New Hampshire Living Will
This Living Will is made in accordance with the New Hampshire Advance Directives laws, RSA 137-J. It serves to document the desires of the undersigned regarding medical treatment in situations where they are unable to make decisions for themselves due to incapacity or terminal illness.
Part 1: Information of the Declarant
Name of Declarant: _________________________________
Date of Birth: ______________________________________
Address: ___________________________________________
City: ______________________ State: NH Zip: __________
Phone Number: _____________________________________
Part 2: Treatment Preferences
This section documents your preferences regarding the acceptance or refusal of medical treatment, including life-sustaining treatment and artificially provided nutrition and hydration, under certain conditions.
- I do not want my life to be prolonged if (check one):
____ I am in a terminal condition with an irreversible cessation of all functions of the brain, including the brain stem, as confirmed by two physicians.
____ I am in a permanent unconscious condition (persistent vegetative state) with no reasonable chance of regaining consciousness, as confirmed by two physicians.
- I wish to receive/decline (circle one) the following types of treatments if I am in the conditions described above:
____ Life-sustaining treatments, including CPR, mechanical ventilation, and dialysis.
____ Artificially provided nutrition (feeding tube) and hydration.
- Other instructions:
______________________________________________________
______________________________________________________
Part 3: Signature
This document represents my directions as the undersigned. By signing below, I confirm that I understand the purpose and effect of this document.
Date: _______________ Signature: ___________________________
Part 4: Witnesses
The undersigned witnesses affirm that the declarant is of sound mind and not under undue influence. This document was signed in our presence.
Witness 1:
Name: _________________________ Date: _______________
Signature: _________________________
Witness 2:
Name: _________________________ Date: _______________
Signature: _________________________
Instructions: Keep the original copy of this living will in a safe but accessible place. Provide a copy to your physician, hospital, healthcare agent, and any other relevant parties. Review periodically and update as necessary to reflect your current wishes.