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SOUTH CAROLINA Advance Directive Decisions Planning for Important (NHPCO)

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1
SOUTH
CAROLINA
Advance
Directive
Planning for Important Health Care
Decisions
CaringI
nfo
1731 King St., Suite 100,
Alexandria,
VA 22314
www.caringinfo.org
800/658-8898
CaringInfo, a program of the National Hospice and Palliative Care Organization
(NHPCO), is a national consumer engagement initiative to improve care at the end of
life.
It’s About How You LIVE
It’s About How You LIVE is a national community engagement campaign encouraging
individuals to make informed decisions about end-of-life care and services. The
campaign encourages people to:
Learn about options for end-of-life services and care
Implement plans to ensure wishes are honored
Voice decisions to family, friends and health care providers
Engage in personal or community efforts to improve end-of-life care
Note: The following is not a substitute for legal advice. While CaringInfo updates the
following information and form to keep them up-to-date, changes in the underlying law
can affect how the form will operate in the event you lose the ability to make decisions
for yourself. If you have any questions about how the form will help ensure your
wishes are carried out, or if your wishes do not seem to fit with the form, you may wish
to talk to your health care provider or an attorney with experience in drafting advance
directives. If you have other questions regarding these documents, we
recommend contacting your state attorney general's office.
Copyright © 2005 National Hospice and Palliative Care Organization. All rights reserved. Revised 2020.
Reproduction and distribution by an organization or organized group without the written permission of
the National Hospice and Palliative Care Organization is expressly forbidden.
2
Using these Materials
BEFORE YOU BEGIN
1. Check to be sure that you have the materials for each state in which you may receive
health care.
2. These materials include:
•
Instructions for preparing your advance directive, please read all the
instructions.
•
Your state-specific advance directive forms, which are the pages with the gray
instruction bar on the left side.
ACTION STEPS
1. You may want to photocopy or print a second set of these forms before you start so
you will have a clean copy if you need to start over.
2. When you begin to fill out the forms, refer to the gray instruction bars — they will
guide you through the process.
3. Talk with your family, friends, and physicians about your advance directive. Be sure
the person you appoint to make decisions on your behalf understands your wishes.
4. Once the forms are completed and signed, photocopy the forms and give them to the
person you have appointed to make decisions on your behalf, your family, friends,
health care providers, and/or faith leaders so that the forms are available in the event
of an emergency.
5. You may also want to save a copy of your form in an online personal health records
application, program, or service that allows you to share your medical documents with
your physicians, family, and others who you want to take an active role in your
advance care planning.
3
INTRODUCTION TO YOUR SOUTH CAROLINA ADVANCE DIRECTIVE
This packet contains two legal documents that protect your right to refuse medical
treatment you do not want, or to request treatment you do want, in the event you lose
the ability to make decisions yourself. You may complete either, or both, depending on
your advance-planning needs.
South Carolina Health Care Power of Attorney. This document lets you name an
adult, your “agent,” to make decisions about your health care—including decisions about
life-sustaining procedures—if you can no longer speak for yourself. The health care power
of attorney is especially useful because it appoints someone to speak for you any time you
are unable to make your own health care decisions, not only at the end of life.
Your health care power of attorney goes into effect when your doctor, and one other
doctor or your agent certify that you are unable to appreciate the nature and implications
of your condition and proposed health care, to make a reasoned decision concerning the
proposed health care, or to communicate that decision in an unambiguous manner.
South Carolina Declaration of a Desire for a Natural Death, or Declaration, is your
state’s living will. Your declaration lets you state your wishes about health care in the
event that you can no longer make your own health care decisions and you are terminally
ill or in a persistent vegetative state.
Your living will goes into effect when your doctor and one other doctor certify that you are
no longer able to make or communicate your health care decisions and you are terminally
ill or in a persistent vegetative state.
These forms do not expressly address mental illness. If you would like to make advance
care plans regarding mental illness, you should talk to your physician and an attorney
about an advance directive tailored to your needs.
Note: These
documents
will be legally
binding
only if the
person completing
them is an
individual
of
sound
mind who is 18 years or older.
4
COMPLETING YOUR SOUTH CAROLINA ADVANCE DIRECTIVE
How do I make my South Carolina Documents legal?
In order to make your South Carolina Health Care Power of Attorney legal, you must sign
and date it or acknowledge your signature in the presence of two witnesses. These witnesses
cannot be:
•
your agent or alternate agent;
•
related to you by blood, marriage, or adoption;
•
your attending physician or an employee of your attending physician;
•
directly financially responsible for your medical care;
•
entitled to any portion of your estate after your death either under a will or by operation of
law;
•
a beneficiary of your life insurance policy; or
•
anyone with a claim against your estate upon your death.
In addition, at least one of your witnesses must not be an employee of a health facility in which
you are a patient.
If you are unable to sign, you may direct someone to sign on your behalf and in your presence.
In order to make your South Carolina Declaration of a Desire for a Natural Death legal,
you must sign it in the presence of two witnesses and have it notarized. Your notary may act as
one of your witnesses. These witnesses cannot be:
•
related to you by blood, marriage, or adoption;
•
your attending physician or an employee of your attending physician;
•
directly financially responsible for your medical care;
•
entitled to any portion of your estate after your death either under a will or by operation of
law;
•
a beneficiary of your life insurance policy; or
•
anyone with a claim against your estate upon your death.
In addition, at least one of your witnesses must not be an employee of a health facility in which
you are a patient. Finally, if you are a resident in a hospital or nursing facility, one of the witnesses
must be an ombudsman designated by the State Ombudsman, Office of the Governor.
Whom should I appoint as my agent?
Your agent is the person you appoint to make decisions about your health care if you
become unable to make those decisions yourself. Your agent may be a family member or a
close friend whom you trust to make serious decisions. The person you name as your agent
should clearly understand your wishes and be willing to accept the responsibility of making
health care decisions for you.
You can appoint a second person as your alternate agent. The alternate will step in if the first
person you name as an agent is unable, unwilling, or unavailable to act for you.
5
Your agent must be at least 18 and cannot be:
•
a health care provider, or an employee of a provider, with whom the you have a
provider-patient relationship, or
•
an employee of a nursing care facility in which the principal resides, or
•
a spouse of the health care provider or employee.
You may appoint one of the people above as your agent if he or she is your relative.
Can I add personal instructions to my advance directive?
One of the strongest reasons for naming an agent is to have someone who can respond
flexibly as your health care situation changes and deal with situations that you did not
foresee. If you add instructions to this document it may help your agent carry out your
wishes, but be careful that you do not unintentionally restrict your agent’s power to act in
your best interest. In any event, be sure to talk with your agent about your future medical
care and describe what you consider to be an acceptable “quality of life.”
If you complete both documents included in this packet, be sure that the instructions you
give match. Any agent you appoint in your health care power of attorney is bound by the
choices you make in your declaration.
What if I change my mind?
You may revoke your health care power of attorney by notifying your health care provider or agent
in writing or orally. You can also revoke by executing a new health care power of attorney, if that
document states an intention to revoke your earlier health care power of attorney.
You may revoke your declaration by destroying it (or directing someone to destroy it in your
presence), by a signed and dated written revocation, by an oral expression to your physician, or by
executing a new declaration. You may also appoint an agent in your declaration with the power to
revoke it on your behalf.
What other important facts should I know?
You may appoint an agent in your declaration. Unlike an agent appointed under your durable
power of attorney for health care, an agent appointed through your declaration is only
empowered to enforce or revoke your declaration, and may not make other medical treatment
decisions.
No instruction by your agent or in your declaration to withhold or withdraw life-sustaining
procedures will be honored in the event you are pregnant.
6
SOUTH CAROLINA HEALTH CARE POWER OF ATTORNEY
PAGE 1 OF 9
HEALTH CARE POWER OF ATTORNEY
INFORMATION ABOUT THIS DOCUMENT
THIS IS AN IMPORTANT LEGAL DOCUMENT. BEFORE SIGNING THIS
DOCUMENT, YOU SHOULD KNOW THESE IMPORTANT FACTS:
1. THIS DOCUMENT GIVES THE PERSON YOU NAME AS YOUR AGENT THE
POWER TO MAKE HEALTH CARE DECISIONS FOR YOU IF YOU CANNOT MAKE
THE DECISION FOR YOURSELF. THIS POWER INCLUDES THE POWER TO
MAKE DECISIONS ABOUT LIFE-SUSTAINING TREATMENT. UNLESS YOU
STATE OTHERWISE, YOUR AGENT WILL HAVE THE SAME AUTHORITY TO
MAKE DECISIONS ABOUT YOUR HEALTH CARE AS YOU WOULD HAVE.
NOTICE
© 2005 National
Hospice and
Palliative Care
Organization.
2020 Revised.
2. THIS POWER IS SUBJECT TO ANY LIMITATIONS OR STATEMENTS OF
YOUR DESIRES THAT YOU INCLUDE IN THIS DOCUMENT. YOU MAY STATE
IN THIS DOCUMENT ANY TREATMENT YOU DO NOT DESIRE OR TREATMENT
YOU WANT TO BE SURE YOU RECEIVE. YOUR AGENT WILL BE OBLIGATED
TO FOLLOW YOUR INSTRUCTIONS WHEN MAKING DECISIONS ON YOUR
BEHALF. YOU MAY ATTACH ADDITIONAL PAGES IF YOU NEED MORE SPACE
TO COMPLETE THE STATEMENT.
3. AFTER YOU HAVE SIGNED THIS DOCUMENT, YOU HAVE THE RIGHT TO
MAKE HEALTH CARE DECISIONS FOR YOURSELF IF YOU ARE MENTALLY
COMPETENT TO DO SO. AFTER YOU HAVE SIGNED THIS DOCUMENT, NO
TREATMENT MAY BE GIVEN TO YOU OR STOPPED OVER YOUR OBJECTION
IF YOU ARE MENTALLY COMPETENT TO MAKE THAT DECISION.
4. YOU HAVE THE RIGHT TO REVOKE THIS DOCUMENT, AND TERMINATE
YOUR AGENT'S AUTHORITY, BY INFORMING EITHER YOUR AGENT OR YOUR
HEALTH CARE PROVIDER ORALLY OR IN WRITING.
5. IF THERE IS ANYTHING IN THIS DOCUMENT THAT YOU DO NOT
UNDERSTAND, YOU SHOULD ASK A SOCIAL WORKER, LAWYER, OR OTHER
PERSON TO EXPLAIN IT TO YOU.
6. THIS POWER OF ATTORNEY WILL NOT BE VALID UNLESS TWO PERSONS
SIGN AS WITNESSES. EACH OF THESE PERSONS MUST EITHER WITNESS
YOUR SIGNING OF THE POWER OF ATTORNEY OR WITNESS YOUR
ACKNOWLEDGMENT THAT THE SIGNATURE ON THE POWER OF ATTORNEY
IS YOURS.
7
SOUTH CAROLINA HEALTH CARE POWER OF ATTORNEY
PAGE 2 OF 9
THE FOLLOWING PERSONS MAY NOT ACT AS WITNESSES:
A. YOUR SPOUSE; YOUR CHILDREN, GRANDCHILDREN, AND OTHER LINEAL
DESCENDANTS; YOUR PARENTS, GRANDPARENTS, AND OTHER LINEAL
ANCESTORS; YOUR SIBLINGS AND THEIR LINEAL DESCENDANTS; OR A
SPOUSE OF ANY OF THESE PERSONS.
B. A PERSON WHO IS DIRECTLY FINANCIALLY RESPONSIBLE FOR YOUR
MEDICAL CARE.
NOTICE
(CONTINUED)
© 2005 National
Hospice and
Palliative Care
Organization.
2020 Revised.
C. A PERSON WHO IS NAMED IN YOUR WILL, OR, IF YOU HAVE NO WILL,
WHO WOULD INHERIT YOUR PROPERTY BY INTESTATE SUCCESSION.
D. A BENEFICIARY OF A LIFE INSURANCE POLICY ON YOUR LIFE.
E. THE PERSONS NAMED IN THE HEALTH CARE POWER OF ATTORNEY AS
YOUR AGENT OR SUCCESSOR AGENT.
F. YOUR PHYSICIAN OR AN EMPLOYEE OF YOUR PHYSICIAN.
G. ANY PERSON WHO WOULD HAVE A CLAIM AGAINST ANY PORTION OF
YOUR ESTATE (PERSONS TO WHOM YOU OWE MONEY).
IF YOU ARE A PATIENT IN A HEALTH FACILITY, NO MORE THAN ONE
WITNESS MAY BE AN EMPLOYEE OF THAT FACILITY.
7. YOUR AGENT MUST BE A PERSON WHO IS 18 YEARS OLD OR OLDER AND
OF SOUND MIND. IT MAY NOT BE YOUR DOCTOR OR ANY OTHER HEALTH
CARE PROVIDER THAT IS NOW PROVIDING YOU WITH TREATMENT; OR AN
EMPLOYEE OF YOUR DOCTOR OR PROVIDER; OR A SPOUSE OF THE
DOCTOR, PROVIDER, OR EMPLOYEE; UNLESS THE PERSON IS A RELATIVE
OF YOURS.
8. YOU SHOULD INFORM THE PERSON THAT YOU WANT HIM OR HER TO
BE YOUR HEALTH CARE AGENT. YOU SHOULD DISCUSS THIS DOCUMENT
WITH YOUR AGENT AND YOUR PHYSICIAN AND GIVE EACH A SIGNED
COPY. IF YOU ARE IN A HEALTH CARE FACILITY OR A NURSING CARE
FACILITY, A COPY OF THIS DOCUMENT SHOULD BE INCLUDED IN YOUR
MEDICAL RECORD.
8
SOUTH CAROLINA HEALTH CARE POWER OF ATTORNEY
PAGE 3 OF 9
PRINT YOUR NAME
1. DESIGNATION OF HEALTH CARE AGENT
I, , hereby appoint:
(Principal)
PRINT
THE
NAME,
HOME ADDRESS,
AND TELEPHONE
NUMBERS OF YOUR
AGENT
(Agent’s Name)
(Address’s Address)
Telephone: Home: Work: Mobile: as
my agent to make health care decisions for me as authorized in this
document.
2. Successor Agent: If an agent named by me dies, becomes legally
disabled, resigns, refuses to act, becomes unavailable, or if an agent who is
my spouse is divorced or separated from me, I name the following as
successors to my agent, each to act alone and successively, in the order
named:
PRI
NT THE NAME,
ADDRESS AND
TELEPHONE
NUMBER OF YOUR
ALTERNATE
AGENT(S)
a. First Alternate Agent:
Address:
_
Telephone: Home: Work: Mobile:
b. Second Alternate Agent:
Address:
Telephone: Home: Work: Mobile:
© 2005 National
Hospice and
Palliative Care
Organization.
2020 Revised.
Unavailability of Agent(s): If at any relevant time the agent or successor
agents named here are unable or unwilling to make decisions concerning my
health care, and those decisions are to be made by a guardian, by the
Probate Court, or by a surrogate pursuant to the Adult Health Care Consent
Act, it is my intention that the guardian, Probate Court, or surrogate make
those decisions in accordance with my directions as stated in this document.
9
SOUTH CAROLINA HEALTH CARE POWER OF ATTORNEY
PAGE 4 OF 9
2. EFFECTIVE DATE AND DURABILITY
By this document I intend to create a durable power of attorney effective
upon, and only during, any period of mental incompetence, except as
provided in Paragraph 3 below.
3. HIPAA AUTHORIZATION
When considering or making health care decisions for me, all individually
identifiable health information and medical records shall be released without
restriction to my health care agent(s) and/or my alternate health care
agent(s) named above including, but not limited to, (i) diagnostic, treatment,
other health care, and related insurance and financial records and
information associated with any past, present, or future physical or mental
health condition including, but not limited to, diagnosis or treatment of
HIV/AIDS, sexually transmitted disease(s), mental illness, and/or drug or
alcohol abuse and (ii) any written opinion relating to my health that such
health care agent(s) and/or alternate health care agent(s) may have
requested. Without limiting the generality of the foregoing, this release
authority applies to all health information and medical records governed by
the Health Insurance Portability and Accountability Act of 1996 (HIPAA), 42
USC 1320d and 45 CFR 160-164; is effective whether or not I am mentally
competent; has no expiration date; and shall terminate only in the event that
I revoke the authority in writing and deliver it to my health care provider.
AGENT'S POWERS
© 2005 National
Hospice and
Palliative Care
Organization.
2020 Revised.
4. AGENT'S POWERS
I grant to my agent full authority to make decisions for me regarding my
health care. In exercising this authority, my agent shall follow my desires as
stated in this document or otherwise expressed by me or known to my
agent. In making any decision, my agent shall attempt to discuss the
proposed decision with me to determine my desires if I am able to
communicate in any way. If my agent cannot determine the choice I would
want made, then my agent shall make a choice for me based upon what my
agent believes to be in my best interests. My agent's authority to interpret
my desires is intended to be as broad as possible, except for any limitations I
may state below.
10
SOUTH CAROLINA HEALTH CARE POWER OF ATTORNEY
PAGE 5 OF 9
Accordingly, unless specifically limited by the provisions specified below, my
agent is authorized as follows:
A. To consent, refuse, or withdraw consent to any and all types of medical
care, treatment, surgical procedures, diagnostic procedures, medication, and
the use of mechanical or other procedures that affect any bodily function,
including, but not limited to, artificial respiration, nutritional support and
hydration, and cardiopulmonary resuscitation;
AGENT'S POWERS
CONTINUED
ADD INSTRUCTIONS
HERE ONLY IF YOU
WANT TO LIMIT
YOUR AGENT'S
AUTHORITY
© 2005 National
Hospice and Palliative
Care Organization.
2020 Revised.
B. To authorize, or refuse to authorize, any medication or procedure
intended to relieve pain, even though such use may lead to physical
damage, addiction, or hasten the moment of, but not intentionally cause, my
death;
C. To authorize my admission to or discharge, even against medical advice,
from any hospital, nursing care facility, or similar facility or service;
D. To take any other action necessary to making, documenting, and assuring
implementation of decisions concerning my health care, including, but not
limited to, granting any waiver or release from liability required by any
hospital, physician, nursing care provider, or other health care provider;
signing any documents relating to refusals of treatment or the leaving of a
facility against medical advice, and pursuing any legal action in my name,
and at the expense of my estate to force compliance with my wishes as
determined by my agent, or to seek actual or punitive damages for the
failure to comply.
E. The powers granted above do not include the following powers or are
subject to the following rules or limitations:
(attach additional pages if needed)
11
SOUTH CAROLINA HEALTH CARE POWER OF ATTORNEY
PAGE 6 OF 9
ORGAN DONATION
INITIAL TO
INDICATE
WHETHER YOU
WANT YOUR AGENT
TO BE ABLE TO
DONATE YOUR
ORGANS
5. ORGAN DONATION (INITIAL ONLY ONE)
My agent may ; may not consent to the donation of all or any of my
tissue or organs for purposes of transplantation.
6. EFFECT ON DECLARATION OF A DESIRE FOR A NATURAL DEATH (LIVING
WILL)
I understand that if I have a valid Declaration of a Desire for a Natural
Death, the instructions contained in the Declaration will be given effect in
any situation to which they are applicable. My agent will have authority to
make decisions concerning my health care only in situations to which the
Declaration does not apply.
7. STATEMENT OF DESIRES CONCERINING LIFE SUSTAINING TREATEMENT
With respect to any Life-Sustaining Treatment, I direct the following:
(INITIAL ONLY ONE OF THE FOLLOWING 3 PARAGRAPHS)
INITIAL ONLY ONE
(1) GRANT OF DISCRETION TO AGENT. I do not want my life to be
prolonged nor do I want life-sustaining treatment to be provided or continued
if my agent believes the burdens of the treatment outweigh the expected
benefits. I want my agent to consider the relief of suffering, my personal
beliefs, the expense involved and the quality as well as the possible extension
of my life in making decisions concerning life-sustaining treatment.
OR
(2) DIRECTIVE TO WITHHOLD OR WITHDRAW TREATMENT. I do not
want my life to be prolonged and I do not want life-sustaining treatment:
a. if I have a condition that is incurable or irreversible and, without the
administration of life-sustaining procedures, expected to result in death within
a relatively short period of time; or
b. if I am in a state of permanent unconsciousness.
OR
(3) DIRECTIVE FOR MAXIMUM TREATMENT. I want my life to be
© 2005 National
Hospice and
Palliative Care
Organization.
2020 Revised.
prolonged to the greatest extent possible, within the standards of accepted
medical practice, without regard to my condition, the chances I have for
recovery, or the cost of the procedures.
12
SOUTH CAROLINA HEALTH CARE POWER OF ATTORNEY
PAGE 7 OF 9
8. STATEMENT OF DESIRES REGARDING TUBE FEEDING
With respect to Nutrition and Hydration provided by means of a nasogastric
tube or tube into the stomach, intestines, or veins, I wish to make clear that
in situations where life sustaining treatment is being withheld or withdrawn
pursuant to Item 7,
(INITIAL ONLY ONE OF THE FOLLOWING THREE PARAGRAPHS)
INITIAL ONLY ONE
(A) GRANT OF DISCRETION TO AGENT. I do not want my life to be
prolonged by tube feeding if my agent believes the burdens of tube feeding
outweigh the expected benefits. I want my agent to consider the relief of
suffering, my personal beliefs, the expense involved, and the quality as well
as the possible extension of my life in making this decision.
OR
(B) DIRECTIVE TO WITHHOLD OR WITHDRAW TUBE FEEDING. I do not
want my life prolonged by tube feeding.
OR
(C) DIRECTIVE FOR PROVISION OF TUBE FEEDING. I want tube feeding
to be provided within the standards of accepted medical practice, without
regard to my condition, the chances I have for recovery, or the cost of the
procedure, and without regard to whether other forms of life-sustaining
treatment are being withheld or withdrawn.
IF YOU DO NOT INITIAL ANY OF THE STATEMENTS IN PARAGRAPH 8, YOUR
AGENT WILL NOT HAVE AUTHORITY TO DIRECT THAT NUTRITION AND
HYDRATION NECESSARY FOR COMFORT CARE OR ALLEVIATION OF PAIN BE
WITHDRAWN.
© 2005 National
Hospice and
Palliative Care
Organization.
2020 Revised.
13
SOUTH CAROLINA HEALTH CARE POWER OF ATTORNEY
PAGE 8 OF 9
9. ADMINISTRATIVE PROVISIONS
A. I revoke any prior Health Care Power of Attorney and any provisions
relating to health care of any other prior power of attorney.
B. This power of attorney is intended to be valid in any jurisdiction in which it
is presented.
10. ADDITIONAL INSTRUCTIONS
I provide the following additional instructions for the guidance of my agent:
ADD OTHER
INSTRUCTIONS, IF
ANY, REGARDING
YOUR ADVANCE
CARE
PLANS
THESE
INSTRUCTIONS CAN
FURTHER ADDRESS
YOURHEALTH
CARE
PLANS,
SUCH
AS
YOUR
WISHES
REGARDING
HOSPICE
TREATMENT, BUT
CAN ALSO ADDRESS
OTHER
ADVANCE
PLANNING ISSUES,
SUCH AS YOUR
BURIAL WISHES
ATTACH
ADDITIONAL
PAGES
IF
NEEDED
© 2005 National
Hospice and
Palliative Care
Organization. 2020
Revised.
(attach additional pages if needed)
14
SOUTH CAROLINA HEALTH CARE POWER OF ATTORNEY
PAGE 9 OF 9
DATE AND PRINT
YOUR ADDRESS
SI
GN AND PRINT
YOUR NAME
BY SIGNING HERE I INDICATE THAT I UNDERSTAND THE CONTENTS OF THIS DOCUMENT
AND THE EFFECT OF THIS GRANT OF POWERS TO MY AGENT.
I sign my name to this Health Care Power of Attorney on this _ day of
, 20____. My current home address is:
_
Principal’s Signature: _
Print Name of Principal: _
WITNESS STATEMENT
I declare, on the basis of information and belief, that the person who signed or
acknowledged this document (the principal) is personally known to me, that he/she signed
or acknowledged this Health Care Power of Attorney in my presence, and that he/she
appears to be of sound mind and under no duress, fraud, or undue influence. I am not
related to the principal by blood, marriage, or adoption, either as a spouse, a lineal ancestor,
descendant of the parents of the principal, or spouse of any of them. I am not directly
fi
nancially responsible for the principal's medical care. I am not entitled to any portion of the
prin
cipal's estate upon his decease, whether under any will or as an heir by intestate
succession, nor am I the beneficiary of an insurance policy on the principal's life, nor do
I
have
a claim against the principal's estate as of this time. I am not the principal's attending
physician, nor an employee of the attending physician. No more than one witness is an
employee of a health facility in which the principal is a patient. I am not appointed as Health
Care Agent or Successor Heal
th Care Agent by this document.
Witness No. 1
Signature: _
Date:
Print
Name: _ Telephone:
Address:
Witness No. 2
Signature: _ Date: _
Print Name:
_ Telephone: _
Address:
_
STATE OF SOUTH CAROLINA
COUNTY
OF
The foregoing instrument was acknowledged before me by Principal on
, 20 .
Notary Public for South Carolina
M
y Commission Expires: _
WITNESSES MUST
SIGN, DATE, AND
PRINT THEIR
TELEPHONE
NUMBERS AND
ADDRESSES HERE
A NOTARY PUBLIC
MUST COMPLETE
THIS PORTION OF
THE FORM
© 2005 National
Hospice and
Palliative Care
Organization.
2020 Revised.
Courtesy
of CaringInfo
1731
King St.,
Suite 100, Alexandria,
VA 22314
www.caringinfo.org,
800/658-8898
15
SOUTH CAROLINA DECLARATION – PAGE 1 OF 4
DECLARATION OF A DESIRE FOR A NATURAL DEATH
STATE OF SOUTH CAROLINA COUNTY OF
PRINT NAME,
ADDRESS, AND
DATE
INITIAL ONLY ONE
I, (print your
name), Declarant, being at least eighteen years of age and a resident of and
domiciled in the City of _, County of
_, State of South
Carolina, make this Declaration this day of _, 20_____.
I willfully and voluntarily make known my desire that no life-sustaining
procedures be used to prolong my dying if my condition is terminal or if I am
in a state of permanent unconsciousness, and I declare:
If at any time I have a condition certified to be a terminal condition by two
physicians who have personally examined me, one of whom is my attending
physician, and the physicians have determined that my death could occur
within a reasonably short period of time without the use of life-sustaining
procedures or if the physicians certify that I am in a state of permanent
unconsciousness and where the application of life-sustaining procedures
would serve only to prolong the dying process, I direct that the procedures be
withheld or withdrawn, and that I be permitted to die naturally with only the
administration of medication or the performance of any medical procedure
necessary to provide me with comfort care.
INSTRUCTIONS CONCERNING ARTIFICIAL NUTRITION AND HYDRATION
INITIAL ONE OF THE FOLLOWING STATEMENTS
If my condition is terminal and could result in death within a reasonably short
time,
I direct that nutrition and hydration BE PROVIDED through any
medically indicated means, including medically or surgically implanted tubes.
I direct that nutrition and hydration NOT BE PROVIDED through
any medically indicated means, including medically or surgically implanted
tubes.
INITIAL ONE OF THE FOLLOWING STATEMENTS
INITIAL ONLY ONE
© 2005 National
Hospice and
Palliative Care
Organization. 2020
Revised.
If I am in a persistent vegetative state or other condition of permanent
unconsciousness,
I direct that nutrition and hydration BE PROVIDED through any
medically indicated means, including medically or surgically implanted tubes.
I direct that nutrition and hydration NOT BE PROVIDED through
any medically indicated means, including medically or surgically implanted
tubes.
16
SOUTH CAROLINA DECLARATION — PAGE 2 OF 4
In the absence of my ability to give directions regarding the use of life-
sustaining procedures, it is my intention that this Declaration be honored by
my family and physicians and any health facility in which I may be a patient
as the final expression of my legal right to refuse medical or surgical
treatment, and I accept the consequences from the refusal.
I am aware that this Declaration authorizes a physician to withhold or
withdraw life-sustaining procedures. I am emotionally and mentally
competent to make this Declaration.
Other Instructions:
ADD OTHER
INSTRUCTIONS, IF
ANY, REGARDING
YOUR ADVANCE
CARE PLANS
THESE
INSTRUCTIONS CAN
FURTHER ADDRESS
YOUR
HEALTH
CARE
PLANS, SUCH AS
YOUR WISHES
REGARDING
HOSPICE
TREATMENT,
BUT
CAN
ALSO
ADDRESS
OTHER
ADVANCE
PLANNING ISSUES,
SUCH AS YOUR
BURIAL WISHES
ATTACH
ADDITIONAL PAGES
IF NEEDED
PROVIDE NAME,
ADDRESS AND
TELEPHONE
NUMBER OF
AGENT(S)
(OPTIONAL)
© 2005 National
Hospice and
Palliative Care
Organization. 2020
Revised.
(attach additional pages if needed)
APPOINTMENT OF AN AGENT (OPTIONAL)
1. You may give another person authority to revoke this declaration on your
behalf. If you wish to do so, please enter that person's name in the space
below.
Name of Agent with Power to Revoke:
Address:
Telephone Number:
2. You may give another person authority to enforce this declaration on your
behalf. If you wish to do so, please enter that person's name in the space
below.
Name of Agent with Power to Enforce:
Address:
Telephone Number:
17
SOUTH CAROLINA DECLARATION — PAGE 3 OF 4
REVOCATION PROCEDURES
THIS DECLARATION MAY BE REVOKED BY ANY ONE OF THE FOLLOWING
METHODS. HOWEVER, A REVOCATION IS NOT EFFECTIVE UNTIL IT IS
COMMUNICATED TO THE ATTENDING PHYSICIAN.
(1) BY BEING DEFACED, TORN, OBLITERATED, OR OTHERWISE DESTROYED,
IN EXPRESSION OF YOUR INTENT TO REVOKE, BY YOU OR BY SOME
PERSON IN YOUR PRESENCE AND BY YOUR DIRECTION. REVOCATION BY
DESTRUCTION OF ONE OR MORE OF MULTIPLE
THE ORIGINAL DECLARATIONS;
(2) BY A WRITTEN REVOCATION SIGNED AND DATED BY YOU EXPRESSING
YOUR INTENT TO REVOKE;
REVOCATION
© 2005 National
Hospice and
Palliative Care
Organization.
2020 Revised.
(3) BY YOUR ORAL EXPRESSION OF YOUR INTENT TO REVOKE THE
DECLARATION. AN ORAL REVOCATION COMMUNICATED TO THE
ATTENDING PHYSICIAN BY A PERSON OTHER THAN YOU IS EFFECTIVE
ONLY IF:
(a) THE PERSON WAS PRESENT WHEN THE ORAL REVOCATION WAS MADE;
(b) THE REVOCATION WAS COMMUNICATED TO THE PHYSICIAN WITHIN A
REASONABLE TIME;
(c) YOUR PHYSICAL OR MENTAL CONDITION MAKES IT IMPOSSIBLE FOR
THE PHYSICIAN TO CONFIRM THROUGH SUBSEQUENT CONVERSATION
WITH YOU THAT THE REVOCATION HAS OCCURRED.
TO BE EFFECTIVE AS A REVOCATION, THE ORAL EXPRESSION CLEARLY
MUST INDICATE YOUR DESIRE THAT THE DECLARATION NOT BE GIVEN
EFFECT OR THAT LIFE-SUSTAINING PROCEDURES BE ADMINISTERED;
(4) IF YOU, IN THE SPACE ABOVE, HAVE AUTHORIZED AN AGENT TO
REVOKE THE DECLARATION, THE AGENT MAY REVOKE ORALLY OR BY A
WRITTEN, SIGNED, AND DATED INSTRUMENT. AN AGENT MAY REVOKE
ONLY IF YOU ARE INCOMPETENT TO DO SO. AN AGENT MAY REVOKE THE
DECLARATION PERMANENTLY OR TEMPORARILY.
(5) BY YOUR EXECUTING ANOTHER DECLARATION AT A LATER TIME.
18
SOUTH CAROLINA DECLARATION — PAGE 4 OF 4
SIGN AND DATE
Signature of Declarant Date
WITNESS AFFIDAVIT
PRINT STATE AND
COUNTY
STATE OF COUNTY OF
PRINT NAMES OF
WITNESSES AND
DATE
We, and , the
undersigned witnesses to the foregoing Declaration, dated the day of
, 20 , at least one of us being first duly sworn, declare to the
undersigned authority, on the basis of our best information and belief, that the
Declaration was on that date signed by the declarant as and for his DECLARATION
OF A DESIRE FOR A NATURAL DEATH in our presence and we, at his request and in
hi
s presence, and in the presence of each other, subscribe our names as witnesses
on that date. The declarant is personally known to us, and we believe him to be of
sound mind. Each of us affirms that he is qualified as a witness to this Declaration
under the provisions of the South Carolina Death With Dignity Act in that he is not
related to the declarant by blood, marriage, or adoption, either as a spouse, lineal
ancestor, descendant of the parents of the declarant, or spouse of any of them; nor
directly financially responsible for the declarant's medical care; nor entitled to any
portion of the decla
rant's es
tate upon his decease, whether under any will or as an
heir by intestate succession; nor the beneficiary of a life insurance policy of the
declarant; nor the declarant's attending physician; nor an employee of the
attending physician; nor a person who has a claim against the declarant's
de
cedent's estate as of this time. No more than one of us is an employee of a health
facility in which the declarant is a patient. If the declarant is a resident in a hospital
or nursing care facility at the date of execution of this Declaration, at least one of us
is an ombudsman designated by the State Ombudsman, Office of the Governor.
Signature: Date:
Print Name:
Signature: Date:
Print Name:
Subscribed before me by , the declarant, and
subscribed and sworn to before me by , the witnesses, this
day of , 20 .
Sign
ature
Notary Public for
My commission expires: SEAL
WITNESSES SIGN
HERE
A NOTARY MUST
COMPLETE THIS
PORTION OF THE
FORM
© 2005 National
Hospice and
Palliative Care
Organization.
2020 Revised.
Courtesy
of
Caring
In
fo
1731 King St., Suite 100,
Alexandria,
VA
22314
www.caringinfo.org,
800
/
658-8898
19
You Have Filled Out Your Health Care Directive, Now What?
1. Your South
Carolina Health
Care Power of
Attorney
and
Declaration
are important legal
documents. Keep the originals signed document in a secure but accessible place. Do not put
the original documents in a safe deposit box or any other security box that would keep
others from having access to it.
2. Give photocopies of the signed originals to your agent and alternate agent, doctor(s), family,
close friends, clergy, and anyone else who might become involved in your health care. If you
enter a nursing home or hospital, have photocopies of your document placed in your medical
records.
3. Be sure to talk to your agent(s), doctor(s), clergy, family, and friends about your wishes
concerning medical treatment. Discuss your wishes with them often, particularly if your
medical condition changes.
4. You may also want to save a copy of your form in an online personal health records
application, program, or service that allows you to share your medical documents with your
physicians, family, and others who you want to take an active role in your advance care
planning.
5. If you want to make changes to your documents after they have been signed and witnessed,
you must complete a new document.
6. Remember, you can always revoke your South Carolina document.
7. Be aware that your South Carolina document will not be effective in the event of a medical
emergency. Ambulance and hospital emergency department personnel are required to
provide cardiopulmonary resuscitation (CPR) unless they are given a separate directive that
states otherwise. These directives called “prehospital medical care directives” or “do not
resuscitate orders” are designed for people whose poor health gives them little chance of
benefiting from CPR. These directives instruct ambulance and hospital emergency personnel
not to attempt CPR if your heart or breathing should stop.
Currently not all states have laws authorizing these orders. We suggest you speak to your
physician if you are interested in obtaining one. CaringInfo does not distribute these
forms.
OR donate online today: www.NationalHospiceFoundation.org/donate
Congratulations!
You’ve downloaded your free, state specific advance directive.
You are taking important steps to make sure your wishes are known. Please consider helping us
keep this resource free.
Your generous support to the National Hospice Foundation allows us to continue to provide FREE
resources, tools, and information to educate and empower individuals to access advance care
planning, caregiving, hospice and grief services.
Please show your support for our mission and consider making a tax-deductible gift
to the National Hospice Foundation today.
Since 1992, the National Hospice Foundation has been dedicated to creating FREE resources for
individuals and families facing a life-limiting illness, raising awareness for the need for hospice
and palliative care, and providing ongoing professional education and skills development to
hospice and palliative care professionals across the nation. To learn more, please visit
www.NationalHospiceFoundation.org
You may wonder if a gift of $35, $50 or $100 to the National Hospice Foundation would make a
difference, but it is only because of the generosity of others like you that these FREE resources
are made available.
Please consider supporting our mission by returning a generous tax-deductible donation.
Every gift makes a difference! Your gift strengthens the Foundation’s ability to provide FREE
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the most generous amount you can send. Thank you.
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Return to:
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PO Box 824401
Philadelphia, PA 19182-4401
2020AD
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Completed 28 December 2021

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