NEW HAMPSHIRE ADVANCE DIRECTIVE FOR HEALTH CARE
(LIVING WILL & DURABLE POWER OF ATTORNEY FOR HEALTH CARE)
Prepared in accordance with N.H. Rev. Stat. Ann. § 137-J et seq.
This document combines a Living Will and a Durable Power of Attorney for Health Care.
TABLE OF CONTENTS
- Document Header
- Definitions
- Operative Provisions
3.1. Appointment of Health Care Agent
3.2. Appointment of Alternate Agent(s)
3.3. Agent’s Scope of Authority
3.4. Statement of Treatment Preferences (Living Will)
3.5. Special Directives & Limitations
3.6. Organ & Tissue Donation (Optional)
3.7. Nomination of Guardian (Optional) - Representations & Warranties
- Covenants & Restrictions
- Default & Remedies
- Risk Allocation
- General Provisions
- Revocation Procedures
- Execution Block (Signature, Witnesses/Notary)
[// GUIDANCE: Practitioners may remove or re-order sections that are not customarily included in an advance directive. The numbering mirrors the client’s requested architecture but may be streamlined in final client-facing form.]
1. DOCUMENT HEADER
1.1 Title
NEW HAMPSHIRE ADVANCE DIRECTIVE FOR HEALTH CARE (LIVING WILL & DURABLE POWER OF ATTORNEY FOR HEALTH CARE)
1.2 Parties
(a) “Principal”: [FULL LEGAL NAME] of [ADDRESS]
(b) “Agent”: [FULL LEGAL NAME] of [ADDRESS]
(c) “Alternate Agent(s)” (if any): [FULL LEGAL NAME(S)] of [ADDRESS(ES)]
1.3 Recitals
A. Principal desires to ensure that health care decisions made on Principal’s behalf conform to Principal’s wishes and best interests.
B. Pursuant to N.H. Rev. Stat. Ann. § 137-J, Principal is authorized to execute this combined Living Will and Durable Power of Attorney for Health Care (“Advance Directive”).
C. Consideration is the mutual promises herein and the legal rights granted to Agent.
1.4 Effective Date & Governing Law
This Advance Directive is effective upon execution and is governed exclusively by the laws of the State of New Hampshire.
2. DEFINITIONS
For purposes of this Advance Directive, capitalized terms have the meanings set forth below:
“Advance Directive” – This written instrument executed in compliance with N.H. Rev. Stat. Ann. § 137-J, containing both a Durable Power of Attorney for Health Care and a Living Will.
“Agent” – The person designated in Section 3.1 to make health care decisions for the Principal when the Principal lacks capacity.
“Capacity” – The ability to understand the nature and consequences of a health care decision, including the significant benefits, risks, and alternatives, and to make and communicate that decision.
“Health Care” – Any care, treatment, service, or procedure to maintain, diagnose, or otherwise affect an individual’s physical or mental condition.
“Life-Sustaining Treatment” – Mechanical or other artificial means that sustain, restore, or replace a vital function which, if withdrawn, is expected to result in death within a short time.
“Principal” – The individual executing this Advance Directive.
“Revocation” – Any act described in Section 9 that cancels all or part of this Advance Directive.
[// GUIDANCE: Add additional definitions as required by client specifics.]
3. OPERATIVE PROVISIONS
3.1 Appointment of Health Care Agent
The Principal hereby designates [AGENT NAME] as Agent to make any and all health care decisions on Principal’s behalf if Principal is determined to lack capacity, subject to the limitations in this Advance Directive and applicable law.
3.2 Appointment of Alternate Agent(s) (optional)
If the Agent is unavailable, unwilling, or unable to act, the Principal appoints the alternate agent(s) in the following order of priority:
1. First Alternate Agent: [NAME]
2. Second Alternate Agent: [NAME]
3.3 Agent’s Scope of Authority
a. General Authority. Agent may give, refuse, or withdraw consent to any health care, including life-sustaining treatment, consistent with Principal’s wishes and Section 3.4.
b. Financial Obligation. Agent is not personally liable for the cost of care solely by virtue of acting under this Advance Directive.
c. Access to Information. Agent has the same right to receive medical information as the Principal pursuant to HIPAA and applicable state law.
d. Limitations. [SPECIFY ANY LIMITATIONS, e.g., “Agent shall not authorize electro-convulsive therapy.”]
3.4 Statement of Treatment Preferences (Living Will)
If I am near death or permanently unconscious, and I lack capacity to make health care decisions, I direct that:
[ ] Life-sustaining treatment be WITHHELD or WITHDRAWN.
[ ] Artificial nutrition and hydration be PROVIDED.
[ ] Artificial nutrition and hydration be WITHHELD or WITHDRAWN.
[INSERT ADDITIONAL PREFERENCES]
[// GUIDANCE: Under RSA 137-J, Principal may indicate whether artificial nutrition/hydration are to be continued.]
3.5 Special Directives & Limitations (optional)
[PLACEHOLDER for religious beliefs, pain management, do-not-resuscitate (DNR) instructions, etc.]
3.6 Organ & Tissue Donation (optional)
Upon death, I wish to donate:
[ ] Any needed organs or tissues
[ ] Only the following: ______
[ ] I do NOT wish to make anatomical gifts.
3.7 Nomination of Guardian (optional)
If guardianship proceedings are initiated, I nominate my Agent as guardian of my person.
4. REPRESENTATIONS & WARRANTIES
4.1 Principal’s Representation of Capacity
Principal affirms being of sound mind and at least 18 years of age.
4.2 Agent’s Willingness & Eligibility
Agent has confirmed willingness to serve and is not disqualified under RSA 137-J.
4.3 No Undue Influence
Execution of this Advance Directive is voluntary and free from coercion.
5. COVENANTS & RESTRICTIONS
5.1 Principal’s Covenant to Inform
Principal shall provide a copy of this Advance Directive to the Agent, alternate agent(s), and primary health care providers.
5.2 Agent’s Duty
Agent shall act in good faith, consistent with the Principal’s instructions and best interests, and in accordance with RSA 137-J.
6. DEFAULT & REMEDIES
6.1 Removal of Agent
If a court finds the Agent is not acting in accordance with the Principal’s wishes or best interests, the court may remove the Agent and appoint a successor.
6.2 Health Care Provider Protections
Providers acting in good faith reliance on this Advance Directive are immune from civil or criminal liability to the fullest extent permitted by law.
7. RISK ALLOCATION
7.1 Indemnification of Providers
The Principal’s estate shall indemnify health care providers who comply in good faith with the decisions of the Agent or the instructions in this Advance Directive.
7.2 Limitation of Liability
No party acting under this Advance Directive shall incur liability for acts performed in good faith pursuant to RSA 137-J.
8. GENERAL PROVISIONS
8.1 Amendment
Principal may amend this Advance Directive only by executing a subsequent, properly witnessed or notarized instrument.
8.2 Severability
Any invalid provision shall not affect the remaining provisions, which shall remain enforceable.
8.3 Copies
Photostatic, electronic, or facsimile copies of this signed document shall be as effective as the original.
8.4 Entire Agreement
This Advance Directive constitutes the entire directive of the Principal regarding health care decisions and supersedes all prior directives to the extent of any inconsistency.
9. REVOCATION PROCEDURES
9.1 Methods of Revocation (N.H. Rev. Stat. Ann. § 137-J)
a. Execution of a subsequent Advance Directive.
b. A signed, dated written revocation delivered to the Agent and the supervising health care provider.
c. Oral expression of intent to revoke, made in the presence of two witnesses, communicated to the supervising health care provider.
d. Destruction or cancellation of the document by the Principal or at the Principal’s direction.
9.2 Effect of Revocation
Revocation of either the Durable Power of Attorney for Health Care or the Living Will portion revokes only that portion unless the Principal expressly revokes both.
10. EXECUTION BLOCK
Executed this ___ day of _, 20, at [CITY], New Hampshire.
PRINCIPAL
[PRINTED NAME OF PRINCIPAL]
Signature: _____
OPTION A – NOTARIZATION
State of New Hampshire
County of ____
On this ___ day of _, 20, before me, the undersigned notary public, personally appeared ________, known to me or satisfactorily proven to be the person whose name is subscribed to this instrument, and acknowledged that the same was executed for the purposes therein contained.
Notary Public
My Commission Expires: _______
[// GUIDANCE: If notarized, witnesses are not required under RSA 137-J. Omit Option B.]
OPTION B – TWO WITNESSES
We, the undersigned witnesses, affirm that:
1. The Principal signed or acknowledged this Advance Directive in our presence.
2. The Principal appears to be of sound mind and free from duress.
3. We are at least 18 years of age and are NOT (a) the Agent or Alternate Agent, (b) the Principal’s spouse or heir, (c) attending physician or any person directly involved in the Principal’s health care, nor (d) owners, operators, or employees of the health care facility where the Principal is receiving care.
Witness #1: _____
Address: _____
Signature: _____
Date: __
Witness #2: _____
Address: _____
Signature: _____
Date: __
[// GUIDANCE FOR COUNSEL:
1. Attach HIPAA Authorization if broader access to records is desired.
2. Encourage clients to distribute copies to health care providers, family, and any electronic registry maintained by the State of New Hampshire.
3. Review annually or upon major life changes.]