal or Declarant should be used to identify this document.

blank

Formal Appointment Status

(2) Health Care Representative Appointment. If you intend to appoint a Health Care Representative in the State of Connecticut then proceed to the next section however, if only wish to fill out one or both of the other forms in this packet and do not intend to appoint a Health Care Representative, then you must provide your initials to indicate the omission of this appointment is intentional.

blank

Naming The Connecticut Health Care Representative

(3) Connecticut Health Care Representative.  The complete name of the Connecticut Health Care Agent that shall be appointed to represent the Principal or Declarant’s wishes to attending Doctors and Medical Staff in this state.Successor Agent.

blank

(4) Health Care Representative. You can appoint an additional Party to succeed your Health Care Representative in the State of Connecticut using the next declarative statement. The language provided will achieve this task but requires re-entry of the Health Care Representative’s name.

(5) Alternative Health Care Representative. An Agent can be held in reserve to succeed the Health Care Representative should the Party you originally appoint fail in this role through inaction or ineligibility. Name the individual you wish Connecticut Doctors to seek as your new Health Care Representative (in such a scenario). It is worth noting that so long as the original appointment of the Health Care Representative fulfills his or her role, the Alternative Agent you name will not have principal authority over your treatment. The authority in this document will only transfer to him or her if your original appointment for Health Care Representative steps down, is revoked, is unreachable, unwilling, or incapacitated.

blank

Connecticut Living Will

(6) Including The Living Will. If you wish to make your medical preferences known to Connecticut Physicians through a living will then, attend to the paragraph in the first section. If you do not wish to document your preferences in this form then provide initials as verification of this intentional omission.

blank

(7) Declarant As The Living Will Author. As the Issuer of this directive, identify yourself by name in the first paragraph.

blank

(8) Consenting Or Refusing Medical Treatment. You can provide a basic report by initialing either the column requesting that treatment be provided or be withheld. In this way, your initials can inform Connecticut Physicians whether you wish for Cardiopulmonary Resuscitation, Artificial Respiration (including a respirator), or artificial delivery of nutrition and hydration be provided if you are incapacitated and require these techniques to continue living or withheld.

blank

(9) Requests To Connecticut Health Care Staff. Support your basic requests with a report directly to this form. Here, you may request specific actions be taken or withheld in your medical treatment, set desired treatment goals, and describe your medical instructions in certain scenarios.

blank

Document Of Anatomical Gift

(10) Anatomical Gift Decision. It is recommended that you present your intentions regarding organ and tissue donation upon death. The first or second statement of the next section should be initialed to either refuse anatomical gifts or to consent to make an organ donation upon death.

(11) Determined Anatomical Gifts. A choice to donate all organs, tissues, and body parts or only specific ones by producing your initials to statement 1 or statement 2 (respectively). Keep in mind that if you have elected statement 2, then you must use the area provided to display all organs, tissues, and body parts you approve of donating.

(12) Approved Purpose. An additional choice of statements allows you to approve of anatomical gifts made for any legal purpose as stated by Connecticut Law (subsection (a) of section 19a-279f of the general statutes) or that you only approve of the purposes that you define. Your initials by statement 1 or 2 in this next discussion should be used to present your level of approval.

blank

Conservator Nomination

(13) Waiving Your Nomination. If you do not wish to nominate a Party to act as your Conservator should Connecticut State Courts deem it necessary to appoint to your body or your estate, then initial the statement provided.

(14) Engaging Your Nomination. This document enables you to nominate a specific Party for the consideration of the courts should the State of Connecticut determine that it must assign a Conservator to your body and/or estate. This requires a record of your Nomination’s full name. Additionally, the full name of a Successor Nomination should be listed should your first choice be found unacceptable by the courts or is otherwise unable or unwilling to act in this manner.

blank

Setting Your Directives In Effect

(15) Connecticut Declarant Signature. You must sign and date this document (with the date of your signature) after it is completed. Make sure it is an accurate reflection of the directives, appointments, and instructions you wish to set to paper for the use of Connecticut Medical Personnel seeking to treat you.

blank

Witnesses’ Statements

(16) Connecticut Declarant. The full name of the Connecticut Declarant or Principal who has signed this paperwork should be verified in the Witness statement prior to its review by the Witnesses.

(17) Witness Verification. Both Witnesses should prove their attendance at your signing and that the Witness statement made is accurate by signing their names and documenting their addresses.

blank

Witnesses  Affidavits

(18) Notary Public And Witness Testimony. The Witnesses Affidavits can only be attended to by the Notary Public and Witnesses it concerns. Review this document for its testimony regarding your signing. The location, date, parties that have attended, witness signatures, and notary credentials should all be displayed.

blank

Connecticut MOLST

(19) Patient Identity. If you have decided to work with a Connecticut Physician to issue preemptive medical orders regarding your treatment should you be incapacitated and requiring medical attention, then the Connecticut MOLST form will need to be issued. This requires a complete report on the Patient’s name and address. Make sure this information remains up-to-date even after this form has been completed and filed.

(20) Date Of Birth. Some additional methods of identification are required for this document to be stored with your medical records. Thus, a record of your date of birth must be produced.

(21) Sex. Select male or female to indicate your sex.

blank

Eligible Diagnosis

(22) Principal Condition. It should be indicated whether you are at the end-stage of a fatal illness if you have an advanced chronic progressive frailty condition or both. Additionally, make sure to record the nature of the illness and/or condition.Goals Of Treatment – Medical Interventions.

blank

(23) Level Of Consent Or Limitations. The opening of the MOLST also seeks a general interpretation of the expectations you have for the medical care attending Connecticut Physicians, Responders, and Medical Professionals to provide. By selecting one of three checkboxes, you can document your desire to have treatment with no limitations on your medical treatment, to limit medical treatment and intervention, or to name comfort care as the goal of your treatment.

blank

Cardiopulmonary Resuscitation (CPR)

(24) CPR Directive. When you are incapacitated because your heart has stopped or your lungs have ceased to function, Medical Professionals will employ cardiopulmonary resuscitation to keep them functioning with the hope of restarting these organs. You have the option to either give Connecticut Health Providers to perform cardiopulmonary resuscitation or deliver the instruction that cardiopulmonary resuscitation should not be employed

blank

Transfer To Hospital

(25) Hospitalization. If you are found incapacitated, the question of being transported to a hospital will need to be addressed. You can either document your approval to be admitted to a hospital with further definition on your level of consent to ICU care or you can deny being transported to a hospital altogether unless this is needed to keep you comfortable.

blank

Intubation And Ventilation (Non-CPR Related)

(26) Long-Term Breathing Assistance. There are medical scenarios where CPR would be an inappropriate response and long-term breathing aid is needed. This will often be accomplished with the insertion of a tube (intubation) or through mechanical ventilation. You can approve of this method ahead of time, limit it to a specific trial period that you also define, or deny this procedure altogether by selecting the appropriate statement.

blank

Non-Invasive Ventilation

(27) Request On Ventilation Aid. You can approve the use of a BiPAP breathing assistance (or CPAP) as a noninvasive breathing aid. This involves wearing a mask that will deliver oxygen. Use the appropriate section to present your wishes by choosing the statement approving the use of BiPAP or CPAP breathing assistance, approving this technique for only a limited amount of time (which you must define directly), or by withholding consent from this breathing aid being administered.

blank

Medically Administered Hydration

(28) Hydration Instructions. Medical Staff will desire to keep you hydrated when you are incapacitated for extended lengths of time. When in such a condition the risk of dehydration is great but water and fluids may need to be delivered intravenously or artificially. This section allows the choice of allowing hydration using whatever means are allowed, providing this consent for only a trial period you must describe, or deny the medical administration of water and fluids.

blank

Medically Administered Nutrition

(29) Connecticut Nutrition Directive. The possibility of starvation is also present when incapacitated for a significant period of time. You can deliver approval to Connecticut Medical Personnel when nutrition must be administered medically, provide this consent for a trial period of your definition, or inform Connecticut Health Care Providers that you do not authorize the medical administration of nutrition when you are incapacitated.

blank

Dialysis

(30) Directions On Dialysis. If incapacitated for a significant length of time and under the threat of renal failure, Connecticut Medical Providers will seek to aid your kidneys with a dialysis machine. You have the option of giving consent to dialysis for an unlimited length of time, a trial period or deny it.

blank

Other Treatment Preferences

(31) Connecticut Patient Directives. If you wish to provide additional instructions and preferences to attending Connecticut Health Providers then utilize the final area with the aid of your Doctor to document these consents and refusals.Signature Requirements.

blank

(32) Declarant Name. While this paperwork assumes the Declarant and the Patient to be one and the same, this is not always the case and not mandatory. Thus, it must be established that either the Patient or the Legal Representative of the Patient has completed this form by marking the appropriate selection. It should be mentioned that if this paperwork is completed by a Legally Authorized Representative of the Patient, then the paperwork or court order naming this person as such should be provided. Similarly, if this is a family member, then the relation held with the Patient should be defined.

blank

(33) Patient Signature. The Patient or Legally Authorized Representative issuing this paperwork must sign his or her name to confirm that it represents the Patient’s wishes then report the calendar date when the signature has been supplied.

(34) Printed Name. The printed name of the Signature Declarant must be produced.

blank

(35) Signature Of Provider. The Medical Provider (i.e. Physician, APR Nurse, or Physician’s Assistant) that has aided the Patient or Declarant in completing this form will need to authorize it and prove his or her participation by signing it then indicating his or her status

(36) Printed Name Of Provider.

(37) Date of Provider Signature.

(38) Provider Phone Number.

blank

(39) Witness Signature. The signatures above must be provided before a Witness who can authenticate the provided signatures. This act will be handled with the Witness’s signature and signature date. This Party must also print his or her name.

(40) Interpreter Name Or ID. If an Interpreter was required to complete this form then his or her Name, ID#, or the name of the Interpretation Service obtained must be provided with the date the interpretation took place.

blank

(41) MOLST Review And Update. The final section allows Reviewers to document their interview with the Patient or Declarant when updating this form. The date when this takes place, the Provider’s signature printed named and credentials should all be provided during such sessions. Additionally, it must be indicated if the interview took place with the Patient or another Party and where this occurred. Finally, the status of this MOLST form should be indicated as either current and unchanged, invalidated in favor of a more recent MOLST, or if it has been terminated without a replacement or update issued.

blank