Fillable New Hampshire Advance Directive printable pdf download

NEW HAMPSHIRE ADVANCE DIRECTIVE

NOTE: This form has two sections: the Durable Power of Attorney for Health Care and the

Living Will. You may complete both sections, or only one section.

SECTION I. DURABLE POWER OF ATTORNEY FOR HEALTH CARE

I, _______________________________, (__________), hereby appoint ______________________________

(Name)

(Date of Birth)

(Name of Health Care Agent)

of _________________________________________________________________________________________

(Health Care Agent’s address and phone #)

If you choose more than one agent, they will have authority in priority of the order their

names are listed, unless you indicate another form of decision making.) as my agent to

make any and all health care decisions for me, except to the extent I state otherwise in this

directive or as prohibited by law. This Durable Power of Attorney for Health Care shall take

effect in the event I lack the capacity to make my own health care decisions.

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 Health Care Agent)

of _________________________________________________________________________________________

(Health Care Agent’s address and phone #)

Statement of Desires, Special Provisions, and Limitations about 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).)

ed.

_____ (a) life-sustaining treatment not be started, or if started, be discontinu

-or-

_____ (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:

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

-or-

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

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New Hampshire Advance Directive

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