New Hampshire Living Will Template
This Living Will is designed in accordance with the New Hampshire Advance Directives Laws. It is intended to express the preferences concerning medical treatment or non-treatment by the signatory in the event that they are no longer able to communicate their medical decisions due to incapacity.
Personal Information
Full Name: ________________________________________________________
Date of Birth: ________________________
Address: __________________________________________________________
City: ________________________ State: NH Zip Code: _________________
Directive Statement
I, ____________ [Your Full Name], being of sound mind, hereby direct that my health care providers and others involved in my care follow the instructions provided in this document regarding my health care and treatment. Should I be in a state whereby I can no longer make my own health care decisions, the wishes expressed here shall guide my care.
Life-Sustaining Treatment Preferences
In the event that I am in a terminal condition, permanently unconscious, or in another condition in which I am unable to communicate my desires for treatment, I request the following actions to be taken:
- Administration of treatment to alleviate pain or discomfort, even if it does not prolong life, unless specified otherwise below.
- Withholding or withdrawal of life-sustaining treatments that only prolong the process of dying or are unlikely to result in significant recovery.
- Withholding of food and water if the provision of such is deemed life-sustaining treatment and I have indicated a desire to have it withheld.
Specific Instructions: _____________________________________________
___________________________________________________________________
Designation of Health Care Agent
I designate the following individual as my health care agent to make medical decisions for me when I am unable to do so. This person shall have the same authority to request or refuse treatment on my behalf as I would have if capable of making and communicating decisions.
Agent's Full Name: _________________________________________________
Relationship to Signatory: __________________________________________
Agent's Phone Number: ______________________________________________
Alternate Agent's Full Name: ________________________________________
Relationship to Signatory: __________________________________________
Alternate Agent's Phone Number: _____________________________________
Signatures
This document is executed this _____ day of ____________, 20____, in the presence of the undersigned witnesses, by ____________ [Your Full Name], the principal.
Principal's Signature: _____________________________________________
Date: _____________________________________________________________
Witness 1 Signature: _______________________________________________
Print Name: ________________________________________________________
Witness 2 Signature: _______________________________________________
Print Name: ________________________________________________________
This Living Will becomes effective only upon my incapacity to participate in health care decisions. It affirms my right to accept or refuse medical treatment and is valid throughout New Hampshire.
Notice to Health Care Providers
Health care providers shall to the extent possible, make reasonable efforts to consult with my health care agent before implementing decisions related to my health care. This document revokes all prior advance directives and represents my current wishes regarding my health care.