Fillable New Hampshire Durable Power Of Attorney For Health Care (Page 2 of 3) in pdf

New Hampshire Durable Power Of Attorney For Health Care Page 2

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2. Whether near death or not, if I become permanently unconscious and life-

sustaining treatment has no reasonable hope of benefit, 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.

B. ADDITIONAL INSTRUCTIONS.

Here you may include any specific desires or limitations you deem appropriate,

such as your preferences concerning medically administered nutrition and hydration,

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 directive will be kept at ______________________ and the

following persons and institutions will have signed copies:

_____________________________________________________________________

New Hampshire Durable Power Of Attorney For Health Care Page 2

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