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    DNR0901009

    Uploaded by

    ellybear
    This document outlines a living will or health care instructions. It requests that if the author is terminally ill or permanently unconscious, they not be kept alive through life support. It defines terminal and permanently unconscious conditions. It lists types of life support and whether to provide or withhold each. It requests sufficient pain medication but not direct life-taking. The document must be signed by the author and two witnesses.

    Copyright:

    Attribution Non-Commercial (BY-NC)
    Download as PDF, TXT or read online from Scribd

    DNR0901009

    Uploaded by

    ellybear
    24 views3 pages
    This document outlines a living will or health care instructions. It requests that if the author is terminally ill or permanently unconscious, they not be kept alive through life support. It defines terminal and permanently unconscious conditions. It lists types of life support and whether to provide or withhold each. It requests sufficient pain medication but not direct life-taking. The document must be signed by the author and two witnesses.

    Original Description:

    Eleanor Wu September 10, 2009 DNR Order Connecticut

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    This document outlines a living will or health care instructions. It requests that if the author is terminally ill or permanently unconscious, they not be kept alive through life support. It defines terminal and permanently unconscious conditions. It lists types of life support and whether to provide or withhold each. It requests sufficient pain medication but not direct life-taking. The document must be signed by the author and two witnesses.

    Copyright:

    Attribution Non-Commercial (BY-NC)
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
    24 views3 pages

    DNR0901009

    Uploaded by

    ellybear
    This document outlines a living will or health care instructions. It requests that if the author is terminally ill or permanently unconscious, they not be kept alive through life support. It defines terminal and permanently unconscious conditions. It lists types of life support and whether to provide or withhold each. It requests sufficient pain medication but not direct life-taking. The document must be signed by the author and two witnesses.

    Copyright:

    Attribution Non-Commercial (BY-NC)
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
    of 3

    LIVING WILL or HEALTH CARE INSTRUCTIONS

    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 as to my own medical care, I
    wish this statement to stand as a statement of my wishes.

    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.

    Specific Instructions
    Listed below are my instructions regarding particular types of life support systems. This list is not
    all-inclusive. My general statement that I not be kept alive through life support systems provided
    to me is limited only where I have indicated that I desire a particular treatment to be provided.

    Provide Withhold
    Cardiopulmonary Resuscitation __________________________
    Artificial Respiration (including a respirator) __________________________
    Artificial means of providing nutrition and hydration __________________________
    ________________________________________ __________________________
    ________________________________________ __________________________

    Other specific requests: _________________________________________________________


    ____________________________________________________________________________
    ____________________________________________________________________________
    ____________________________________________________________________________
    ____________________________________________________________________________
    ____________________________________________________________________________
    ____________________________________________________________________________
    ____________________________________________________________________________
    ____________________________________________________________________________

    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.

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

    ______ / ______ / ______ (Date) X______________________________


    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 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.

    x__________________________ x___________________________
    (Witness) (Witness)
    x__________________________ x___________________________
    (Number and Street) (Number and Street)
    x__________________________ x___________________________
    (City, State and Zip Code) (City, State and Zip Code)
    OPTIONAL FORM

    WITNESSES' AFFIDAVITS

    STATE OF CONNECTICUT )
    )
    ) :ss.__________________________
    ) (Town)
    COUNTY OF ____________________________ )

    We, the subscribing witnesses, being duly sworn, say that we witnessed the execution of this
    living will or health care instructions 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____.

    x_____________________________ x_______________________________
    (Witness) (Witness)
    x_____________________________ x_______________________________
    (Number and Street) (Number and Street)
    x_____________________________ x_______________________________
    (City, State and Zip Code) (City, State and Zip Code)

    Subscribed and sworn to before me by ___________________and ______________________,


    the signing witnesses to the foregoing affidavit 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)

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