New Hampshire Durable Power Of Attorney For Health Care
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DURABLE POWER OF ATTORNEY FOR HEALTH CARE
I, ___________________, hereby appoint ____________________ of
_____________________ (Please choose only one person. 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 _______________________
of _______________________ as alternate agent. (Please choose only one person. If
you choose more than one alternate agent, they will have authority in priority of the
order their names are listed.)
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.
-or-
___ (b) life-sustaining treatment continue to be given to me.
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