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Bar Journal - Spring 2007

ADVANCE DIRECTIVES REVISITED Health Care Decision - Making Legislation Approved

By:

A significantly revised RSA 137-J, “Written Directives for Medical Decision Making for Adults Without Capacity to Make Health Care Decisions,” became law on January 1, 2007, following a long process of study and considerable debate.1 This article briefly describes how the revised statute was developed, and highlights some of the significant changes in the law that are intended to promote a better understanding of health care decision-making and more efficient access to the necessary legal documents. An overriding goal of this legislative effort was to facilitate improved communication of a person’s health care choices to those who provide the care.

 

Approximately one-third of people who die in New Hampshire require some form of alternate decision-making process at the end of their lives due to their lack of capacity to make health care decisions at that critical time.2 In addition, many people who are injured or who become suddenly seriously ill and are therefore temporarily or permanently unable to communicate or make health care decisions do not have a way to tell their health care providers their beliefs and preferences regarding treatment. It comes as a surprise to many people that in New Hampshire an adult’s family members (including a spouse) are not automatically legally authorized to consent to medical treatment. Only a court-appointed legal guardian or an agent appointed under a Durable Power of Attorney for Healthcare (“DPOAH”) can legally consent to medical care for a person who lacks the capacity to make health care decisions on his or her own behalf.3 A 2004 statewide poll by the University of New Hampshire Survey Center found that only 29 percent of adults had completed a Durable Power of Attorney for Healthcare, and that more than one out of every four respondents had never heard of a Durable Power of Attorney for Healthcare.4 These findings highlight the need for increased accessibility to and public awareness about New Hampshire’s advance directive laws.

 

The New Hampshire legislature passed the first Living Will statute in New Hampshire in 19855, and subsequently passed the Durable Power of Attorney for Healthcare statute in 1991.6 The Foundation for Healthy Communities (“the Foundation”), a non-profit organization with a mission to improve health and healthcare delivery in New Hampshire, initiated work on improving advance directives in 1999 following a series of 13 town hall-style meetings held across the state. At those meetings, people consistently expressed concerns that end-of-life care information and communication were confusing and difficult. A major focus of confusion was the statutory forms for the Living Will and the Durable Power of Attorney for Healthcare.7 Meeting attendees often cited the use of double negatives in the forms and unfamiliar terminology (such as “life-sustaining treatment” or “lack capacity”) as potential barriers to clearly understanding and using the forms. The Foundation convened a multi-disciplinary group, the NH Partnership for End-of-Life Care (“the Partnership”), to study the issues related to advance directives in New Hampshire, and to then recommend changes to the statutes.

 

The Partnership initially considered going directly to the legislature to make changes, but decided instead to work within the then-existing statutes to make improvements and clarifications. The Partnership conducted a survey of the members of the NH Bar Association Elder Law, Estate Planning and Probate Section and of health care professionals at New Hampshire hospitals who help patients with advance directives, to better understand the challenges those groups experienced working with advance directives. The outcome of these efforts was the creation of the “Advance Care Planning Guide” (“the Guide”) in 2001.8 The Guide re-worked the Living Will and DPOAH forms into more consumer-friendly language (derived directly from the statutory requirements) and placed them both within the context of a Guide that emphasized the process of thinking through and talking about future health decisions with one’s health care providers and family members, rather than merely signing the legal documents and putting them on a shelf. The Foundation also made the Guide available in Spanish, French, Braille, and on audiotape for the visually-impaired. The Foundation has distributed more than 100,000 copies of the Guide since its development.

 

In tandem with the introduction of the new Guide in 2001 to improve access to Living Will and DPOAH forms and information, the Partnership identified through the medical literature an intensive two-day training program, “Respecting Choices,” in LaCrosse, Wisconsin.9 The Partnership brought “Respecting Choices” to New Hampshire as means of educating health care professionals to help people consider their future health care choices and preferences, and how to discuss those issues with their loved ones and health care providers. More than 600 people have completed the “Respecting Choices” program since 2001, with the majority of participants coming from nursing, social work, and spiritual care services. New Hampshire initiated the model for the expansion of “Respecting Choices” outside of LaCrosse and the program has grown nationally to include many states and communities.

 

In 2003, the NH Partnership for End-of-Life Care decided to raise awareness among public policymakers of the issues the Partnership was addressing related to advance directives, and requested the establishment of a legislative study committee on end-of-life care.

 

Representative Peter Batula (R-Merrimack), chairman of the House Health and Human Services Committee, appointed a special subcommittee for that purpose, chaired by Representative Hilda Sokul (D-Hanover). The study committee held hearings and issued a final report in December 2003, recommending a re-examination of the state’s advance directive laws. The special subcommittee decided to organize a larger group to develop legislative recommendations.

 

A Healthcare Decisions Coalition (“the Coalition”) was subsequently convened to draft legislation to update and clarify New Hampshire’s advance directive statutes. The Coalition was a multi-disciplinary group of about 30 people, representing medical, nursing, legal, judicial, religious, advocacy and consumer organizations.10 The Coalition endeavored to incorporate the suggestions and address the concerns of a wide variety of interested groups. The goal was to make advance directive documents more accessible to people who want to make their wishes known in the event they can no longer participate in their health care decisions and to make it easier for health care providers to comply with those wishes and follow the documents. The Coalition considered four primary issues: the Living Will; Durable Power of Attorney for Healthcare; Do Not Attempt Resuscitation (“DNR” or “DNAR”) orders; and, medical surrogacy. Three of the four issues considered by the Coalition were included in the proposed new legislation; medical surrogacy, however, was not included because consensus was not reached in time about how to determine the priority of potential “surrogate decision-makers,” and how to address concerns about how a default surrogacy law might interact with court-appointed guardianship and broader issues of individual self-determination.

 

The Coalition met monthly for over a year to discuss these issues and ultimately drafted legislation that was introduced in January 2005 with bi-partisan sponsorship as House Bill 656.11 While the revisions proposed by the Coalition did not address every concern raised, the Coalition members viewed the revisions as significant improvements. HB 656 repealed RSA 137-H and RSA 137-J and replaced them with a significantly revised RSA 137-J, which combined the provisions of both the former statutes with the aim of streamlining the statute, eliminating conflicting provisions and preventing confusion. In addition to adding a statutory scheme for DNR orders – thereby giving legal authority to an already-existing practice based on the basic right of a person to refuse medical treatment – the proposed new RSA 137-J included many changes to clarify and simplify the statutory framework for advance directives, such as: updating several definitions; reorganizing and retitling provisions for easier reference; clarifying the confidentiality of and access to medical records; codifying the steps to be taken prior to withholding or withdrawing life-sustaining treatment by an agent; simplifying the execution of advance directives by requiring only a notary/justice of the peace or two witnesses; simplifying the language of the “Disclosure Statement” and forms; clarifying what happens if a principal names multiple agents; and, clarifying the legal process available to challenge the authority of an agent.

 

The bill was assigned to the House and Senate Judiciary Committees, led by Representative Cynthia Dokmo (R-Amherst) and Senator Joseph Foster (D-Nashua). The 17-month legislative process received additional attention due to the widely publicized death of Terry Schiavo on March 31, 2005, in Florida, which occurred just as public hearings and committee discussions of HB 656 got underway. There were extensive debates within both committees, and several significant amendments were made to the Coalition’s initial legislative proposal. A final bill was passed in May 2006 and signed the following month by Governor John Lynch.12

 

The Foundation for Healthy Communities convened a work group in the summer of 2006 to assist the public, health care providers, and others with implementing the new law. The Foundation developed an RSA 137-J Education Manual, with a comparison chart of the new law and former law, print materials to explain the new law to key audiences (e.g., physicians, emergency medical services professionals), and a training video. The Foundation, in consultation with the NH Bureau of Emergency Medical Services, also developed a sample order form for DNR outside of a healthcare facility (“Portable-DNR”). The Portable-DNR order form is now being used statewide. The Foundation held education sessions throughout the state with healthcare provider organizations (e.g., hospitals, long-term care facilities, home health care, hospices, emergency medical services) to assist them in understanding the new law and updating their policies and protocols – particularly for DNR orders – in concert with the revised RSA 137-J. In addition, a public education program was launched in February to raise awareness among the public as to how the new law makes it easier for people to communicate their future health decisions not just at the end of life, but at any time when they are temporarily or permanently unable to make and communicate those choices. These education efforts have emphasized that advance care planning is the process of thinking about values and choices for medical care and discussing them with family and health care providers. The advance directive printed form (i.e. the Living Will or DPOAH document) is a tool for the patient to communicate, but it should not be a barrier to listening and respecting patient choices under varying circumstances. Understanding and honoring a patient’s choices is the important task of health care providers in delivering quality care.

 

GRAPHIC A

 

The distinction between an advance directive (i.e. a Living Will or a DPOAH) and a DNR order is often a confusing one for laypersons. An advance directive is a written guide whereby a person can indicate what treatment they do or do not want in the event they are not able to directly communicate those wishes for himself or herself. An advance directive can include a patient’s wishes regarding many different types of medical decisions, treatments, and procedures. A DNR order is a medical order that documents the particular, specific decision of a patient (or his or her agent) that he or she does not want health care providers to attempt resuscitation in the event of a cardiac or respiratory arrest.

 

In New Hampshire, the term advance directive refers specifically to a single legal document with two sections (that may be executed separately): a Durable Power of Attorney for Health Care and a Living Will. A DPOAH states that if a patient loses the capacity to make medical decisions for him or herself, whether the loss of capacity is temporary or permanent, that patient grants authority to another adult of his or her choosing to make the decisions. “Losing capacity” is a medical judgment which means the patient cannot generally understand the significant risks and benefits of a health care decision, as well as any alternative options. In order for the agent to have authority to withhold or withdraw life-sustaining treatment, including medically administered nutrition and hydration, the DPOAH document must specifically include a statement granting such authority to the agent.

 

A Living Will states an express direction by a patient that life-sustaining treatment be withheld or withdrawn if that patient is diagnosed with a medical condition which renders him or her near death or permanently unconscious without hope of recovery and the patient is unable to actively participate in the decision-making process. A patient must specifically indicate whether this direction to withhold or withdraw life-sustaining treatment includes medically administered nutrition or hydration.

 

While a patient’s advance directive document(s) may make reference to his or her wishes regarding whether to be resuscitated or not, these documents do not constitute a DNR order. A DNR order is an official medical order, written by a physician or advanced registered nurse practitioner (ARNP) – on either a standardized in-patient facility DNR order form or on a State-recognized Portable-DNR order form – that identifies the patient’s choice regarding resuscitation if he or she suffers a cardiac or respiratory arrest. The purpose of the DNR order is to translate the patient’s specific wishes regarding resuscitation into an actual medical order that will subsequently direct the care of that patient by health care professionals.

 

CHANGES IN THE ADVANCE DIRECTIVES LAW

 

Some of the significant changes in the new legislation are highlighted below. (A detailed side-by-side comparison the new and former statutes may be found at www.healthynh.com.)

 

Updated Definitions include:


     Near death - An incurable condition caused by injury, disease, or illness which is such that death is imminent and the application of life-sustaining treatment would, to a reasonable degree of medical certainty, only postpone the moment of death. These criteria must be determined and documented by two physicians or by a physician and an ARNP. (RSA 137-J: 2, XVI.)

New statute: Previously, this term was referred to as “terminal condition” and the criteria could only be determined by the attending physician in consultation with another physician. Adds “to a reasonable degree of medical certainty” to account for variation and change in diagnostic/prognostic capabilities of medicine. (RSA 137-H: 2, VI)

     Permanently unconscious - A lasting condition, indefinitely without improvement, in which thought, awareness of self and environment, and other indicators of consciousness are absent as determined by an appropriate neurological assessment by a physician in consultation with the attending physician or ARNP. (RSA 137-J:2, XVII)

New statute: Determination of “permanently unconscious” did not previously require a neurological assessment. (RSA 137-H: 2, VII)

Life-sustaining treatment - Any medical procedures or interventions that use mechanical or other medically administered means to sustain, restore, or replace a vital function which, in the written judgment of the attending physician or ARNP, would serve only to artificially postpone the moment of death, and where the person is near death or is permanently unconscious. “Life-sustaining treatment” includes, but is not limited to the following: mechanical respiration, kidney dialysis or the use of other external mechanical or technological devices. Life-sustaining treatment also may include blood transfusions, antibiotics and drugs to maintain blood pressure. “Life-sustaining treatment” does not include the administration of medication, natural ingestion of food or fluids by eating and drinking, or the performance of any medical procedure deemed necessary to provide comfort or to alleviate pain. (RSA 137-J: 2, XIII)

New statute: Removes the requirement for a consulting physician, and adds ARNPs as providers who can determine whether a proposed treatment would “artificially postpone the moment of death.” Provides additional examples of what are and are not life-sustaining treatments. (RSA 137-H:2, II and former 137-J:1, VIII)

     Medically administered nutrition and hydration - Invasive procedures such as, but not limited to the following: Nasogastric tubes; gastrostomy tubes; intravenous feeding or hydration; and hyperalimentation. It does not include the natural ingestion of food or fluids by eating and drinking.(RSA 137-J:2, XV)

New statute: Previously was termed, “artificially administered nutrition and hydration.” Combines the language from the former Living Will and DPOAH statutes, referring to “natural ingestions of food or fluids by eating or drinking” rather than to “sustenance.” (RSA 137-H: 2, VIII and former 137-J: 1, II)

 

Health Care Provider’s Responsibilities


     Advanced Registered Nurse Practitioners (ARNPs), in addition to physicians, now can perform many of the activities related to advance directives that previously required a physician, including certification and documentation of a person’s capacity to make health care decisions and the authority to write DNR orders. (e.g. RSA 137-J:5, II and RSA 137-J:26) (Note, however, that a principal may exclude or strike references to ARNPs and the powers granted to ARNPs in his or her advance directive, and such a decision by the principal must be honored. RSA 137-J:14, III)

 

Scope of Agent’s Health Care Responsibilities


     As with the prior DPOAH statute, the agent has the authority to make any and all health care decisions on the principal’s behalf that the principal could make only when the principal does not have capacity to make health care decisions, unless otherwise prohibited by law. Lack of capacity must be certified in writing by the principal’s attending physician or ARNP and the agent’s name must be noted and placed in the principal’s medical record.(RSA 137-J:5 Cf. Former RSA 137-J:2)

     Also, as with the previous law, the attending physician or ARNP must make reasonable efforts to inform the principal of any proposed treatment or any proposal to withdraw or withhold treatment. If the principal objects to the proposed plan, even though he or she lacks capacity and an advance directive is in effect, treatment may not be given or withheld over his/her objection. (RSA 137-J:5, IV  Cf. Former RSA 137-J:2, IV)

 

The new statute provides an exception to this, however, if the principal’s advance directive includes the following statement initialed by the principal: “Even if I am incapacitated and I object to treatment, treatment may be given to me against my objection.” For example, a person with stage1 dementia who does not know how the disease will progress may want to give his or her agent additional authority to use his or her best judgment to make health care decisions on his or her behalf, even if the person objects to the treatment. In order for the agent to override the principal’s objections related to life sustaining treatment or medically administered hydration or nutrition, the principal’s DPOAH must expressly grant authority to the agent to make such decisions (see the next bullet). Note that this “override” provision applies only to treatment, and it does not preclude the principal from changing his or her mind about his or her selection of health care agent. It also is important to note that in a situation where a principal (who lacks capacity to make health care decisions) objects to proposed treatment, a family member, health care provider or other interested party may still petition the Probate Court to appoint a legal guardian for the principal, and/or to determine the principal’s capacity to make health care decisions. Furthermore, health care providers are not required to provide or withhold/withdraw treatment that would not be contrary to accepted medical practice.

     For decisions regarding the withholding or withdrawal of medically administered nutrition and hydration, and/or to withhold or withdraw other life-sustaining treatment, the advance directive must include a clear expression of such intent, and for a DPOAH, the agent must be expressly granted such authority. (RSA 137-J:7, III and RSA 137-J:10, II) An exception, however, will apply if the proposed life-sustaining treatment or administration of medical nutrition and hydration would have the unintended consequence of hastening the principal’s death or causing irreparable harm, as certified by the attending physician and a physician knowledgeable about the patient’s condition. (RSA 137-J:7, IIIc and RSA 137-J:10, IIc)

 

Confidentiality and Access to Information


     The revised statute clarifies that health care providers, residential care providers, and persons acting for them or under their control, must share medical information with the principal’s agent when a DPOAH is in effect, and provide copies of advance directives to other providers as needed to facilitate the principal’s care. As with the prior law and consistent with the agent’s scope of authority to make health care decisions on the principal’s behalf, agents are permitted to execute consents and other necessary health care documents, and to review the principal’s medical information. (RSA 137-J:9, Cf former RSA 137-J:7)

 

Statutory Forms


     In order for an advance directive to be legally valid and enforceable in New Hampshire, it must be “substantially in the form” provided in the statute. (RSA 137-J:13) (Previously, a Living Will document was not required to be in the form set forth in the statute. RSA 137-H:3) The text on the forms, particularly for the DPOAH and its accompanying “Disclosure Statement” was revised to be more “consumer-friendly,” to address concerns that the language was too arcane or legalistic. (RSA 137-J:19-20 Cf RSA 137-J:14-15)

     It is important to note that a “General Power of Attorney” or a “Durable Power of Attorney” executed pursuant to RSA 506:6 that purports to give an agent authority regarding health care decisions is not sufficient to give the agent authority to make such decisions. It does not function as a DPOAH in New Hampshire and does not give that “agent” legal authority to make health care decisions. Moreover, such a document likely lacks the necessary language regarding authorization for withholding or withdrawing life-sustaining treatment and medically administered nutrition and hydration.

     Any advance directive created under prior New Hampshire law must still be honored under the new law. (RSA 137-J:16) As always, advance directives validly executed in other states or jurisdictions are valid in New Hampshire; the authority under such “foreign” documents, however, is restricted by the limitations in our advance directive statutes (e.g., requiring express authority for withholding or withdrawing medically administered nutrition and hydration). (RSA 137-J:17 Cf RSA 137-H:14a and former RSA 137-J:10)

 

Execution and Witnesses


     Whereas under the prior statutes, an advance directive required the signatures of two witnesses and a notary public, (RSA 137-H:4 and former RSA 137-J:5) now an advance directive must be signed by the principal in the presence of either: (RSA 137-J:14)

     Two or more witnesses, neither of whom can be the agent, the principal’s spouse or heir at law, or a person entitled to any part of the estate of the principal upon death of the principal under a will, trust, or other testamentary instrument or deed in existence or by operation of law, or attending physician or ARNP, or person acting under the direction or control of the attending physician or ARNP. No more than one such witness may be the principal’s health or residential care provider or such provider’s employee; OR

     A notary public or justice of the peace.

 

Naming of Multiple Agents


     The new statute clarifies that, if a principal lists more than one person as the agent in a DPOAH, the agents have authority in priority by the order they are listed on the document. If another method of joint agency is desired by the principal (for example, all agents must agree on any action taken), the principal must expressly state the method in the DPOAH. (RSA 137-J:18)

 

Civil Action


     The principal, or any person who is a near relative of the principal, or who is a responsible adult who is directly interested in the principal by personal knowledge and acquaintance (this includes guardians, social workers, physicians, or clergy members), may file an action in Probate Court to:

     Request that the authority granted to the agent under a DPOAH be revoked because the petitioner believes that the principal was not of sound mind or was under duress, fraud, or undue influence when the advance directive was executed; (RSA 137-J:22, Ia  Cf former RSA 137-J:16) OR

     Challenge the right of an agent to act, and request the appointment of a guardian for the purpose of making healthcare decisions, if for example, the petitioner believes that the agent is not acting according to the known wishes of the principal, or in the principal’s best interest if his/her wishes are unknown. (RSA 137-J:22, Ib)

 

DO NOT RESUSCITATE ORDERS

 

Under the prior law, there was no express provision authorizing the use of Do Not Resuscitate (“DNR”) orders. The prior definition of “life-sustaining treatment” specifically included cardiopulmonary resuscitation as an example of such treatment; (see former RSA 137-J: 1, VII) arguably, therefore, the only legally authorized means to withhold or withdraw CPR was to: (a) obtain the express consent of the patient; (b) invoke the terms of an advance directive that expressly authorized the withholding or withdrawing of life-sustaining treatment; or (c) obtain a court order. The updated RSA 137-J includes a new subsection to provide clear statutory authority to DNR orders, the use of which has been a common and accepted practice in the medical community for many years.

 

Presumed Consent to Cardio-Pulmonary Resuscitation (RSA 137-J: 25)

 

In the event of cardiac or respiratory arrest, every person is presumed to consent to cardiopulmonary resuscitation (“CPR”), except when:

§    A DNR order has been issued for that person, OR

§    A completed advance directive for that person is in effect stating the person does not want CPR or their agent under a DPOAH determines that the person would not want CPR under the circumstances, OR

§    The person’s attending physician or ARNP issues a DNR order, pursuant to RSA 137-J:26, IV (as explained in the section below); OR

§    A person is under treatment solely by spiritual means through prayer in accordance with the tenets and practices of a recognized church or religious denomination by a duly accredited practitioner.

 

Issuance of a Do Not Resuscitation Order (DNR) (RSA 137-J: 26)

     A Living Will or DPOAH is not a prerequisite for a DNR order; all matters pertaining to the availability of and parameters for DNR orders apply to all persons regardless of whether or not a person has executed an advance directive.

     An attending physician or ARNP may issue a DNR order for a person if the person, or the person’s agent under a DPOAH, has consented to the order.

     An agent may consent to a DNR order for a person who lacks the capacity to make health care decisions, if the principal’s DPOAH grants the agent the authority to make decisions regarding withholding or withdrawing life-sustaining treatment.

     If an agent is not reasonably available and the facility has made diligent efforts to contact the agent without success, or the agent is not legally capable of making a decision regarding a DNR order, an attending physician or ARNP may issue a DNR order for a person who lacks capacity to make health care decisions. This may only occur if the person is near death and is admitted to a health care facility, and only if a second physician who has personally examined the person concurs with the opinion of the attending physician or ARNP that CPR would be contrary to accepted medical standards and would cause harm or pain and suffering.

     If the person is present in a health care facility, the DNR order must be written either on a form consistent with that facility’s policy and procedures, on a DNR “card” that complies with NH law, or on a medical order form that complies with NH law. (RSA 137-J:26, V)

 

Protection of Persons Carrying Out in Good Faith a Do Not Attempt Resuscitation Order (RSA 137-J: 28)

     No health care provider or residential care provider, or any other person acting for the provider or under the provider’s control, can be held criminally or civilly liable, or be deemed to have engaged in unprofessional conduct, for complying with a valid DNR order.

     Nobody (including health care providers) who witnesses a cardiac or respiratory arrest can be held criminally or civilly liable for performing cardiopulmonary resuscitation on a person that has a DNR order, provided that the person performing CPR is unaware of the DNR order or believed that the DNR order had been revoked or canceled.

     If a physician or ARNP refuses to issue a DNR order or comply with a DNR order because of his or her personal beliefs or conscience, he or she must immediately inform the patient, the patient’s family, or the patient’s agent. The patient, family, or agent may then request a referral to another physician or ARNP.

 

Revocation of a DNR Order (RSA 137-J: 29)

     A person in a health care facility can revoke his or her DNR order at any time by making either or other act of communication to the attending physician, ARNP, or other professional staff of the facility.

Portability of DNR Orders (RSA 137-J: 31)

     If a person with a DNR order is transferred from one health care facility to another health care facility, the facility initiating the transfer must communicate the existence of a DNR order to the receiving facility prior to the transfer. The written DNR order—on a Portable-DNR order form or on a DNR card – remains effective until a physician at the receiving facility issues admission orders.


There is a significant statewide education program underway to help inform health providers, other professionals and the public about this new law. A broad range of people with health care experience, legal knowledge and consumer education developed the materials for the education program. The Foundation for Healthy Communities plants to assess health care quality improvement issues once the law is fully implemented.

 

Endnotes


1.   2006 NH Laws Ch. 302 (HB 656), signed by Governor Lynch on June 19, 2006.

2.   Solloway, M, LaFrance, S, Bakitas, M and Gerken, M.  “A Chart Review of Seven Hundred Eighty-Two Deaths in Hospitals, Nursing Homes, and Hospice/Home Care” Journal of Palliative Medicine, 2005; vol. 8, no. 4, 789-796.

3.   A Living Will is another means for a person who lacks the capacity to make health care decisions to give directions to health care providers at the end of life.  A Living Will is a “self-executing” document that does not, however, require a person to give consent to implement its directives; once the preconditions stated in the document occur, a physician or ARNP is authorized to act according to the stated wishes of the declarant.

4.   Granite State Poll, Fall 2004, University of New Hampshire Survey Center.

5.   NH RSA 137-H (1985 NH Laws Ch. 157).  It was updated in 1991/1992 to conform more closely with then-new passed DPOAH statute, RSA 137-J, by adding “permanently unconscious” as a criterion, adding references to “artificial nutrition and hydration,” and adding the “reciprocity” section.

6.   NH RSA 137-J (1991 NH Laws Ch. 146).  Only two technical amendments had been to the DPOAH statute – one in 1993, changing “superior” to “probate” court in 137-J:16, and another in 2004 to update a statutory reference in 137-J:1, X.

7.   The prior statutory form for a Living Will was at NH RSA 137-H:3, and the prior statutory form for the DPOAH was at (former) NH RSA 137-J:15.

8.   A copy of the updated Advance Care Planning Guide may be found at www.healthynh.com.

9.   Hammes, B and Rooney, B. “Death and End-of-Life Care in One Midwestern Community”, Archives of Internal Medicine, vol. 158, February 23, 1998, 383-390.

10. Special thanks to the members of the Coalition for their insightful and cooperative work to complete the proposed legislation.

11. Representatives H. Sokol (D-Hanover), L. Hammond (D-Lebanon), J. MacKay (R-Concord), A. Millham (R-Gilford), and E. Hager (R-Concord).  Senators B. Odell (R-Lempster), I. Estabrook (D-Durham), and J. Foster (D-Nashua).

12. See FN 1.

 

 

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