New Hampshire Living Will Form

01 Jul, 2017 Legal Forms, living-will 0

The New Hampshire Living Will is a form that can be used for allowing the establishment of a living will in the State of North Hampshire. This will is concerned with decisions regarding the end of life health care.

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9 NEW HAMPSHIRE ADVANCE DIRECTIVE — PAGE 4 OF 11

PART I: NEW HAMPSHIRE DURABLE POWER OF ATTORNEY
FOR HEALTH CARE

I , _________________________________________________________,
(name)

hereby appoint _______________________________________________
(name of agent)

of __________________________________________________________
(address)

____________________________________________________________

In the event the person I appoint above is unable, unwilling or unavailable,
or ineligible to act as my health care agent, I hereby appoint

_________________________________________________________
(name of an alternate agent)

of ____________________________________________________
(address)

____________________________________________________
as alternate agent.

When making health-care decisions for me, my agent should think about
what action would be consistent with past conversations we have had, my
treatment preferences as expressed in this advance directive, my religious
and other beliefs and values, and how I have handled medical and other
important issues in the past. If what I would decide is still unclear, then
my health-care agent should make decisions for me that my health-care
agent believes are in my best interest, considering the benefits, burdens,
and risks of my current circumstances and treatment options.

PRINT YOUR NAME

PRINT THE NAME
AND ADDRESS OF
YOUR AGENT

PRINT THE NAME
AND ADDRESS OF
YOUR ALTERNATE
AGENT

10 NEW HAMPSHIRE ADVANCE DIRECTIVE — PAGE 5 OF 11

STATEMENT OF DESIRES, SPECIAL PROVISIONS, AND LIMITATIONS
REGARDING HEALTH CARE DECISIONS.

For your convenience in expressing your wishes, some general statements concerning
the withholding or removal of life-sustaining treatment are set forth below. (Life-
sustaining treatment is defined as procedures without which a person would die, such
as but not limited to the following: mechanical respiration, kidney dialysis or the use of
other external mechanical and technological devices, drugs to maintain blood pressure,
blood transfusions, and antibiotics.) There is also a section which allows you to set
forth specific directions for these or other matters. If you wish, you may indicate your
agreement or disagreement with any of the following statements and give your agent
power to act in those specific circumstances.

A. LIFE-SUSTAINING TREATMENT.

1.
If I am near death and lack the capacity to make health care decisions, I
authorize my agent to direct that:

(Initial beside your choice of (a) or (b).)

____(a) life-sustaining treatment not be started, or if started, be
discontinued.

____(b) life-sustaining treatment continue to be given to me.

2. Whether near death or not, if I become permanently unconscious I authorize
my agent to direct that:

(Initial beside your choice of (a) or (b).)

____(a) life-sustaining treatment not be started, or if started, be
discontinued.

____(b) life-sustaining treatment continue to be given to me.

B. MEDICALLY ADMINISTERED NUTRITION AND HYDRATION.

1. I realize that situations could arise in which the only way to allow me to die would
be to not start or to discontinue medically administered nutrition and hydration. In
carrying out any instructions I have given in this document, I authorize my agent
to direct that:

(Initial beside your choice of (a) or (b).)

____(a) medically administered nutrition and hydration not be
started or, if started, be discontinued.

____(b) even if all other forms of life-sustaining treatment have been
withdrawn, medically administered nutrition and hydration continue to
be given to me.

INSTRUCTION
STATEMENTS

INITIAL THE
RESPONSES THAT
REFLECT YOUR
WISHES

INITIAL ONLY ONE
CHOICE

11 NEW HAMPSHIRE ADVANCE DIRECTIVE — PAGE 6 OF 11

C. ADDITIONAL INSTRUCTIONS.

Here you may include any specific desires or limitations you deem
appropriate, such as when or what life-sustaining treatment you would want
used or withheld, or instructions about refusing any specific types of
treatment that are inconsistent with your religious beliefs or are unacceptable
to you for any other reason. You may leave this question blank if you desire.

____________________________________________________________

(attach additional pages as necessary)

I hereby acknowledge that I have been provided with a disclosure
statement explaining the effect of this directive. I have read and
understand the information contained in the disclosure statement.

The original of this document will be kept at: ______________________,
and the following persons and institutions will have signed copies:

____________________________________________________________
Name

____________________________________________________________
Address

____________________________________________________________
Name

____________________________________________________________
Address

ADD OTHER
INSTRUCTIONS, IF
ANY, REGARDING
YOUR ADVANCE
CARE PLANS

THESE
INSTRUCTIONS CAN
FURTHER ADDRESS
YOUR HEALTH CARE
PLANS, SUCH AS
YOUR WISHES
REGARDING
HOSPICE
TREATMENT, BUT
CAN ALSO ADDRESS
OTHER ADVANCE
PLANNING ISSUES,
SUCH AS YOUR
BURIAL WISHES

ATTACH
ADDITIONAL PAGES
IF NEEDED

LOCATION OF THE
ORIGINAL AND
COPIES

12 NEW HAMPSHIRE ADVANCE DIRECTIVE – PAGE 7 OF 11

PART II. NEW HAMPSHIRE DECLARATION

Declaration made this ___________ day of ____________________.
(day) (month, year)

I, ____________________________________________________,
(name)
being of sound mind, willfully and voluntarily make known my desire that
my dying shall not be artificially prolonged under the circumstances set
forth below, do hereby declare:

If at any time I should have an incurable injury, disease or illness and I am
certified to be near death or in a permanently unconscious condition by 2
physicians or a physician and an ARNP, and two physicians or a physician
and an ARNP have determined that my death is imminent whether or not
life-sustaining treatment is utilized and where the application of life-
sustaining treatment would serve only to artificially prolong the dying
process, or that I will remain in a permanently unconscious condition, I
direct that such procedures be withheld or withdrawn, and that I be
permitted to die naturally with only the administration of medication, the
natural ingestion of food or fluids by eating or drinking, or the performance
of any medical procedure deemed necessary to provide me with comfort
care. I realize that situations could arise in which the only way to allow me
to die would be to discontinue medically administered nutrition and
hydration.

In carrying out any instruction I have given under this section, I authorize
that:

(Initial beside your choice of (a) or (b).)

____(a) medically administered nutrition and hydration not be
started or, if started, be discontinued,

____(b) even if other forms of life-sustaining treatment have been
withdrawn, medically administered nutrition and hydration continue
to be given to me.

PRINT THE DATE

PRINT YOUR NAME

INITIAL ONLY ONE
CHOICE

13 NEW HAMPSHIRE ADVANCE DIRECTIVE — PAGE 8 OF 11

Other directions:

____________________________________________________________

In the absence of my ability to give directions regarding the use of such
life-sustaining treatment, it is my intention that this declaration shall be
honored by my family and health care providers as the final expression of
my right to refuse medical or surgical treatment and accept the
consequences of such refusal.

I understand the full meaning and significance of this declaration, and I
am emotionally and mentally competent to make this declaration.

ADD ADDITIONAL
INSTRUCTIONS, IF
ANY

PART II IS ONLY
EFFECTIVE TO
STATE A DECISION
TO WITHHOLD OR
WITHDRAW LIFE-
SUSTAINING
TREATMENTS IF
YOU ARE NEAR
DEATH OR
PERMENANTLY
UNCONSCIOUS

BECAUSE PART II IS
LIMITED IN THIS
WAY, IF YOU PLAN
TO COMPLETE PART
I, YOU MAY WISH
TO LEAVE PART II
BLANK AND
RECORD YOUR
ADVANCE
PLANNING WISHES
IN PART I.

14 NEW HAMPSHIRE ADVANCE DIRECTIVE – PAGE 9 OF 11

PART III: EXECUTION

This advance directive will not be valid unless it is EITHER:

Alternative No. 1: Signed by two (2) adult witnesses who are present
when you sign or acknowledge your signature.

Neither of your witnesses can be:
 your agent,
 your spouse,
 your heir or any person entitled to any part of your estate either
under your last will and testament or by operation of law,
 your attending physician or ARNP, or person acting under the
direction and control of your attending physician or ARNP.

In addition, one of your witnesses cannot be:
 your health or residential care provider, or an employee of your
health or residential care provider

Alternative No. 2: Witnessed by a notary public or justice of the peace

IF YOU DECIDE TO
HAVE YOUR
ADVANCED
DIRECTIVE
WITNESSED, USE
ALTERNATIVE NO.
1, BELOW (P. 15)

IF YOU DECIDE TO
HAVE YOUR
ADVANCE
DIRECTIVE
NOTARIZED, USE
ALTERNATIVE NO.
2, BELOW (P. 16)

15 NEW HAMPSHIRE ADVANCE DIRECTIVE - PAGE 10 OF 11

Alternative No. 1: Sign before witnesses.

I sign my name to this Advance Directive on
________________ at ______________________,______________.
(date) (city) (state)

_____________________________________

(signature)

_____________________________________

(print name)

WITNESS ATTESTATION

We declare that the principal appears to be of sound mind and free from
duress at the time this advance directive is signed and that the principal
affirms that he or she is aware of the nature of the advance directive and is
signing it freely and voluntarily.

Witness 1:

Signature: ____________________________________Date___________

Print Name: ___________________________________________________

Residence Address: _____________________________________________

Witness 2:

Signature: ____________________________________Date___________

Print Name: ___________________________________________________

Residence Address: _____________________________________________

SIGN AND PRINT
YOUR NAME, THE
DATE, AND
LOCATION HERE

HAVE YOUR
WITNESSES SIGN,
DATE AND PRINT
THEIR NAMES AND
ADDRESSES HERE

16 NEW HAMPSHIRE ADVANCE DIRECTIVE - PAGE 11 OF 11

Alternative No. 2: Sign before a notary public or justice of the
peace.

I sign my name to this Advance Directive on
________________ at _______________________,____________.
(date) (city) (state)

_____________________________________

(signature)

_____________________________________

(print name)

CERTIFICATE OF ACKNOWLEDGMENT OF NOTARY PUBLIC OR JUSTICE
OF THE PEACE
STATE OF NEW HAMPSHIRE
COUNTY OF ____________________
The foregoing advance directive was acknowledged before me this ___
day of __________, 20___, by __________ (the "Principal'').

___________________________________________________________
Notary Public/Justice of the Peace

My Commission Expires:

Courtesy of Caring Connections
1731 King St., Suite 100, Alexandria, VA 22314
www.caringinfo.org, 800/658-8898

SIGN AND PRINT
YOUR NAME, THE
DATE, AND
LOCATION HERE

A NOTARY PUBLIC
OR JUSTICE OF THE
PEACE MUST
COMPLETE THIS
SECTION

17 NEW HAMPSHIRE ORGAN DONATION FORM – PAGE 1 OF 1

Initial the line next to the statement below that best reflects your wishes. You do
not have to initial any of the statements. If you do not initial any of the
statements, your attorney for health care, proxy, or other agent, or your family,
may have the authority to make a gift of all or part of your body under New
Hampshire law.

_____ I do not want to make an organ or tissue donation and I do not want my
attorney for health care, proxy, or other agent or family to do so.
_____ I have already signed a written agreement or donor card regarding organ
and tissue donation with the following individual or institution:

Name of individual/institution:_____________________

_____ Pursuant to New Hampshire law, I hereby give, effective on my death:

_____ Any needed organ or parts.
_____ The following part or organs listed below:

For (initial one):

_____ Any legally authorized purpose.
_____ Transplant or therapeutic purposes only.

Declarant name: ____________________________________________

Declarant signature: _______________________, Date: ____________

The declarant voluntarily signed or directed another person to sign this writing in
our presence. We signed this document as witnesses in the declarant’s presence
and in each other’s presence.

Witness ____________________________Date__________________

Address __________________________________________________

___________________________________________________

Witness ______________________________Date________________

Address __________________________________________________

__________________________________________________

Courtesy of Caring Connections
1731 King St., Suite 100, Alexandria, VA 22314
www.caringinfo.org, 800/658-8898

ORGAN DONATION
(OPTIONAL)

INITIAL THE
OPTION THAT
REFLECTS YOUR
WISHES

ADD NAME OR
INSTITUTION (IF
ANY)

PRINT YOUR NAME,
SIGN, AND DATE
THE DOCUMENT

YOUR WITNESSES
MUST SIGN AND
PRINT THEIR
ADDRESSES

18 You Have Filled Out Your Health Care Directive, Now What?

1. Your New Hampshire Advance Directive is an important legal document. Keep the
original signed document in a secure but accessible place. Do not put the original
document in a safe deposit box or any other security box that would keep others from
having access to it.

2. Give photocopies of the signed original to your agent and alternate agent, doctor(s),
family, close friends, clergy, and anyone else who might become involved in your
healthcare. If you enter a nursing home or hospital, have photocopies of your
document placed in your medical records.

3. Be sure to talk to your agent(s), doctor(s), clergy, family, and friends about your wishes
concerning medical treatment. Discuss your wishes with them often, particularly if your
medical condition changes.

4. You may also want to save a copy of your form in Google Health, or another online
medical records management service that allows you to share your medical documents
with your physicians, family, and others who you want to take an active role in your
advance care planning. You can read more about Google Health at
http://www.caringinfo.org/googlehealth
.

5. If you want to make changes to your documents after they have been signed and
witnessed, you must complete a new document.

6. Remember, you can always revoke your New Hampshire document.

7. Be aware that your New Hampshire document will not be effective in the event of a
medical emergency. Ambulance and hospital emergency department personnel are
required to provide cardiopulmonary resuscitation (CPR) unless they are given a
separate directive that states otherwise. These directives called “prehospital medical
care directives” or “do not resuscitate orders” are designed for people whose poor
health gives them little chance of benefiting from CPR. These directives instruct
ambulance and hospital emergency personnel not to attempt CPR if your heart or
breathing should stop.

Currently not all states have laws authorizing these orders. We suggest you speak to
your physician if you are interested in obtaining one. Caring Connections does not
distribute these forms.

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New Hampshire Living Will Form

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