New Hampshire Advance Directive Form

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A New Hampshire advance directive lets a person set up a durable power of attorney for health care and a living will. This allows someone to choose an agent to handle their health care needs, in case they cannot do so for themselves, and to outline their end-of-life care. This form is common to be completed by the elderly or individuals with health issues. The form becomes in effect after the person can no longer speak for themselves due to unconsciousness or incapacitation.

Table of Contents

Laws

StatuteChapter 137-J (Written Directives for Medical Decision Making for Adults Without Capacity to Make Health Care Decisions)

Signing Requirements (§ 137-J:14) – Two (2) witnesses or a notary public.

State Definition – (§ 137-J:2(I)) – “Advance directive” means a directive allowing a person to give directions about future medical care or to designate another person to make medical decisions if he or she should lose the capacity to make health care decisions. The term “advance directives” shall include living wills and durable powers of attorney for health care.

Versions (4)


Core Physicians

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Healthy NH

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New Hampshire Health Care Assoc.

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WellSense.org Version

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How to Write

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Step 1 – Obtain The New Hampshire Advance Directive

The New Hampshire Advance Directive is obtainable through the “PDF” button captioning the sample on this page or the “Adobe PDF” link visible in this instruction area.

Step 2 – Supplement The Introduction With The Party Names

The first task required by the New Hampshire Advance Directive is to formally “Name” the New Hampshire Principal behind it. Use the first empty line of this document to present the New Hampshire Principal’s full “Name” then document his or her “Date Of Birth” on the second blank line. The Party identified using the blank lines before the term “Hereby Appoint” will be considered the future New Hampshire Patient who intends to authorize another individual to act as his or her Health Care Agent or Representative with New Hampshire Medical Personnel seeking to treat the Principal (or Future Patient) while he or she is unconscious. Naturally, the blank line following the term “…Hereby Appoint” and labeled “Name Of Health Care Agent” requires the full name of the individual that will accept this role. 

 

Step 3 – Dispense New Hampshire Health Care Agent’s Contact Information

It will be important that a reliable means of contact for the New Hampshire Health Care Agent is included in this statement. Record the building number, street, apartment number, city, state, and zip code of the New Hampshire Health Care Agent’s residential address then disclose his or her cell phone number or home telephone number. It should be considered imperative to make sure that a New Hampshire Health Care Provider reviewing this document for the first time and attempting to provide care be able to locate or contact the New Hampshire Health Care Agent quickly when desired. 

 

Step 4 – Name A Successor New Hampshire Health Care Agent

The next portion of the New Hampshire appointment seeks a successor to the role of Health Care Agent in case the Principal’s first choice for New Hampshire Attorney-in-Fact over health care decisions denies the role, is not available or is otherwise unable to represent the Principal effectively. If this happens at a time when the Principal cannot communicate, the result could lead to accidental violation of the Principal’s treatment preferences. To make sure that someone will be ready to assume the New Hampshire Health Care Agent role for the Principal, the next blank line (also labeled “Name Of Health Care Agent”) seeks the full name of this Successor.  The line that follows should be supplied with the Second or Alternate New Hampshire Health Care Agent’s home address and current telephone number. It is worth noting this Health Care Agent will not have the ability or authority to make your medical decisions while the original one named is active. 

Step 5 – Convey Life-Sustaining Preferences To New Hampshire Physicians

Section “A. Life-Sustaining Treatment” expects a presentation of the New Hampshire Principal’s initials next to each statement he or she agrees with. Life-sustaining treatments can be considered medical procedures, medication, or other therapies that will keep the Patient alive but not necessarily aid in his or her recovery. The goal of life-sustaining treatments is to aid in maintaining the vital functions of a body for as long as possible regardless of the possibility of recovery. Read through the first scenario description to this section before proceeding to the first item.  As mentioned earlier, the first item presents two statements (labeled “A” and “B”) of which the New Hampshire Principal must choose from to define what his or her instructions in the given scenario is. The first item (“1. If I am Near Death…”) defines a scenario where the New Hampshire Principal cannot communicate and is experiencing a fatal or end-of-life medical event. If he or she intends that the Attorney-in-Fact should withdraw the Principal’s consent to life-sustaining treatments in this situation then select Statement “(A)” Life-Sustaining Treatment Not Be Started, Or If Started Be Discontinued” by initialing the blank line that precedes it.    If the New Hampshire Principal requests that the Agent, make sure that “Life-Sustaining Treatment Continue…” then the New Hampshire Principal must initial Statement “(B).” 
Step 6 – Report If You Wish Life-Sustaining Procedures When Persistently Unconscious

The second item seeks to discuss the New Hampshire Principal preferences when faced with an irreversible vegetative or unconscious state. Regardless of whether he or she is near death the Principal can instruct the New Hampshire Attorney-in-Fact to cease any life-sustaining treatment being administered and deny any not yet administered by initialing the blank line corresponding to Statement A below the Scenario “Whether Near Death Or Not, If I Become Permanently Unconscious…”If the New Hampshire Principal wishes his or her Attorney-in-Fact to consent to life-sustaining treatments be administered when necessary even when in a persistent or permanent coma, then Statement B in this scenario should be selected. 

 

Step 7 – Inform New Hampshire Physicians Of Your Decisions On Artificial Hydration And Nutrition

Section “B. Medically Administered Nutrition And Hydration” seeks definition to the Principal’s preference on being given nutrition and liquids artificially. There may be times when he or she can only be allowed a natural death by starvation or dehydration. If he or she prefers that all “Medically Administered Nutrition And Hydration” be denied or discontinued when faced with a permanently being unconscious, then Statement “(A)” must be initialed by the New Hampshire Principal. If the New Hampshire Principal agrees to medically delivered nutrition and liquids while in a permanently unconscious state, then Statement “(B)” should be initialed.

 

Step 8 – Provide Additional Instructions To Your New Hampshire Health Care Agent And Medical Personnel

Sections “C. Explaining Your Instructions In More Detail” allows some additional and specific powers to be assigned to the New Hampshire Health Care Agent. If the Principal authorizes the New Hampshire Health Care Agent to request and complete a DNR order declaring the Principal as the issuing Patient then, the New Hampshire Principal must initial Statement 1 in this section.

 

Step 9 – Indicate The New Hampshire Health Care Agent’s Level Of Principal Authority

If the New Hampshire Principal wishes to make it clear that the Attorney-in-Fact or Health Care Agent has the “Full Authority To make Any And All Care Decision(s)” on his or her behalf, then Statement 2 must be initialed by the concerned Principal.  Statement 3, beginning with the phrase “Even If I am Incapacitated And Object To Treatment…” allows New Hampshire Medical Staff to follow your Health Care Agent’s instructions over your own. This may be useful in cases where dementia or a severe mental health crisis however, it is recommended that you and your Attorney-in-Fact have as clear an understanding as possible as to your medical treatment preferences. The New Hampshire Principal should initial this statement to make it effective once this appointment is properly executed.   

Step 10 – Document Instructions Specific To Your New Hampshire Health Care Agent And Providers

Statement 4 of this section allows the declaration being made to be put in your own words. Use the blank lines provided if you have any additional instructions that should be set in writing for the New Hampshire Health Care Agent. If this is not necessary, then strike through this section or present its contents with a phrase indicating this option has been reviewed and will be left unattended intentionally.

Step 11 – Formally Attach The Second Page To This Directive

The bottom of Page B requires that the New Hampshire Principal’s full name be recorded on the “Print Name” line and that his or her “Date Of Birth” be displayed beside it. Seek out the appropriately labeled line at the bottom of Page B then make sure this information is entered. 

 

Step 12 – Present The Location Where The Signed Original Will Be Filed And Stored

Now, it will be important to document where the original signed directive currently being completed will be stored. This will add in keeping its contents safe and lending to its authenticity. Therefore, locate the blank line after the words “The Original Of This Directive Will Be Kept At” then produce the physical address where the completed and signed original New Hampshire Directive can be physically accessed on this line. 

 

Step 13 – Distribute A Record Of Each Copy Recipient

Many would strongly suggest that multiple copies of the completed and signed directive be distributed to Parties such as the Health Care Providers responsible for the New Hampshire Principal’s care, a trusted family member of the New Hampshire Principal, and even his or her insurance company. Use the final set of blank lines in this area (underneath the words “…Persons And Institutions Will Have Copies” 

 

Step 14 – Attach A Specific Signature Date To This New Hampshire Declaration

The three spaces appearing in the “Signed This…” statement expects a record of the New Hampshire Principal’s signature date as a calendar day, month name, and two-digit year. The New Hampshire Principal should furnish the current date to these spaces when he or she is about to sign this document.

 

Step 15 – This Paperwork Requires The New Hampshire Principal’s Executing Signature

The New Hampshire Principal must sign the “Principal’s Signature” line before a couple of Witnesses, a Notary Public, or Justice Of The Peace. once done he or she must surrender the signed paperwork to the Party who has watched the signing produced.

Step 16 – Surrender This Paperwork For Witness Review

Two Witnesses can be used to verify the Principal’s signing if they have physically seen the New Hampshire Principal sign this directive and can agree to the Witness declaration provided. 

 

Step 17 – Acquire The New Hampshire Witness Signature

After reviewing the Witness declaration, the First Witness is expected to sign the “Witness” line then supply his or her “Address.”  The Second Witness must sign the “Witness” line that follows then document his or her complete “Address” on the next line. 

 

Step 18 – If Preferred Acquire Notarization For the New Hampshire Appointment’s Execution

A New Hampshire Notary Public Or Justice Of The Peace can use the next section (starting with the words “State Of New Hampshire County Of” to subject this document and its signing to the notarization process. Once the signing is completed, make sure that the name of the New Hampshire Principal along with his or her birth date are supplied where requested at the bottom of the page. This will claim Page C as part of the Patient’s advance directive.  

 

Step 19 – Declare The Date Your Living Will Is Made

The next area of the advanced directives is titled “Section II. Living Will” and shall deal specifically with the topic of being diagnosed with an incurable medical condition, being permanently unconscious, or suffering a near-death event. If there is no chance of recovery and life support, life-sustaining, or life-prolonging measures will not result in recovery then, as the New Hampshire Declaration of this document retains the right to deny such procedures from being administered. If the Declarant is already on life support when two New Hampshire Physician (or One New Hampshire Physician and One APRN formally diagnoses him or her as permanently unconscious, then he or she can prematurely instruct attending Physicians to withdraw all life support so that he or she die naturally. The first step of this order is to name the date of its issue by dispensing the two-digit calendar day, the name of the month, and the two-digit year after the phrase “Declaration Made This…”

 

Step 20 – Identify Yourself As The New Hampshire Declarant

The full name of the New Hampshire Declarant is required on the first line that follows the declaration date you have reported. This is the New Hampshire Patient or future New Hampshire Patient who will use this document to refuse to receive life-sustaining treatment when in such a position. 

 

Step 21 – Review The Language Needed To Set Your Preferences In Motion

The circumstances and the declaration of this living will be discussed in the statement presented. Read the text of this issue, making sure the New Hampshire Patient fully comprehends its content.

 

Step 22 – Include Living Will Preferences Regarding Medically Administered Nutrition

If the New Hampshire Declarant has determined that “Medically Administered Nutrition And Hydration Not Be Started, Or If Started Be Discontinued” when he or she is officially permanently unconscious then Statement “(A)” must be initialed to verify this desire to the New Hampshire Medical Staff responsible for his or her care. Statement “(B)” should be initialed if the New Hampshire Declarant wishes the medically administered nutrition and hydration be continued or administered as needed to prevent starvation or dehydration even if all other life-prolonging procedures or techniques are being withdrawn.  Before continuing with the declaration, continue to the bottom of the page, then record the full name and date of birth to verify that Page D belongs to the New Hampshire Declarant.

 

Step 23 – Establish The Date Of The New Hampshire Principal’s Signature

Once the information defining the identity of the New Hampshire Declarant has been presented and his or her instructions regarding medically administered nutrition and hydration have been dispensed, this declaration will need to be executed if it is to carry weight with New Hampshire Medical Personnel. This process begins on Page E with a request for the date of the New Hampshire Declarant’s act of signing. Report this date across the spaces provided in the closing statement “Signed On This…”

 

Step 24 – The Principal Signing Must Occur Before New Hampshire Approved Entities

The New Hampshire Declarant in this document must sign the “Principal’s Signature” presented after the signature date. This action will only be considered a legitimate action of the New Hampshire Declarant if it can be verified by a qualifying second Party. This verifying Party can be two Witnesses, a Notary Public, or a Justice of the Peace. Therefore, after dating and signing this paperwork, the New Hampshire Declarant must surrender this paperwork to the Party in attendance. If two Witnesses will document their observance of the New Hampshire Declarant, then each should be referred to the statement beginning with “We Declare…” This statement should be read by Witness One, then the “Witness” line below it signed by Witness One. After providing this signature, the Witness must supply his or her “Address.”Witness Two is also required to read the statement starting with the phrase “We Declare…” then sign the second “Witness” line presented. The “Address” line to the right of this expects Witness Two’s residential address recorded for display.   

 

Step 25 – Obtain Notarization From One Of Two Entities

If a New Hampshire Notary Public or Justice Of The Peace has watched the Declarant sign this declaration then, he or she shall complete the notarization section at the end of this document. When it is completed, this section must present the county where the New Hampshire Declarant’s signature was provided along with the date and the Signer’s identity. This process requires that the credentials of the New Hampshire Notary Public or Justice of the Peace be included. 

Step 26 – Attach Page E To This Document

It is important that the full name of the New Hampshire Declarant and his or her “Date Of Birth” are solidified at the bottom of this page on the lines bearing these labels. 

 

 

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