Connecticut Appointment of Health Care Representative

CONNECTICUT APPOINTMENT OF HEALTH CARE REPRESENTATIVE

Conn. Gen. Stat. § 19a-577

I understand that, as a competent adult, I have the right to make decisions about my health care. There may come a time when I am unable, due to incapacity, to make my own health care decisions. In those circumstances, those caring for me will need direction and will turn to someone who knows my values and health care wishes. By signing this document, I appoint a health care representative with legal authority to make health care decisions on my behalf in such case or at such time.

Appointment

I appoint _____________________________________________________________________

to be my health care representative.

If my attending physician or advanced practice registered nurse 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 representative is authorized to:

1. Accept or refuse any treatment, service, or procedure used to diagnose or treat my physical or mental condition, except as otherwise provided by law, including psychosurgery or shock therapy as defined in Conn. Gen. Stat. § 17a-540; and

2. Make the decision to provide, withhold, or withdraw life support systems.

I direct my health care representative to make decisions on my behalf in accordance with my wishes as stated in a living will, or as otherwise known to my health care representative. If my wishes are not clear or a situation arises that I did not anticipate, my health care representative may make a decision in my best interests, based upon what is known of my wishes.

Alternative Health Care Representative

If ___________________________________ is unwilling or unable to serve,

I appoint _____________________________________________________________________

to be my alternative health care representative.

Declarant’s Statement and Signature

This request is made, after careful reflection, while I am of sound mind.

Printed name: ___________________________________________________________

Date: ______________________________

________________________________________________________

Signature of Declarant

Witnesses’ Statements

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 when 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.

Each witness is an adult. Neither witness is the health care representative or alternative health care representative appointed in this document.

Witness 1

Printed name: ___________________________________________________________

Number and street: ______________________________________________________

City, state, and ZIP code: ________________________________________________

________________________________________________________

Signature of Witness 1

Witness 2

Printed name: ___________________________________________________________

Number and street: ______________________________________________________

City, state, and ZIP code: ________________________________________________

________________________________________________________

Signature of Witness 2

Signing note: The declarant must sign and date this appointment in the presence of two adult witnesses, who must also sign. An appointed representative may not act as a witness. Conn. Gen. Stat. § 19a-576.