DURABLE HEALTHCARE POWER OF ATTORNEY
(Connecticut)
[// GUIDANCE: This template complies with Conn. Gen. Stat. §§ 19a-575a et seq. (health-care agent and advance directives) and 45 C.F.R. § 164.508 (HIPAA). Customize bracketed items, confirm witness capacity requirements, and review for client-specific medical, religious, or ethical preferences before execution.]
TABLE OF CONTENTS
- Document Header
- Definitions
- Operative Provisions
- Representations & Warranties
- Covenants & Restrictions
- Default & Remedies
- Risk Allocation
- Dispute Resolution
- General Provisions
- Execution Block
1. DOCUMENT HEADER
1.1 Title. Durable Power of Attorney for Health Care and Advance Directive (the “Instrument”).
1.2 Parties. This Instrument is made as of [EFFECTIVE DATE] (“Effective Date”) by [PRINCIPAL FULL LEGAL NAME], residing at [ADDRESS] (the “Principal”), appointing [AGENT FULL LEGAL NAME], residing at [ADDRESS] (the “Agent”).
1.3 Recitals.
(a) Principal desires to authorize Agent to make health-care decisions on Principal’s behalf if Principal is unable to do so.
(b) This Instrument is intended to be valid in all jurisdictions, but is governed by Connecticut law, including Conn. Gen. Stat. § 19a-576.
1.4 Consideration. Mutual promises herein constitute sufficient consideration.
1.5 Governing Law. This Instrument shall be governed by the laws of the State of Connecticut (“Governing Law”).
2. DEFINITIONS
For purposes of this Instrument, capitalized terms have the meanings set forth below:
“Advance Directive” – Written instructions regarding health-care treatment choices, including end-of-life decisions, expressed in Section 3.4.
“Durable” – Surviving the Principal’s incapacity pursuant to Conn. Gen. Stat. § 19a-576.
“Good Faith” – Honesty in fact and the observance of reasonable standards of health-care decision making under the circumstances.
“Health Care Decision” – Any consent, refusal, withdrawal, or continuation of any medical treatment, service, or procedure affecting the Principal’s physical or mental condition.
“HIPAA” – The Health Insurance Portability and Accountability Act of 1996 and regulations promulgated thereunder, including 45 C.F.R. § 164.508.
“Qualified Witness” – A natural person at least eighteen (18) years old, not named as Agent or Alternate Agent, and not a health-care provider or employee directly involved in Principal’s care at the time of execution, as required by Conn. Gen. Stat. § 19a-575a.
3. OPERATIVE PROVISIONS
3.1 Appointment of Agent. Principal hereby appoints Agent, with full power of substitution, to act as Principal’s health-care agent in accordance with Connecticut law.
3.2 Grant of Authority.
(a) General Authority. Agent may make any Health Care Decision the Principal could make if able, including without limitation: selecting and discharging health-care providers; consenting to, refusing, or withdrawing treatment; and accessing medical records.
(b) Limitation. Agent’s authority is subject to the restrictions expressly stated in this Instrument.
3.3 Decision-Making Standard. Agent shall act according to Principal’s expressed wishes; if unknown, Agent shall act in Principal’s Best Interests, considering Principal’s personal values.
3.4 End-of-Life Directives.
(a) Life-Sustaining Treatment. If Principal is terminally ill or permanently unconscious, Principal [CHOOSE ONE: “does” / “does NOT”] want life-sustaining treatment (including CPR, mechanical ventilation, dialysis).
(b) Artificial Nutrition & Hydration. Principal [CHOOSE ONE: “authorizes” / “does NOT authorize”] artificial nutrition or hydration when death is imminent or Principal is permanently unconscious.
(c) Palliative Care. Principal directs provision of medication or procedures necessary for pain relief even if they may hasten death, consistent with Good Medical Practice.
[// GUIDANCE: Modify subsections (a)–(c) to reflect the client’s specific wishes.]
3.5 HIPAA Authorization. Pursuant to 45 C.F.R. § 164.508, Principal authorizes all health-care providers and insurers to disclose to Agent any of Principal’s protected health information (“PHI”) necessary to carry out purposes of this Instrument. This authorization is effective immediately and survives Principal’s death to the extent PHI is needed to effectuate health-care decisions.
3.6 Nomination of Conservator. If a conservator of the person is later required, Principal nominates Agent to serve in that role.
3.7 Alternate Agents. If Agent is unable or unwilling to serve, Principal appoints [ALTERNATE AGENT 1], and if that person is unable or unwilling, [ALTERNATE AGENT 2] (each, an “Alternate Agent”), in the order named.
3.8 Effective Date & Durability. This Instrument becomes effective upon execution and remains effective during any period in which Principal lacks capacity, and terminates upon revocation or Principal’s death except as otherwise provided herein.
4. REPRESENTATIONS & WARRANTIES
4.1 Principal’s Representations. Principal represents that:
(a) Principal is at least eighteen (18) years old and of sound mind;
(b) No undue influence or fraud affects this Instrument;
(c) Execution complies with Connecticut law.
4.2 Agent’s Representations. By signing the Acknowledgment in Section 10, Agent represents that Agent:
(a) Is willing and able to serve;
(b) Understands and accepts the duties herein;
(c) Is not disqualified under Conn. Gen. Stat. § 19a-576.
5. COVENANTS & RESTRICTIONS
5.1 Duty of Loyalty & Care. Agent shall act in Good Faith, consistent with Principal’s known wishes and Best Interests.
5.2 Recordkeeping. Agent shall maintain records of material decisions and, upon reasonable request, provide copies to interested persons permitted under law.
5.3 Consultation. Agent shall consult with attending physicians and, where feasible, with family members or spiritual advisors the Principal customarily consults.
5.4 Delegation. Agent may not delegate decision-making authority except to an Alternate Agent duly appointed herein.
6. DEFAULT & REMEDIES
6.1 Events of Default. Any of the following constitutes an “Event of Default”:
(a) Agent’s breach of duty under Section 5;
(b) Agent’s incapacity or resignation without timely notice;
(c) Judicial determination of Agent’s misconduct.
6.2 Remedies. Upon an Event of Default, any interested person may petition the Connecticut Probate Court for:
(i) Removal of Agent;
(ii) Appointment of an Alternate Agent or conservator;
(iii) Injunctive relief to prevent or compel specific health-care actions.
6.3 Notice & Opportunity to Cure. Unless immediate action is required to prevent substantial harm, Agent shall receive written notice and seventy-two (72) hours to cure the alleged breach.
7. RISK ALLOCATION
7.1 Indemnification. Principal agrees to indemnify and hold Agent harmless from any liability, cost, or expense (including reasonable attorneys’ fees) incurred as a result of actions taken in Good Faith under this Instrument (“Indemnification”).
7.2 Limitation of Liability. Agent shall not be liable for any act or omission undertaken in Good Faith and in accordance with Connecticut law (“Liability Cap”).
7.3 Insurance. Principal encourages Agent to verify that Principal’s health-care coverage includes professional liability protection for Good-Faith decisions; however, no separate insurance is mandated.
8. DISPUTE RESOLUTION
8.1 Governing Law. Connecticut substantive law governs all disputes arising under this Instrument.
8.2 Forum Selection. Exclusive jurisdiction and venue lie in the probate court of the district where the Principal resides or is located at the time the dispute arises (“Designated Court”).
8.3 Arbitration. Arbitration is expressly not available.
8.4 Jury Waiver. Jury waiver is not provided.
8.5 Injunctive Relief. Nothing herein limits the Designated Court’s power to grant emergency or permanent injunctive relief respecting Health Care Decisions.
9. GENERAL PROVISIONS
9.1 Amendment & Revocation. Principal may amend or revoke this Instrument at any time by executing a written instrument or by physically destroying all executed originals.
9.2 Assignment. Neither Agent nor Alternate Agent may assign or delegate powers except as expressly permitted herein.
9.3 Successors & Assigns. This Instrument binds and benefits the parties and their respective successors, heirs, and personal representatives.
9.4 Severability. If any provision is held invalid, remaining provisions remain in full force, and the invalid provision shall be reformed to the minimum extent necessary to comply with applicable law.
9.5 Integration. This Instrument constitutes the entire agreement regarding the subject matter, superseding all prior oral or written directives.
9.6 Counterparts; Electronic Signatures. This Instrument may be executed in counterparts and by electronic signature, each of which is deemed an original.
9.7 Copies. Photocopies and electronic copies of this Instrument have the same effect as an original.
10. EXECUTION BLOCK
10.1 Principal’s Signature
I, the undersigned Principal, execute this Durable Healthcare Power of Attorney and Advance Directive on the Effective Date.
[PRINCIPAL NAME] – Principal
Date: _____
10.2 Agent’s Acknowledgment
I, the undersigned Agent, accept the appointment and acknowledge my fiduciary duties under this Instrument and Connecticut law.
[AGENT NAME] – Agent
Date: _____
10.3 Alternate Agent(s) Acknowledgment (optional)
[ALTERNATE AGENT 1 NAME] – Alternate Agent
Date: _____
[ALTERNATE AGENT 2 NAME] – Alternate Agent
Date: _____
10.4 Witness Attestation
We, the undersigned Qualified Witnesses, declare that the Principal voluntarily signed or acknowledged this Instrument in our presence and appears to be of sound mind and under no duress or undue influence.
Witness #1:
Name: ___
Address: ___
Date: _____
Witness #2:
Name: ___
Address: ___
Date: _____
[// GUIDANCE: Confirm each witness meets the “Qualified Witness” criteria under Conn. Gen. Stat. § 19a-575a.]
10.5 Notary Public (optional but recommended)
State of Connecticut
County of ____
On this _ day of __, 20___, before me, the undersigned Notary Public, personally appeared [PRINCIPAL NAME], who acknowledged executing the foregoing instrument for the purposes therein contained.
Notary Public
My Commission Expires: ____
[// GUIDANCE: Retain executed originals in easily accessible locations, and provide copies to Agent, Alternate Agents, primary physician, and loved ones. File a copy with the Principal’s medical records when feasible.]