New Hampshire Living Will
This document serves to express the wishes of the undersigned regarding medical treatment in the event that they become unable to communicate their decisions personally. It is crafted in accordance with the New Hampshire Advance Directives Law.
Personal Information
Name: ___________________________
Date of Birth: ___________________________
Address: ___________________________
______________________________________
City: ______________________ State: __________ Zip Code: ____________
Phone Number: ___________________________
1. Appointment of Health Care Agent
In the event I am unable to make or communicate my health care decisions, I hereby designate the following individual as my Health Care Agent:
Name: ___________________________
Relationship: ___________________________
Phone Number: ___________________________
2. General Instructions
I instruct that all health care decisions made on my behalf should be made in accordance with the beliefs and values I personally hold. If my Health Care Agent is unsure about what to decide, it is my wish that they consult with my family and doctors to make a decision that closely aligns with my values.
3. End-of-Life Decisions
If I am ever in a state where recovery is not expected, as confirmed by two physicians, and I am unable to communicate my preferences myself, I wish for the following to be considered:
- Do not prolong my life through mechanical ventilation if I am in a permanent vegetative state.
- Do not use artificial nutrition and hydration if the efforts to sustain life are futile.
- I prefer to receive pain relief and comfort care, even if it may hastide the moment of my death.
4. Additional Instructions
______________________________________________________
______________________________________________________
5. Signatures
By signing below, I affirm that I understand the purpose and effect of this document. I make these directives of my own free will, without any form of pressure or influence from others.
Signature: ___________________________ Date: ___________________________
This Living Will must be witnessed by two individuals who are not related to me, not entitled to any part of my estate, and not directly responsible for my medical care.
Witness 1 Signature: ___________________________ Date: ___________________________
Witness 1 Printed Name: ___________________________
Witness 2 Signature: ___________________________ Date: ___________________________
Witness 2 Printed Name: ___________________________