|
New Hampshire Advance Health Directive(Living Will) Form |
The New Hampshire advance health directive(living will) is a legal document that is specifically designed to guide an individual (Principal) through the steps of creating a document that will outline the wishes of the Principal, in the even they are unable to no longer make their own health care decisions or are in a persistent vegetative state. The document will instruct the physicians and their health care agent as to how to implement the end of life treatment. The Principal may also elect a health care agent in this document, if they have not already done so. The document or any portion of it may be revoked at any time.
Laws – § 137-J:20 (Advance Directive; Durable Power of Attorney and Living Will Forms)
How to Write
Step 1 – Durable Power of Attorney for Health Care – The Principal may appoint a health care agent here (optional) – Submit:
- Enter the name of the Principal
- Principal’s Date of Birth in mm/dd/yyyy format
- AND
- Enter the name of the health care agent
- Read the Paragraph
- Enter an alternate agent by providing:
- Name of the alternate agent
- Address and Telephone number
- Review the remainder of this section
Step 2 – Life Sustaining Treatment – Principal must read the authorization statement:
- Initial either A or B in 1 and 2, that would reflect the Principal’s wishes
Step 3 – Medically Administered Nutrition and Hydration – Read information before proceeding – If this section is left blank the health care provider will not have permission to authorize withholding of life sustaining treatment
- Carefully consider and initial A or B in this section
Step 4 – Explanation of the Principals Instructions in More Detail –
- Initial any or all of the statements that are applicable to the Principal’s wishes
- If there are more specific instructions, the Principal may enter them in the lines provided
- Once complete, Print the Principal’s name and Date of Birth in mm/dd/yyyy format at the end of all pages in the document
Step 5 – Disclosure – The Principal must read the statement –
- Enter the locations and persons who will have possession of a copy of this instrument
- Date the Principal’s signature in dd/m/yy format
- Principal’s Signature
Step 6 – Witness Signatures – The power of attorney must be be signed by two witnesses OR a notary or Justice of the Peace:
- Witnesses must read and agree to the witness statement
- If in agreement the witnesses must provide their respective signatures
- Witnesses addresses
- OR
- If the Principal elects to use a notary or Justice, they shall witness the Principal’s information and acknowledge the signature
Step 7 – Living Will – Enter the date of execution in dd/m/yy format
- Enter the Principal’s name
- Select one statement, A or B and initial
- The Principal must read the competency statement
- Enter the date in dd/m/yy format
- Submit the Principal’s signature or have someone do it for the Principal
- AND
- The witnesses must read the witness statement, if in agreement, enter:
- The respective signatures of each witness
- Complete address
- OR
- If using a notary or Justice of the Peace, they must witness the Principal’s signature and complete the remainder of the section in acknowledgement
