State of South Carolina

Advance Directive for Health Care

This Document Contains:

• Medical Power of Attorney

• Living Will
 HEALTH CARE POWER OF ATTORNEY
(South Carolina Statutory Form, Code of Laws Section 62-5-504)

__________________________, Name

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.

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 ACKOWLEDGMENT
THAT THE SIGNATURE OF THE POWER OF ATTORNEY IS YOURS.

THE FOLLOWING PERSONS MAY NOT ACT AS A WITNESS:

 A. YOUR SPOUSE, YOUR CHILDREN, GRANDCHILDREN, AND OTHER
LINEAL DECENDANTS; 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.

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 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

END OF INFORMATION ABOUT THIS DOCUMENT

STATE OF SOUTH CAROLINA ) DURABLE POWER OF ATTORNEY FOR
) HEALTH CARE FOR
COUNTY OF _____________ ) ______________________, Name

1. DESIGNATION OF HEALTH CARE AGENT.

I, _____________________, hereby appoint:

Name: ______________________
Address:______________________
____________________________
Home Telephone: _____________
Work Telephone: _____________
Cell Telephone: ______________

as my Agent to make health care decisions for me as authorized in this document.

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:

a. First Alternate Agent:

Name: _______________________
Address: _______________________________
Telephone: Home:_________________ ; Work: ________________; Cell:____________

b. Second Alternate Agent:

Name: ________________________
Address: _________________________________
Telephone: Home: ________________; Work: _________________; Cell:____________

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.

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 alternative 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 1320(d) 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.

4. AGENT’S POWER

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.

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.

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 another 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 power granted above does not include the following powers or are subject to the
following rules or limitations:

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 CONCERNING LIFE SUSTAINING TREATMENT.

With respect to any Life-Sustaining Treatment, I direct the following:

(INITIAL ONLY ONE OF THE FOLLOWING 3 PARAGRAPHS)

(A) _______ 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

(B) _______ DIRECTIVE TO WITHHOLD OR WITHDRAW TREATMENT. I do not

want my life to be prolonged and I do not want life-sustaining treatment:

1. 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

2. if I am in a state of permanent unconsciousness.

OR
(C) _______ DIRECTIVE FOR MAXIMUM TREATMENT. I want my life to be
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.

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):

(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
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 STATEMENT IN ITEM 8, YOUR AGENT WILL
NOT HAVE THE AUTHORITY TO DIRECT THAT NUTRITION AND HYDRATION
NECESSARY FOR YOUR COMFORT CARE OR ALLEVIATION OF PAIN BE
WITHDRAWN.

9. ADMINISTRATIVE PROVISIONS.

A. I revoke any prior Health Care Power of Attorney and any provisions relating to health
care of any other power of attorney.

B. This power of attorney is intended to be valid in any jurisdiction in which it is presented.

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: _____________________________________.

Signature: ________________________________
Print Name: ____________________, 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 she signed or acknowledged this Health
Care Power of Attorney in my presence, and that 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 financially responsible for the Principal’s medical care.
I am not entitled to any portion of the Principal’s estate upon her 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 Health Care Agent by this document.

Witness No. 1:

Signature:_______________________________ Date: __________ ____, 20__

Print Name: _______________________; Telephone: _____________________
Address: ______________________________________

Witness No. 2:

Signature:_______________________________ Date: ___________ ____, 20__

Print Name:_________________________________; Telephone: ________________
Address: ________________________________________
STATE OF SOUTH CAROLINA ) DECLARATION OF A DESIRE FOR A
) NATURAL DEATH
COUNTY OF _____________ )

I, __________________, 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

1. If my condition is terminal and could result in death within a reasonably short time,

A._____________I direct that nutrition and hydration BE PROVIDED through any medically
indicated means, including medically or surgically implanted tubes.

B._____________I direct that nutrition and hydration NOT BE PROVIDED through any
medically indicated means, including medically or surgically implanted tubes.

The following line is not part of the standard South Carolina form. It has been added at the
request of many people as a point of clarification. If you do want it to apply, please initial the
line below:

C._____________Nevertheless, I do want treatment to ensure my comfort and to relieve pain

and suffering and minimal intravenous fluids to avoid discomfort.

INITIAL ONE OF THE FOLLOWING STATEMENTS

2. If I am in a persistent vegetative state or other condition of permanent unconsciousness,

A._____________I direct that nutrition and hydration BE PROVIDED through any medically
indicated means, including medically or surgically implanted tubes.
B._____________I direct that nutrition and hydration NOT BE PROVIDED through any
medically indicated means, including medically or surgically implanted tubes.

The following line is not part of the standard South Carolina form. It has been added at the
request of many people as a point of clarification. If you do want it to apply, please initial the
line below:

C._____________ Nevertheless, I do want treatment to ensure my comfort and to relieve pain

and suffering and minimal intravenous fluids to avoid discomfort.

3. 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.

4. 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.

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: ____________________________________________

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 ORIGINAL DECLARATIONS REVOKES ALL OF THE
ORIGINAL DECLARATIONS;

(2) BY A WRITTEN REVOCATION SIGNED AND DATED BY YOU EXPRESSING YOUR

INTENT TO REVOKE;
(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.

__________________________________________
Declarant

STATE OF SOUTH CAROLINA )

) AFFIDAVIT
COUNTY OF ______________ )

We, _________________________ and __________________________, the undersigned

witnesses to the foregoing Declaration, dated this _____ 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 her
request and in her 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 her to be of sound mind.
Each of us affirms that he/she is qualified as a witness to this Declaration under the provisions of the
South Carolina Death With Dignity Act in that he/she 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 Declarant's estate 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 decedent'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.

__________________________________ ___________________________________
Witness Witness

Subscribed, sworn to, and acknowledged before me by ____________________, the Declarant, and
subscribed and sworn to before me by _________________ and _________________________,
the witnesses, this _____ day of ___________________, 20____.

______________________________ (SEAL)
Notary Public for South Carolina
My Commission Expires:__________