Dartmouth Dementia Directive: Planning for Cognitive Decline in New Hampshire

Standard advance directives are built for a binary scenario: you either have decision-making capacity, or you don't. But dementia doesn't work that way. Alzheimer's disease and other progressive cognitive conditions erode capacity gradually — over months or years — creating a gray zone where the standard statutory form offers little practical guidance.

The Dartmouth Dementia Directive was developed specifically to address this gap. It's a supplemental planning document that lets you articulate your treatment preferences across the stages of cognitive decline, not just at the moment you lose all capacity.

What the Standard NH Form Misses

New Hampshire's statutory advance directive under RSA 137-J activates when your attending practitioner certifies that you lack capacity to make informed healthcare decisions. For a sudden event — a car accident, a stroke, a surgical complication — that binary trigger works well.

For dementia, it creates problems. In the early and moderate stages, you may still be able to communicate preferences but lack the judgment to understand complex treatment tradeoffs. Your healthcare agent may be uncertain about when their authority kicks in. Your medical team may disagree about whether you've crossed the capacity threshold.

The Dartmouth Dementia Directive fills this void by letting you document decisions at specific cognitive milestones — such as when you can no longer recognize family members, when you require full-time supervision, or when you can no longer feed yourself.

How the Dartmouth Dementia Directive Works

The directive asks you to make treatment decisions tied to concrete scenarios rather than abstract medical states. You specify your preferences about:

• Hospitalization and aggressive treatment at different stages of cognitive decline
• Antibiotic use for infections that might otherwise be fatal
• Artificial nutrition and hydration when you can no longer eat independently
• Comfort care priorities — pain management versus alertness tradeoffs
• Conditions under which you would want all life-prolonging treatment stopped

This specificity gives your healthcare agent a documented roadmap instead of forcing them to guess what you would have wanted. It also protects them emotionally — they're following your explicit instructions, not making agonizing judgment calls under pressure.

Using It Alongside the NH Statutory Form

The Dartmouth Dementia Directive does not replace New Hampshire's statutory advance directive. It supplements it. The statutory form under RSA 137-J:20 already allows you to add a "Living Will Burdens" addendum listing conditions or treatments you consider excessively burdensome. The dementia directive functions as a structured, detailed version of that addendum.

To use both documents together:

1. Complete the standard New Hampshire advance directive (DPOAH + Living Will)
2. Execute the Dartmouth Dementia Directive as a separate supplement
3. Reference the dementia directive in the "Additional Instructions" section of your statutory form
4. Provide copies of both documents to your healthcare agent, your primary care physician, and any care facility

Both documents should be executed with the same witnessing standards — either two qualified witnesses or a notary public — to ensure enforceability.

When to Complete It

The critical requirement for any advance directive is that you must have decision-making capacity at the time of execution. For dementia planning, this creates urgency: if you wait until after a diagnosis progresses to moderate-stage Alzheimer's, your capacity to execute the document may be legally challenged.

The ideal time to complete a dementia directive is either before any diagnosis (as a precautionary measure) or immediately after an early-stage diagnosis, while your capacity is still clearly intact. Family members who have a genetic predisposition or family history of Alzheimer's should consider completing the directive as part of their routine advance care planning.

The Role of Your Healthcare Agent

Your designated agent under the DPOAH gains significant authority once the directive activates. Under the 2021 SB 74 amendments, your agent can consent to or refuse treatment, request a POLST form from your physician, and coordinate care transitions between facilities.

The dementia directive strengthens this authority by providing documented evidence of your specific wishes. If a care facility or physician questions your agent's decisions, the directive serves as proof that the agent is carrying out your expressed preferences — not imposing their own judgment.

The New Hampshire Advance Directive & Living Will Kit includes a dementia planning worksheet alongside the statutory form and execution checklist, so you can address cognitive decline scenarios in the same planning session.

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