Life Sustaining Statute, New Hampshire

Statutory Declaration in Conformance with New Hampshire Terminal Care Document Law, N.H. R.S. 137-H: 3


DECLARATION OF ___________________


Declaration made this __________ day of ________________ 20____. I ________________, being of sound mind, willfully and voluntarily make known my desires 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 by two 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 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procedures would serve only to artificially prolong the dying process, I direct that such procedures be withheld or withdrawn, and that I be permitted to die naturally with only the administration of medication, sustenance, or the performance of any medical procedure deemed necessary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.


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 legal right to refuse medical or surgical treatment and accept the consequences from such refusal.


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






State of _______________

_________ County


We, the Declarant and the 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.











Sworn to and signed before me by ____________ Declarant, and ___________________________ witnesses on _____________________, 20____.






Official Capacity: _____________________

Statutory Declaration in Conformance with New Hampshire Terminal Care Document Law, N.H. R.S. 137-H: 3

Review List

This review list is provided to inform you about this document in question and assist you in its preparation.  This simple Life Sustaining Declaration is valid in New Hampshire. Check with a local hospital or doctor’s office, as well as with an experienced medical attorney, to assure yourself of its compliance with current statute (s) in your state.


  1. Make multiple copies.  Give one to your doctor (s), the local hospital, and have others available through your attorney and family.  Remember, these kinds of documents are needed in emergency situations at worst and under stressful circumstances at best.  So be sure they are available to the appropriate people easily, when needed.


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