CHAPTER 368w*
REMOVAL OF LIFE SUPPORT SYSTEMS

      Sec. 19a-570. Definitions. For purposes of this section, sections 19a-571 to 19a-580c, inclusive:

      (1) "Advance health care directive" or "advance directive" 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;

      (2) "Appointment of health care representative" 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;

      (3) "Attending physician" means the physician selected by, or assigned to, the patient, who has primary responsibility for the treatment and care of the patient;

      (4) "Beneficial medical treatment" includes the use of medically appropriate treatment, including surgery, treatment, medication and the utilization of artificial technology to sustain life;

      (5) "Health care representative" means the individual appointed by a declarant pursuant to an appointment of health care representative for the purpose of making health care decisions on behalf of the declarant;

      (6) "Incapacitated" means being unable to understand and appreciate the nature and consequences of health care decisions, including the benefits and disadvantages of such treatment, and to reach and communicate an informed decision regarding the treatment;

      (7) "Life support system" means any medical procedure or intervention which, when applied to an individual, would serve only to postpone the moment of death or maintain the individual in a state of permanent unconsciousness, including, but not limited to, mechanical or electronic devices, including artificial means of providing nutrition or hydration;

      (8) "Living will" 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;

      (9) "Next of kin" means any member of the following classes of persons, in the order of priority listed: (A) The spouse of the patient; (B) an adult son or daughter of the patient; (C) either parent of the patient; (D) an adult brother or sister of the patient; and (E) a grandparent of the patient;

      (10) "Permanently unconscious" means an irreversible condition in which the individual is at no time aware of himself or herself or the environment and shows no behavioral response to the environment and includes permanent coma and persistent vegetative state;

      (11) "Terminal condition" means the final stage of an incurable or irreversible medical condition which, without the administration of a life support system, will result in death within a relatively short period time, in the opinion of the attending physician.

      (P.A. 85-606, S. 1; P.A. 91-283, S. 1; P.A. 93-407, S. 3; P.A. 06-195, S. 63.)

      History: P.A. 91-283 redefined "life support system" and "terminal condition" and added definitions of "permanently unconscious", "health care agent", "incapacitated", "living will", "next of kin" and "attending physician"; P.A. 93-407 deleted reference to Sec. 19a-575 and added reference to Sec. 19a-580c in introductory language and in Subdiv. (7); P.A. 06-195 alphabetized and renumbered existing definitions, substituted "health care representative" for "health care agent" and redefined the term, and defined "advance health care directive" or "advance directive" and "appointment of health care representative".

      Cited. 209 C. 692.

      Sec. 19a-571. Liability re removal of life support system of incapacitated patient. Consideration of wishes of patient. (a) Subject to the provisions of subsection (c) of this section, any physician licensed under chapter 370 or any licensed medical facility who or which withholds, removes or causes the removal of a life support system of an incapacitated patient shall not be liable for damages in any civil action or subject to prosecution in any criminal proceeding for such withholding or removal, provided (1) the decision to withhold or remove such life support system is based on the best medical judgment of the attending physician in accordance with the usual and customary standards of medical practice; (2) the attending physician deems the patient to be in a terminal condition or, in consultation with a physician qualified to make a neurological diagnosis who has examined the patient, deems the patient to be permanently unconscious; and (3) the attending physician has considered the patient's wishes concerning the withholding or withdrawal of life support systems. In the determination of the wishes of the patient, the attending physician shall consider the wishes as expressed by a document executed in accordance with sections 19a-575 and 19a-575a, if any such document is presented to, or in the possession of, the attending physician at the time the decision to withhold or terminate a life support system is made. If the wishes of the patient have not been expressed in a living will the attending physician shall determine the wishes of the patient by consulting any statement made by the patient directly to the attending physician and, if available, the patient's health care representative, the patient's next of kin, the patient's legal guardian or conservator, if any, any person designated by the patient in accordance with section 1-56r and any other person to whom the patient has communicated his wishes, if the attending physician has knowledge of such person. All persons acting on behalf of the patient shall act in good faith. If the attending physician does not deem the incapacitated patient to be in a terminal condition or permanently unconscious, beneficial medical treatment including nutrition and hydration must be provided.

      (b) A physician qualified to make a neurological diagnosis who is consulted by the attending physician pursuant to subdivision (2) of subsection (a) of this section shall not be liable for damages or subject to criminal prosecution for any determination made in accordance with the usual and customary standards of medical practice.

      (c) In the case of an infant, as defined in 45 CFR 1340.15 (b), the physician or licensed medical facility shall comply with the provisions of 45 CFR 1340.15 (b)(2) in addition to the provisions of subsection (a) of this section.

      (P.A. 85-606, S. 2; P.A. 91-283, S. 2; June Sp. Sess. P.A. 91-11, S. 19; P.A. 93-407. S. 5; P.A. 01-195, S. 162, 181; P.A. 02-105, S. 7; P.A. 06-195, S. 64.)

      History: P.A. 91-283 changed "incompetent" to "incapacitated", added "in accordance with the usual and customary standards of medical practice" after "judgment of the attending physician", deleted requirement of informed consent of next of kin, added requirement that physician qualified to make neurological diagnosis deem patient to be permanently unconscious, added provision re determination of wishes of patient, and added provision re immunity of physician qualified to make a neurological diagnosis for determination made in accordance with usual and customary standards of medical practice as new Subsec. (b); June Sp. Sess. P.A. 91-11 added Subsec. (c) to require compliance with federal regulations regarding an infant; P.A. 93-407 amended Subsec. (a) by adding reference to Sec. 19a-575a; P.A. 01-195 amended Subsec. (c) to make a technical change, effective July 11, 2001; P.A. 02-105 amended Subsec. (a) by adding a person designated by the patient in accordance with Sec. 1-56r to the list of those to be consulted to determine the wishes of the patient; P.A. 06-195 amended Subsec. (a) by substituting "health care representative" for "health care agent".

      Cited. 209 C. 692.

      Sec. 19a-572. Failure to execute document creates no presumption re wishes of patient. Sections 19a-571 and 19a-573 to 19a-575a, inclusive, create no presumption concerning the wishes of a patient who has not executed a document as described in sections 19a-575 and 19a-575a.

      (P.A. 85-606, S. 3; P.A. 93-407, S. 6.)

      History: P.A. 93-407 added references to Sec. 19a-575a.

      Cited. 209 C. 692.

      Sec. 19a-573. Comfort care and pain alleviation to be provided. Documents executed prior to October 1, 1991. (a) Notwithstanding the provisions of sections 19a-571, 19a-572, 19a-574, 19a-575, 19a-575a, 19a-577, 19a-580a and 19a-580b, comfort care and pain alleviation shall be provided in all cases.

      (b) Any document executed prior to October 1, 1991, in accordance with section 19a-575, revision of 1958, revised to January 1, 1991, and section 19a-575a shall not be invalidated by any provision of public act 91-283*. Any document executed prior to October 1, 1991, shall not be presumed to prohibit withholding or withdrawal of life support systems as defined in section 19a-570, revision of 1958, revised to January 1, 1991, unless such prior document specifically addresses such withholding or withdrawal.

      (P.A. 85-606, S. 4; P.A. 91-283, S. 4; P.A. 93-407, S. 7.)

      *Public act 91-283 is entitled "An Act Concerning Living Wills". (See Reference Table captioned "Public Acts of 1991" in Volume 16 which lists the sections amended, created or repealed by the act.

      History: P.A. 91-283 added provision re validity of document executed prior to October 1, 1991, and presumption re withholding or withdrawal of life support systems; P.A. 93-407 added references to Sec. 19a-575a.

      Cited. 209 C. 692.

      Sec. 19a-574. Nonapplicability to pregnant patient. The provisions of sections 19a-571 to 19a-573, inclusive, 19a-575 and 19a-575a shall not apply to a pregnant patient.

      (P.A. 85-606, S. 5; P.A. 93-407, S. 8.)

      History: P.A. 93-407 added reference to Sec. 19a-575a.

      Sec. 19a-575. Form of document re health care instructions and withdrawal or withholding of life support systems. Any person eighteen years of age or older may execute a document that contains directions as to any aspect of health care, including the withholding or withdrawal of life support systems. Such document shall be signed and dated by the maker with at least two witnesses and may be in substantially the following form:

DOCUMENT CONCERNING HEALTH CARE AND WITHHOLDING OR WITHDRAWAL OF LIFE SUPPORT SYSTEMS.

       .... (Signature)

.... (Date)

      Sec. 19a-575a. Form of document re health care instructions, appointment of health care representative, designation of conservator for future incapacity and anatomical gift. Revocation of appointment. Absence of knowledge of revocation. (a) Any person eighteen years of age or older may execute a document that contains health care instructions, the appointment of a health care representative, 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 REPRESENTATIVE,

THE DESIGNATION OF MY CONSERVATOR OF THE PERSON

FOR MY FUTURE INCAPACITY

AND

MY DOCUMENT OF ANATOMICAL GIFT

      .... L.S.

We, the subscribing witnesses, being duly sworn, say that we witnessed the execution of these health care instructions, the appointments of a health care representative, 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...

(Print or type name of all persons signing under all signatures)

      Sec. 19a-576. Appointment of health care representative. (a) Any person eighteen years of age or older may appoint a health care representative 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 representative 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 licensed 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 licensed 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 representative 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 that is financially responsible for a person's medical care may not be appointed as a health care representative 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 health care representative 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; P.A. 06-195, S. 67.)

      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"; P.A. 06-195 amended Subsecs. (a), (d) and (e) by substituting "health care representative" for "health care agent" and "agent", amended Subsecs. (b) and (c) by substituting "licensed clinical psychologist" for "clinical psychologist" and made technical changes throughout section.

      Sec. 19a-577. Form of document re appointment of health care representative. 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 REPRESENTATIVE

      .... (Signature)

.... (Date)

      Sec. 19a-578. Proof of living will document or document appointing health care representative. 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 representative 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 a court of competent jurisdiction 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 representative 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 the patient's 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 representative, 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; P.A. 06-195, S. 69.)

      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; P.A. 06-195 substituted "health care representative" for "health care agent" throughout, amended Subsec. (a) to authorize "a court of competent jurisdiction", rather than "the Court of Probate", to accept sworn statements of attesting witnesses to living will documents or documents appointing health care representatives and amended Subsec. (b) to make a technical change for the purpose of gender neutrality.

      Sec. 19a-579. When living will or appointment of health care representative becomes operative. Disclosure of physician's determination of incapacity. A living will or appointment of health care representative 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. At any time after the appointment of a health care representative, the attending physician shall disclose such determination of incapacity, in writing, upon the request of the person named as the health care representative.

      (P.A. 91-283, S. 10; P.A. 06-195, S. 70.)

      History: P.A. 06-195 substituted "health care representative" for "health care agent", made a technical change and added provision requiring attending physician to make written disclosure of determination of declarant's incapacity at health care representative's request.

      Sec. 19a-579a. Revocation of living will. Absence of knowledge of revocation. (a) A living will 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 of a living will, 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; P.A. 06-195, S. 71.)

      History: P.A. 93-407 amended Subsec. (c) by incorporating reference to Sec. 19a-575a; P.A. 06-195 amended Subsec. (a) by deleting provision re revocation of appointment of health care agent and amended Subsec. (c) by deleting provisions re health care agent's immunity from liability when acting without knowledge of revocation.

      See Sec. 19a-575a re revocation of appointment of health care representative and immunity from liability for actions undertaken without knowledge of such revocation.

      Sec. 19a-579b. Revocation of appointment of spouse as health care representative upon divorce or legal separation. The appointment of the principal's spouse as health care representative 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; P.A. 06-195, S. 72.)

      History: P.A. 06-195 substituted "health care representative" for "health care agent".

      See Sec. 19a-575a re revocation of appointment of health care representative, generally.

      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 representative, 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; P.A. 06-195, S. 73.)

      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; P.A. 06-195 substituted "health care representative" for "health care agent".

      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 representative 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 representative as a condition of treatment or receiving health care benefits.

      (P.A. 91-283, S. 13; P.A. 06-195, S. 74.)

      History: P.A. 06-195 substituted "health care representative" for "health care agent".

      Sec. 19a-580c. Probate Court jurisdiction over disputes re provisions concerning withholding or withdrawal of life support systems or other medical treatment and capacity of health care representative. Health care representative's standing to challenge revocation. (a) 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 sections 19a-575 and 19a-575a, the court shall consider whether there is clear and convincing evidence of such communication.

      (b) 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 capacity of the health care representative or over any claim that the actions of the person named as health care representative would interfere with the treatment of the declarant or the person named as health care representative.

      (c) A person whose appointment as a health care representative has been revoked shall have standing to file a claim challenging the validity of such revocation with the probate court for the district in which the declarant is domiciled or is located at the time of the dispute.

      (P.A. 91-283, S. 12; P.A. 93-407, S. 12; P.A. 06-195, S. 75.)

      History: P.A. 93-407 added references to Sec. 19a-575a; P.A. 06-195 designated existing provisions as Subsec. (a) and amended same by adding reference to Sec. 19a-575, added Subsec. (b) re disputes over health care representative's capacity and claims of interference with treatment of declarant or person named as health care representative and added Subsec. (c) re health care representative's standing to challenge validity of revocation of appointment.

      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.

      Sec. 19a-580e. Conservator's duty to comply with ward's health care instructions. Precedence of health care representative's decisions. Exceptions. (a) Except as authorized by a court of competent jurisdiction, a conservator shall comply with a ward's individual health care instructions and other wishes, if any, expressed while the ward had capacity and to the extent known to the conservator, and the conservator may not revoke the ward's advance health care directive unless the appointing court expressly so authorizes.

      (b) Absent a court order to the contrary, a health care decision of a health care representative takes precedence over that of a conservator, except under the following circumstances: (1) When the health care decision concerns a person who is subject to the provisions of section 17a-566, 17a-587, 17a-588 or 54-56d; (2) when a conservator has been appointed to a ward who is subject to an order authorized under subsection (e) of section 17a-543, for the duration of the ward's hospitalization; or (3) when a conservator has been appointed to a ward subject to an order authorized under section 17a-543a.

      (P.A. 06-195, S. 79.)

      Sec. 19a-580f. Validity of advance directives executed before October 1, 2006. An advance directive properly executed prior to October 1, 2006, shall have the same legal force and effect as if it had been executed in accordance with the provisions of this chapter.

      (P.A. 06-195, S. 80.)

      Sec. 19a-580g. Validity of advance directives executed in other states or foreign countries. Health care instructions or appointment of a health care proxy executed under the laws of another state in compliance with the laws of that state or the state of Connecticut, and which are not contrary to the public policy of this state, are deemed validly executed for purposes of this chapter. Health care instructions or appointment of a health care proxy executed in a foreign country in compliance with the laws of the country or the state of Connecticut, and which are not contrary to the public policy of this state, are deemed validly executed for the purposes of this chapter. A healthcare provider may rely on such health care instructions or recognize such appointment of a health care proxy based upon any of the following: (1) An order or decision by a court of competent jurisdiction; (2) presentation of a notarized statement from the patient or person offering the health care proxy that the proxy (A) is valid under the laws of the state or country in which it was made, and (B) is not contrary to the public policy of this state; or (3) the healthcare provider's own good faith legal analysis.

      (P.A. 06-195, S. 81.)