New Hampshire Living Will

New Hampshire Living Will

LIVING WILL

STATE OF NEW HAMPSHIRE

 

A person of sound mind who is 18 years of age or older may execute at any time a document commonly known as a living will, directing that no life-sustaining procedures be used to prolong his life when he is in a terminal condition or is permanently unconscious. The document shall only be effective if the person is permanently incapable of participating in decisions about his care, and it may be, but need not be, in form and substance substantially as follows:

 

DECLARATION

 

Declaration made this ______ day of _________________________ (month, year).

 

I, ________________________________________________________, being of sound mind, willfully and voluntarily make known my desire that my dying shall not be artificially prolonged under the circumstances set forth below, do hereby declare:

 

If at any time I should have an incurable injury, disease, or illness certified to be a terminal condition or a permanently unconscious condition by 2 physicians who have personally examined me, one of whom shall be my attending physician, and the physicians have determined that my death will occur whether or not life-sustaining procedures are utilized or that I will remain in a permanently unconscious condition and where the application of life-sustaining procedures would serve only to artificially prolong the dying process, I direct that such procedures be withheld or withdrawn, and that I be permitted to die naturally with only the administration of medication, sustenance, or the performance of any medical procedure deemed necessary to provide me with comfort care.  I realize that situations could arise in which the only way to allow me to die would be to discontinue artificial nutrition and hydration. In carrying out any instruction I have given under this section, I authorize that artificial nutrition and hydration not be started or, if started, be discontinued.               (yes)         (no)

 

(Circle your choice and initial beneath it. If you do not choose “yes,” artificial nutrition and hydration will be provided and will not be removed.)

 

In the absence of my ability to give directions regarding the use of such life-sustaining procedures, it is my intention that this declaration shall be honored by my family and physicians as the final expression of my right to refuse medical or surgical treatment and accept the consequences of such refusal.

 

I understand the full import of this declaration, and I am emotionally and mentally competent to make this declaration.

 

Signed:     ____________________________________________  

 

Address:  ____________________________________________

____________________________________________

 

WITNESSETH

 

We, the following witnesses, being duly sworn each declare to the notary public or justice of the peace or other official signing below as follows:

 

1. The declarant signed the instrument as a free and voluntary act for the purposes expressed, or expressly directed another to sign for him.

 

2. Each witness signed at the request of the declarant, in his presence, and in the presence of the other witness.

 

3. To the best of my knowledge, at the time of the signing the declarant was at least 18 years of age, and was of sane mind and under no constraint or undue influence.

 

Witness #1:

 

________________

Date

 

____________________________________________
Signature

 

____________________________________________
Printed Name           

                                               

____________________________________________
Address, Line 1

 

____________________________________________
Address, Line 2

 

 

Witness #2:

 

________________

Date

 

____________________________________________
Signature

 

____________________________________________
Printed Name           

                                               

____________________________________________
Address, Line 1

 

____________________________________________
Address, Line 2

 

CERTIFICATE OF NOTARY

 

The affidavit shall be made before a notary public or justice of the peace or other official authorized to administer oaths in the place of execution, who shall not also serve as a witness, and who shall complete and sign a certificate in content and form substantially as follows:

 

 

Sworn to and signed before me by _____________________________________________, declarant, _____________________________________________ and _____________________________________________, witnesses, on ________________.

 

 

 

_____________________________________________

Signature

 

 

_____________________________________________

Official Capacity