Sec. 19a-575a. Form of document re health care instructions, appointment of
health care agent, attorney-in-fact for health care decisions, designation of conservator of the person for future incapacity and anatomical gift. Any person eighteen
years of age or older may execute a document which contains health care instructions,
the appointment of a health care agent, the appointment of an attorney-in-fact for health
care decisions, the designation of a conservator of the person for future incapacity and
a document of anatomical gift. Any such document shall be signed and dated by the
maker with at least two witnesses and may be in the substantially following form:
THESE ARE MY HEALTH CARE INSTRUCTIONS.
MY APPOINTMENT OF A HEALTH CARE AGENT,
MY APPOINTMENT OF AN ATTORNEY-IN-FACT
FOR HEALTH CARE DECISIONS,
THE DESIGNATION OF MY CONSERVATOR OF THE PERSON
FOR MY FUTURE INCAPACITY
AND
MY DOCUMENT OF ANATOMICAL GIFT
To any physician who is treating me: These are my health care instructions including
those concerning the withholding or withdrawal of life support systems, together with
the appointment of my health care agent and my attorney-in-fact for health care decisions, the designation of my conservator of the person for future incapacity and my
document of anatomical gift. As my physician, you may rely on any decision made by
my health care agent, attorney-in-fact for health care decisions or conservator of my
person, if I am unable to make a decision for myself.
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
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 and artificial means of providing
nutrition and hydration. I do want sufficient pain medication to maintain my physical
comfort. I do not intend any direct taking of my life, but only that my dying not be
unreasonably prolonged.
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, my health care agent and attorney-in-fact for health care decisions is authorized 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;
(3) Consent, refuse or withdraw consent to any medical treatment as long as such
action is consistent with my wishes concerning the withholding or removal of life support
systems; and
(4) Consent to any medical treatment designed solely for the purpose of maintaining
physical comfort.
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.
If a conservator of my person should need to be appointed, I designate .... be appointed
my conservator. If .... is unwilling or unable to serve as my conservator, I designate .....
No bond shall be required of either of them in any jurisdiction.
I hereby make this anatomical gift, 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 general
statutes
(2) .... these limited purposes ....
These requests, appointments, and designations are made after careful reflection,
while I am of sound mind. Any party receiving a duly executed copy or facsimile of
this document may rely upon it unless such party has received actual notice of my
revocation of it.
Date ...., 20..
.... L.S.
This document was signed in our presence 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 decisions 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 author's request and in the presence of each
other.
| .... | .... |
| (Witness) | (Witness) |
| .... | .... |
| (Number and Street) | (Number and Street) |
| .... | .... |
| (City, State and Zip Code) | (City, State and Zip Code) |
STATE OF CONNECTICUT
COUNTY OF .... |
)
)
) | ss. .... |
We, the subscribing witnesses, being duly sworn, say that we witnessed the execution
of these health care instructions, the appointments of a health care agent and an attorney-
in-fact, the designation of a conservator for future incapacity and a document of anatomical gift by the author of this document; that the author subscribed, published and declared
the same to be the author's instructions, appointments and designation in our presence;
that we thereafter subscribed the document as witnesses in the author's presence, at the
author's request, and in the presence 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...
| .... | .... |
| (Witness) | (Witness) |
Subscribed and sworn to before me this .... day of .... 20..
|
|
....
Commissioner of the Superior Court
Notary Public
My commission expires: .... |
(Print or type name of all persons signing under all signatures)
(P.A. 93-407, S. 1.)
History: (Revisor's note: In 2001 the references in this section to the date "199.." were changed editorially by the
Revisors to "20.." to reflect the new millennium).
Sec. 19a-576. Appointment of health care agent. (a) Any person eighteen years
of age or older may appoint a health care agent by executing a document in accordance
with section 19a-575a or section 19a-577, signed and dated by such person in the presence of two adult witnesses who shall also sign the document. The person appointed as
agent shall not act as witness to the execution of such document or sign such document.
(b) For persons who reside in facilities operated or licensed by the Department of
Mental Health and Addiction Services, at least one witness shall be an individual who
is not affiliated with the facility and at least one witness shall be a physician or clinical
psychologist with specialized training in treating mental illness.
(c) For persons who reside in facilities operated or licensed by the Department of
Mental Retardation, at least one witness shall be an individual who is not affiliated with
the facility and at least one witness shall be a physician or clinical psychologist with
specialized training in developmental disabilities.
(d) An operator, administrator, or employee of a hospital, residential care home,
rest home with nursing supervision, or chronic and convalescent nursing home may not
be appointed as a health care agent by any person who, at the time of the appointment,
is a patient or a resident of, or has applied for admission to, one of the foregoing facilities.
An administrator or employee of a government agency which is financially responsible
for a person's medical care may not be appointed as a health care agent for such person.
This restriction shall not apply if such operator, administrator or employee is related to
the principal by blood, marriage or adoption.
(e) A physician shall not act as both agent for a principal and attending physician
for the principal.
(P.A. 91-283, S. 3; P.A. 93-407, S. 2; May 25 Sp. Sess. P.A. 94-1, S. 22, 130; P.A. 95-257, S. 11, 58; P.A. 97-112, S. 2.)
History: P.A. 93-407 amended Subsec. (a) by deleting reference to Sec. 19a-577 and adding reference to Sec. 19a-575a; May 25 Sp. Sess. P.A. 94-1 amended Subsec. (a) by adding reference to Sec. 19a-577, effective July 1, 1994; P.A.
95-257 replaced Commissioner and Department of Mental Health with Commissioner and Department of Mental Health
and Addiction Services, effective July 1, 1995; P.A. 97-112 replaced "home for the aged" with "residential care home".
Sec. 19a-577. Form of document re appointment of health care agent. (a) Any
person eighteen years of age or older may execute a document that may, but need not
be in substantially the following form:
DOCUMENT CONCERNING THE APPOINTMENT
OF HEALTH CARE AGENT
"I appoint .... (Name) to be my health care agent. If my attending physician determines
that I am unable to understand and appreciate the nature and consequences of health
care decisions and to reach and communicate an informed decision regarding treatment,
my health care agent is authorized 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 my wishes are given effect.
If this person is unwilling or unable to serve as my health care agent, I appoint ....
(Name) to be my alternative health care agent."
"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)
(P.A. 91-283, S. 6.)
Sec. 19a-578. Proof of living will document or document appointing health
care agent out of court. Physician to make documents and oral communications
re health care and withdrawal of life support systems part of medical record. (a)
Any or all of the attesting witnesses to any living will document or any document appointing a health care agent may, at the request of the declarant, make and sign an
affidavit before any officer authorized to administer oaths in or out of this state, stating
such facts as they would be required to testify to in court to prove such living will. The
affidavit shall be written on the living will document, or if that is impracticable, on
some paper attached thereto. The sworn statement of any such witness so taken shall
be accepted by the Court of Probate as if it had been taken before such court.
(b) A physician or other health care provider who is furnished with a copy of a
written living will or appointment of health care agent shall make it a part of the declarant's medical record. A physician or other health care provider shall also record in the
patient's medical record any oral communication concerning any aspect of his health
care, including the withholding or withdrawal of life support systems, made by the
patient directly to the physician or other health care provider or to the patient's health
care agent, legal guardian, conservator, next-of-kin or person designated in accordance
with section 1-56r.
(P.A. 91-283, S. 7; P.A. 02-105, S. 8.)
History: P.A. 02-105 amended Subsec. (b) by adding a person designated by the patient in accordance with Sec. 1-56r to the list of those whose communications with the patient regarding his wishes must be recorded in the patient's
medical record.
Sec. 19a-579. Living will or appointment of health care agent becomes operative, when. A living will or appointment of health care agent becomes operative when
(1) the document is furnished to the attending physician and (2) the declarant is determined by the attending physician to be incapacitated.
(P.A. 91-283, S. 10.)
Sec. 19a-579a. Revocation of living will or appointment of health care agent.
Absence of knowledge of revocation. (a) A living will or appointment of health care
agent may be revoked at any time and in any manner by the declarant, without regard
to the declarant's mental or physical condition.
(b) The attending physician or other health care provider shall make the revocation
a part of the declarant's medical record.
(c) In the absence of knowledge of the revocation either of a living will or an appointment of health care agent, a person is not subject to civil or criminal liability or discipline
for unprofessional conduct for carrying out the living will pursuant to the requirements
of sections 19a-570, 19a-571, 19a-573 and 19a-575 to 19a-580c, inclusive.
(P.A. 91-283, S. 9; P.A. 93-407, S. 9.)
History: P.A. 93-407 amended Subsec. (c) by incorporating reference to Sec. 19a-575a.
Sec. 19a-579b. Revocation of appointment of spouse as health care agent upon
divorce or legal separation. The appointment of the principal's spouse as health care
agent shall be revoked upon the divorce or legal separation of the principal and spouse
or upon the annulment or dissolution of their marriage, unless the principal specifies
otherwise.
(P.A. 91-283, S. 14.)
Sec. 19a-580. Physician to notify certain persons prior to removal of life support system. Within a reasonable time prior to withholding or causing the removal of
any life support system pursuant to sections 19a-570, 19a-571, 19a-573 and 19a-575 to
19a-580c, inclusive, the attending physician shall make reasonable efforts to notify
the individual's health care agent, next-of-kin, legal guardian, conservator or person
designated in accordance with section 1-56r, if available.
(P.A. 91-283, S. 8; P.A. 93-407, S. 10; P.A. 02-105, S. 9.)
History: P.A. 93-407 incorporated reference to Sec. 19a-575a; P.A. 02-105 amended section by adding person designated
in accordance with Sec. 1-56r to list of those to be notified.
Sec. 19a-580a. Transfer of patient when attending physician or health care
provider unwilling to comply with wishes of patient. An attending physician or health
care provider who is unwilling to comply with the wishes of the patient or sections
19a-570, 19a-571, 19a-573 and 19a-575 to 19a-580c, inclusive, shall, as promptly as
practicable, take all reasonable steps to transfer care of the patient to a physician or
health care provider who is willing to comply with the wishes of the patient and said
sections.
(P.A. 91-283, S. 11; P.A. 93-407, S. 11.)
History: P.A. 93-407 incorporated reference to Sec. 19a-575a.
Sec. 19a-580b. Prohibition re requiring living will or appointment of health
care agent as condition of treatment or health benefits. No physician, health care
provider or health care insurer shall require a person to execute a living will or appoint
a health care agent as a condition of treatment or receiving health care benefits.
(P.A. 91-283, S. 13.)
Sec. 19a-580c. Probate Court to resolve disputes re provisions concerning
withholding or removal of life support system. The probate court for the district in
which the person is domiciled or is located at the time of the dispute shall have jurisdiction over any dispute concerning the meaning or application of any provision of sections
19a-570, 19a-571, 19a-573 and 19a-575 to 19a-580c, inclusive. With respect to any
communication of a patient's wishes other than by means of a document executed in
accordance with section 19a-575a the court shall consider whether there is clear and
convincing evidence of such communication.
(P.A. 91-283, S. 12; P.A. 93-407, S. 12.)
History: P.A. 93-407 added references to Sec. 19a-575a.
Sec. 19a-580d. "Do not resuscitate" orders. Regulations. The Department of
Public Health shall adopt regulations, in accordance with chapter 54, to provide for a
system governing the recognition and transfer of "do not resuscitate" orders between
health care institutions licensed pursuant to chapter 368v and upon intervention by emergency medical services providers certified or licensed pursuant to chapter 368d. The
regulations shall include, but not be limited to, procedures concerning the use of "do
not resuscitate" bracelets. The regulations shall specify that, upon request of the patient
or his authorized representative, the physician who issued the "do not resuscitate" order
shall assist the patient or his authorized representative in utilizing the system. The regulations shall not limit the authority of the Commissioner of Mental Retardation under
subsection (g) of section 17a-238 concerning orders applied to persons receiving services under the direction of the Commissioner of Mental Retardation.
(P.A. 95-113; 95-257, S. 12, 21, 58.)
History: P.A. 95-257 replaced Commissioner and Department of Public Health and Addiction Services with Commissioner and Department of Public Health, effective July 1, 1995.