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Connecticut statutory health care form
Download the August 2026 Connecticut Health Care Instructions (Living Will), the suggested form under Conn. Gen. Stat. § 19a-575, for recording life support wishes. Get the form in editable Word and true fillable PDF. Add the completed sample PDF if you want a filled-in reference.
A state-specific connecticut health care instructions (living will) packet, reviewed against the current Connecticut statute and ready for instant secure access.
Tracks the § 19a-575 form with terminal and permanently unconscious definitions, the statutory life support list, and pregnancy instructions.
Leave a listed life support system unmarked if you do not want it. Cross out and initial a system only if you want it administered.
Complete the files on your own device, then print, initial, and sign with at least two witnesses. Your personal details are never entered into an online form builder.
This download includes 1 document in editable Word and fillable PDF formats. Use the Word version for editing; the fillable PDF can be completed on screen, then printed and signed.
Review the complete form text below before purchasing. Your licensed download (editable Word and fillable PDF) is delivered after checkout.
DOCUMENT CONCERNING HEALTH CARE AND WITHHOLDING OR WITHDRAWAL OF LIFE SUPPORT SYSTEMS
If the time comes when I am incapacitated to the point when I can no longer actively take part in decisions for my own life, and am unable to direct my physician or advanced practice registered nurse as to my own medical care, I wish this statement to stand as a testament of my wishes.
I, __________ (Name), request that, if my condition is deemed terminal or if it is determined that I will 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 or advanced practice registered nurse, 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
(___) Artificial means of providing nutrition and hydration
(Cross out and initial life support systems you want administered)
I do not intend any direct taking of my life, but only that my dying not be unreasonably prolonged.
If I am pregnant:
(Place a check to indicate option (1) or (2) or specify alternative instructions after (3))
☐ (1) I intend to accept life support systems if my doctor believes that doing so would allow my fetus to reach a live birth.
☐ (2) I intend this document to apply without modifications.
☐ (3) I intend this document to apply as follows: __________
Other specific requests: __________
This request is made, after careful reflection, while I am of sound mind.
Printed Name: __________
Date: __________
Principal Signature: __________
This document was signed in our presence, by the above-named person 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 1 Signature: __________
Printed Name: __________
Address: __________
Witness 2 Signature: __________
Printed Name: __________
Address: __________
Legal currency, verified
State your wishes about withholding or withdrawing life support systems using a document that tracks the suggested form in Conn. Gen. Stat. § 19a-575.
The form includes current physician and advanced practice registered nurse language, the statutory treatment list, and pregnancy choices.
Sign and date the document with at least two witnesses. Notarization is not required.
Receive the complete form in editable Word and true fillable PDF. Wet-ink initials and signatures are completed after printing.
Use the separate Connecticut Appointment of Health Care Representative if you also want to name a decision maker.
This form is not legal advice. Consider consulting a Connecticut attorney about your circumstances.
ILRG is committed to top quality legal forms that are valid in all states. If you are not 100 percent satisfied after purchase, contact us for a full refund.
It tracks the suggested health care instructions form in Conn. Gen. Stat. § 19a-575, including APRN language and the pregnancy choices. It was reviewed and verified in August 2026.
An unmarked system is one you do not want. Cross out and initial only a listed system that you want administered.
Sign and date it with at least two witnesses under § 19a-575. The statute does not require notarization for this form.
No. Use the separate Connecticut Appointment of Health Care Representative at /forms/states/ct-healthagent.html if you also want to name a decision maker.
Both contain the same form text. Use Word to edit or the fillable PDF to complete fields on screen. Print either version, then add wet-ink initials and signatures on paper.