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NEW HAMPSHIRE ADVANCE DIRECTIVE

DURABLE POWER OF ATTORNEY AND LIVING WILL DISCLOSURE STATEMENT

AND FORM

THIS IS AN IMPORTANT LEGAL DOCUMENT. BEFORE SIGNING IT, YOU SHOULD

KNOW THESE IMPORTANT FACTS:

Except if you say otherwise in the directive, this directive gives the person you name as your health care

agent the power to make any and all health care decisions for you when you lack the capacity to make

health care decisions for yourself (in other words, you no longer have the ability to understand and

appreciate generally the nature and consequences of a health care decision, including the significant

benefits and harms of and reasonable alternatives to any proposed health care). "Health care'' means

any treatment, service or procedure to maintain, diagnose or treat your physical or mental condition.

Your health care agent, therefore, will have the power to make a wide range of health care decisions for

you. Your health care agent may consent (in other words, give permission), refuse to consent, or

withdraw consent to medical treatment, and may make decisions about withdrawing or withholding life-

sustaining treatment. Your health care agent cannot consent to or direct any of the following:

commitment to a state institution, sterilization, or termination of treatment if you are pregnant and if

the withdrawal of that treatment is deemed likely to terminate the pregnancy, unless the treatment will

be physically harmful to you or prolong severe pain which cannot be alleviated by medication.

You may state in this directive any treatment you do not want, or any treatment you want to be sure

you receive. Your health care agent's power will begin when your doctor certifies that you lack the

capacity to make health care decisions (in other words, that you are not able to make health care

decisions). If for moral or religious reasons you do not want to be treated by a doctor or to be examined

by a doctor to certify that you lack capacity, you must say so in the directive and you must name

someone who can certify your lack of capacity. That person cannot be your health care agent or

alternate health care agent or any person who is not eligible to be your health care agent. You may

attach additional pages to the document if you need more space to complete your statement.

If you want to give your health care agent power to withhold or withdraw medically administered

nutrition and hydration, you must say so in your directive. Otherwise, your health care agent will not be

able to direct that. Under no conditions will your health care agent be able to direct the withholding of

food and drink that you are able to eat and drink normally.

Your agent shall be directed by your written instructions in this document when making decisions on

your behalf, and as further guided by your medical condition or prognosis. Unless you state otherwise in

the directive, your agent will have the same power to make decisions about your health care as you

would have made, if those decisions by your health care agent are made consistent with state law.

It is important that you discuss this directive with your doctor or other health care providers before you

sign it, to make sure that you understand the nature and range of decisions which could be made for

you by your health care agent. If you do not have a health care provider, you should talk with someone

else who is knowledgeable about these issues and can answer your questions. Check with your

community hospital or hospice for trained staff. You do not need a lawyer's assistance to complete this

directive, but if there is anything in this directive that you do not understand, you should ask a lawyer to

explain it to you.

The person you choose as your health care agent should be someone you know and trust, and he or she

must be at least 18 years old. If you choose your health or residential care provider (such as your doctor,

advanced practice registered nurse, or an employee of a hospital, nursing home, home health agency, or

residential care home, other than a relative), that person will have to choose between acting as your

health care agent or as your health or residential care provider, because the law does not allow a person

to do both at the same time.

You should consider choosing an alternate health care agent, in case your health care agent is unwilling,

unable, unavailable or not eligible to act as your health care agent. Any alternate health care agent you

choose will then have the same authority to make health care decisions for you.

You should tell the person you choose that you want him or her to be your health care agent. You

should talk about this directive with your health care agent and your doctor or advanced practice

registered nurse and give each one a signed copy. You should write on the directive itself the people and

institutions who will have signed copies. Your health care agent will not be liable for health care

decisions made in good faith on your behalf.

EVEN AFTER YOU HAVE SIGNED THIS DIRECTIVE, YOU HAVE THE RIGHT TO MAKE HEALTH CARE

DECISIONS FOR YOURSELF AS LONG AS YOU ARE ABLE TO DO SO, AND TREATMENT CANNOT BE GIVEN

TO YOU OR STOPPED OVER YOUR CLEAR OBJECTION. You have the right to revoke the power given to

your health care agent by telling him or her, or by telling your health care provider, orally or in writing,

that you no longer want that person to be your health care agent.

YOU HAVE THE RIGHT TO EXCLUDE OR STRIKE REFERENCES TO APRN'S IN YOUR ADVANCE DIRECTIVE

AND IF YOU DO SO, YOUR ADVANCE DIRECTIVE SHALL STILL BE VALID AND ENFORCEABLE.

Once this directive is executed it cannot be changed or modified. If you want to make changes, you must

make an entirely new directive.

THIS POWER OF ATTORNEY WILL NOT BE VALID UNLESS IT IS SIGNED IN THE PRESENCE OF A NOTARY

PUBLIC OR JUSTICE OF THE PEACE OR TWO (2) OR MORE QUALIFIED WITNESSES, WHO MUST BOTH BE

PRESENT WHEN YOU SIGN AND WHO WILL ACKNOWLEDGE YOUR SIGNATURE ON THE DOCUMENT. THE

FOLLOWING PERSONS MAY NOT ACT AS WITNESSES:

___The person you have designated as your health care agent;

___Your spouse or heir at law;

___Your attending physician or APRN, or person acting under the direction or control of the attending

physician or APRN.

ONLY ONE OF THE TWO WITNESSES MAY BE YOUR HEALTH OR RESIDENTIAL CARE PROVIDER OR ONE OF

YOUR PROVIDER'S EMPLOYEES.

NEW HAMPSHIRE ADVANCE DIRECTIVE

NOTE: This form has two sections.

You may complete both sections, or only one section.

I. 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.

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.

-or-

___ (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.

-or-

___(b) even if all other forms of life-sustaining treatment have been withdrawn, medically

administered nutrition and hydration continue to be given to me.

(If you fail to complete item B, your agent will not have the power to direct the withholding or

withdrawal of medically administered nutrition and hydration.)

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 directive will be kept at __________________________________________

and the

following persons and institutions will have signed copies:

Signed this ___ day of __________, 20___

Principal's Signature: ____________________________

[If you are physically unable to sign, this directive may be signed by someone else writing your

name, in your presence and at your express direction.]

THIS POWER OF ATTORNEY DIRECTIVE MUST BE SIGNED BY TWO WITNESSES OR A NOTARY

PUBLIC OR A JUSTICE OF THE PEACE.

We declare that the principal appears to be of sound mind and free from duress at the time the

durable power of attorney for health care is signed and that the principal affirms that he or she

is aware of the nature of the directive and is signing it freely and voluntarily.

Witness:________________________Address:____________________________

STATE OF NEW HAMPSHIRE

COUNTY OF ____________________

The foregoing durable power of attorney for health care was acknowledged before me this ___

day of __________, 20___, by __________ ("the Principal'').

__________________________________

Notary Public/Justice of the Peace

My Commission expires

II. LIVING WILL

Declaration made this ___ day of ____________, 20___.

I, __________________________, 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 APRN or

PA, and 2 physicians or a physician and an APRN or PA 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 and 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,

-or-

___(b) even if all other forms of life-sustaining treatment have been withdrawn, medically

administered nutrition and hydration continue to be given to me.

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 import of this declaration, and I am emotionally and mentally competent

to make this declaration.

Signed this ___ day of __________, 20___.

Principal's Signature: ______________________________

[If you are physically unable to sign, this directive may be signed by someone else writing your

name, in your presence and at your express direction.]

THIS LIVING WILL DIRECTIVE MUST BE SIGNED BY TWO WITNESSES OR A NOTARY PUBLIC OR A

JUSTICE OF THE PEACE.

We declare that the principal appears to be of sound mind and free from duress at the time the

living will is signed and that the principal affirms that he or she is aware of the nature of the

directive and is signing it freely and voluntarily.

Witness: ________________________ Address: ____________________

STATE OF NEW HAMPSHIRE

COUNTY OF ____________________

The foregoing living will was acknowledged before me this ___ day of __________, 20___, by

__________ (the "Principal'').

_______________________________

Notary Public/Justice of the Peace

My commission expires:

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NEW HAMPSHIRE ADVANCE DIRECTIVE DURABLE POWER OF ATTORNEY

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