NEW HAMPSHIRE ADVANCE DIRECTIVE FORM

Name (Principal’s Name): [NAME]
DOB: [DAY] day of [MONTH], [YEAR]
Address: [ADDRESS, CITY, STATE, ZIP CODE]

I. DURABLE POWER OF ATTORNEY FOR HEALTH CARE
The durable power of attorney for healthcare form names your agent(s) and, if you wish, sets limits on what your agent can decide.

I choose the following person(s) as agent(s) if I have lost capacity to make health care decisions (cannot make health care decisions for myself).

A. Choosing Your Agent:
Agent: I appoint [NAME], of [ADDRESS, CITY, STATE, ZIP CODE], and whose phone number is PHONE NUMBER] to be my agent to make health care decisions for me.

B. Limiting Your Agent’s Authority or Providing Additional Instructions
I have attached additional pages titled “Additional wishes for my Durable Power of Attorney for Health Care” to express my wishes.

II. LIVING WILL
If you would like to provide written guidance to your agent, surrogate, and/or medical practitioners in making decisions about life sustaining medical treatment if you cannot make your own decisions, you may complete the options below.

If I suffer from an advanced life-limiting, incurable and progressive condition:

[INITIALS] A. I wish to have all attempts at life-sustaining treatment (within the limits of generally accepted health care standards) to try to extend my life as long as possible, no matter what burdens, costs or complications may occur.
[INITIALS] B. I do NOT wish to have any life-sustaining treatment attempted that I would consider to be excessively burdensome or that would not have a reasonable hope of benefit for me. I wish to receive only those forms of life-sustaining treatment that I would not consider to be excessively burdensome AND that have a reasonable hope of benefit for me. The following are situations that I would consider excessively burdensome:

[INITIALS] 1. I do not wish to have life-sustaining treatment attempted if I am actively dying (medical treatment will only prolong my dying).
[INITIALS] 2. I do not wish to have life-sustaining treatment attempted if I become permanently unconscious with no reasonable hope of recovery.
[INITIALS] 3. I do not wish to have life-sustaining treatment attempted if I suffer from an advanced life-limiting, incurable and progressive condition and if the likely risks and burdens of treatment would outweigh the expected benefits.

In these situations, I wish for comfort care only. I understand that stopping or starting treatments to achieve my comfort, including stopping medically-administered nutrition and hydration, may be a way to allow me to die when the treatments would be excessively burdensome for me.

III. SIGNATURE
I have received, reviewed, and understood the disclosure statement, and I have completed the durable power of attorney for health care and/or living will consistent with my wishes.

Signed this [DAY] day of [MONTH], 20[XX]
Principal’s Signature: ______________________

THIS ADVANCE 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 this advance directive is signed and that the principal affirms that the principal is aware of the nature of the directive and is signing it freely and voluntarily.
Witness: _______________________________ Address (city/state): [CITY, STATE]
Witness: _______________________________ Address (city/state): [CITY, STATE]