South Carolina Advance Directive Form

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A South Carolina advance directive is a document that combines a health care power of attorney and a living will. This allows a person to select an agent to handle their medical demands and select treatment preferences. Once the form has been written it’s required to be signed with two (2) witnesses and a notary public.

Advance Directive Includes

Table of Contents

Laws

StatuteTitle 44, Chapter 77 (Death with Dignity Act), Title 62, Article 5 (Protection of Persons Under Disability and Their Property)

Signing Requirements (§ 62-5-503, § 62-5-504, 44-77-40) – Two (2) witnesses.

Versions (5)


AARP

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Dept. on Aging

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State BAR

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Spanish (Español) Version

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University of South Carolina

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How to Write

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Step 1 – Save The South Carolina Directive From this Page

Obtain the South Carolina Advance Directive Templates from this page by locating the link “Adobe PDF” above, selecting it, then saving the available file to an easily accessible folder in your machine. The “PDF” attached to the preview can also be used to initiate this download.

Step 2 – Present The Originating South Carolina Country Of This Directive

The first template of this package is titled “Declaration Of A Desire For A Natural Death.” Begin the process of issuing your statement with a recording of the county where it is being executed. Supply the name of this county on the blank line following the term “County Of” 

 

Step 3 – Identify Yourself As The South Carolina Principal Declarant

As the South Carolina Declarant, you must make sure your statement identifies you as its originator. This task will be handled by the first blank line at the start of its introduction. Furnish your full name to the blank line between the word “I” and the phrase “Declarant, Being At Least Years…” 

 

Step 4 – Disclose The Location Of Your South Carolina Home

Continue through the first statement to the blank lines placed after the terms “…City Of” and “County Of.” Use these lines to present the city and county of your residential address.

 

Step 5 – Date The South Carolina Declaration Being Completed

Complete the introduction with the calendar day, month, and year when this paperwork becomes effective. Typically, this will be the same day you sign this statement as the South Carolina Declarant. 

 

Step 6 – Review The Statement Being Made To South Carolina Doctors And Staff

Take a moment to review the body of this paperwork where South Carolina Doctors will be informed that you value maintaining the same quality of life you currently have rather than prolonging your life in a severely debilitated manner or unconscious and unable to maintain your body. The basic statement will request that priority be place on comfort care as opposed to medical treatment. 

 

Step 7 – Direct South Carolina Doctors On Your Nutritional Directives When Terminal

The first article of this declaration seeks your input to define how South Carolina Medical Personnel should handle your nutritional requirements when your condition is “…Terminal And Could Result In Death within A reasonably Short Time.” To formally request that South Carolina Doctors and Medical Staff maintain your nutritional and hydration requirements through any means deemed reasonable and appropriate then initial Statement “A” from this list.  If you want to “…Direct That Nutrition And Hydration Not Be Provided” then initial Statement “B” Statement C has been added by public demand. Initial this item. If you wish nutrition and hydration administered only to ensure your comfort and manage pain.

 

Step 8 – Inform South Carolina Doctors Of Your Nutritional Needs When Permanently Unconscious

The second article seeks your input regarding how South Carolina Doctors and Medical Personnel should treat your nutritional and hydration needs when you are in a vegetative or unconscious state without the possibility of waking up. Three options have been displayed beginning with a request that South Carolina Doctors and Health Care Providers make sure that you are intaking the proper amount of nutrients and liquids in any means available and required to maintain treatment. Initial the blank line labeled “A” if you wish to apply this statement. Initial the blank line labeled “B” in this article if you wish to refuse the medical administration of nutrients and liquids to prevent starvation or dehydration. The third option, labeled as “C,” enables you to authorize the medical administration of food and water when needed so long as artificial feedings will maintain your comfort and to aid in managing your pain. Initial this statement if you prefer that South Carolina Doctors as your request.

 

Step 9 – Formally Declare The Identity Of Your South Carolina Health Care Agent

This declaration provides the option of appointing a South Carolina Health Care Agent to act on your behalf regarding the statements made above. To set this option in place, locate the area titled “Appointment Of Agent.” Here, you may appoint two different Agents; one with the “Power To Revoke” this declaration in your name thereby nullifying it and one to with the “Power To Enforce” this declaration. Generally, the same South Carolina Health Care Agent can be named to both roles however this is not mandatory. If you wish to grant a person with the authorization needed to revoke or terminate the above declaration then, supply his or her full name on the blank line labeled “Name Of Agent With Power To Revoke” in paragraph “1” of this section.  Once you have named a South Carolina Agent Of Revocation for this declaration, provide his or her home “Address” on the next line down.  In addition to the reporting name and address of the South Carolina Agent of Revocation, furnish his or her current “Telephone Number” on the next line. As mentioned earlier, you can grant a person the ability to make sure South Carolina Doctors and other interested Parties adhere to your declaration. If you wish to do so, then locate Statement “2” in the “Appointment Of An Agent Section” where the “Name Of Agent With Power To Enforce” line requires you to identify the person you appoint to this role.  The “Address” line that follows the name of the South Carolina Agent holding the power to enforce this paperwork must be provided with this Agent’s home address.   Lastly, dispense the “Telephone Number” where the South Carolina Agent being discussed can be reliably reached.    

 

Step 10 – Review The South Carolina Principal Declarant’s Rights To Revoke

You will always retain the right to revoke or cancel the above declaration so long as the South Carolina Agents you named, and the concerned Medical Staff are made aware of this intention. The “Revocation Procedures” will spell out your rights concerning this topic and should be reviewed. In general, the most reliable way to revoke a document will be to do so in writing however this is not mandatory for the revocation process.   

 

Step 11 – Execute The South Carolina Directive By Signature

Once you have read and decided to agree with the completed declaration, locate the blank line labeled “Declarant” just before the “Affidavit” section. You must sign the “Declarant” line to formally name this declaration before two Witnesses who will complete the Affidavit. This is required if this document is to be taken as a formal statement of your treatment and life-prolonging procedure preferences when faced with an incurable medical condition.

 

Step 12 – Obtain A Witness Affidavit To Verify Your Signature

The two Witnesses involved must attest to this signing under the guidance of a South Carolina Notary Public. Under his or her guidance and efforts, the “Affidavit” section will be provided with the county of signing, the name of each Witness as well as the date. Each Witness must sign one of the “Witness” lines in the presence of the South Carolina Notary so that he or she can submit this Affidavit to the notarization process.

 

Step 13 – Formally Issue the South Carolina Health Care Power Of Attorney

The next template in the South Carolina advance directives enable you to go one step further from naming an Agent to simply enforce your South Carolina Living Will, revoke it, or both. The South Carolina Statutory Form for the Health Care Power Of Attorney allows you to grant a Health Care Agent with the power to handle many other medical decisions on your behalf when you are unconscious, incapacitated, and/or incognizant. Begin by supplementing your full name to the blank line underneath the title preceding the bold label “Name.” 

Step 14 – Engage A Review Of The Statutory Form’s Introduction

As a South Carolina Resident, you have the right to make certain health-related and treatment-oriented decisions even when you are unconscious or otherwise unable to communicate. The first two pages titled “Information About This Document” will cover some background information such as your rights as the South Carolina Principal Declarant, the expectations you may have of your Agent and South Carolina Doctors, and a few other relevant topics. As the South Carolina Principal Declarant, you are encouraged to read this passage. 

Step 15 – Claim This Document As Your Power Of Attorney

Before completing the first article, the area above it must be supplied with two items to verify the origin of this paperwork. To this end, furnish the South Carolina county where this paperwork will be issued as well as your full “Name” on the blank lines corresponding to the term “County Of” and the word “Name”   

 

Step 16 – Make Your Appointment Statement

The first article, “1. Designation Of Health Care Agent,” begins with a basic statement that requires some supplementation to its language. Locate the phrase “Hereby Appoint” then record your full name to the line that precedes it.

 

Step 17 – Present The South Carolina Health Care Agent Identity

The first empty line following the term “Hereby Appoint” is labeled “Name” and expects the full “Name” of the South Carolina Health Care Agent that you are granting the power to make medical treatment decisions for you if (or when) you are incapacitated and cannot communicate such directives personally. The “Address” where your South Carolina lives should be presented with his or her “Name.” Use the two lines labeled “Address” to supply this information. It should be considered imperative to make sure that any South Carolina Doctor or Medical Personnel using this directive for guidance when you are incapacitated be able to also use this paperwork to contact your Health Care Agent immediately. Naturally, this requires a production of his or her “Home Telephone Number,” “Work Telephone” number, and “Cell Telephone” number. Furnish these items to the blank lines requesting them by label. 

 

Step 18 – Arrange For A Successor Agent To Assume The Health Care Agent Role If Needed

Notice, the section beginning with the label “Successor Agent.” In this area, it is recommended that you name two additional people who can be asked to deliver your medical decisions and directives should you be incapacitated and the originally named South Carolina Agent “…Dies, Becomes Legally Disabled, Resigns, Refuses To Act, Becomes Unavailable,” or (if a Spouse) separates or divorces you. To set up this paperwork to automatically grant a Successor Agent or Alternate Agent, you must attach this person’s “Name” to this role by providing it on the first line in the area labeled “A. First Alternate Agent.” After defining your First Alternate Agent by name, supply his or her residential “Address” on the next available line then deliver the First Alternat Agent’s “Telephone” numbers on the lines labeled “Home,” “Work,” and “Cell.” 

 

Step 19 – Take The Precaution Of Appointing A Second Alternate Agent

If the original South Carolina Health Care Agent becomes ineligible, unavailable, or unwilling to represent you and the First Alternate Agent also cannot represent your wishes to South Carolina Doctors and Medical Staff when you are unconscious then having a Second Alternate Agent put in place can make a crucial difference in making sure your directives are followed. Locate “B. Second Alternate Agent,” then supply the “Name” of the person you believe can represent your medical directives should both previous Agents refuse or cannot. The Second Alternate Agent’s home “Address” and contact phone numbers should be supplied next. Use the “Address” line to dispense the Second Alternate Agent’s place of residence, then supply the “Home” line with the phone number of this residence, continuing with a report of the “Work” phone number, and “Cell” number that can be used to contact the Second Alternate Agent when he or she is not at home. 

 

Step 20 – Familiarize Yourself With The South Carolina Granting Of Power

It is important to review articles “2. Effective Date And Durability” through “4. Agent’s Powers.” These articles provide a wealth of information regarding how this appointment will work and the powers you are granting the Agent. Be advised, that the contents here are set to be compliant with South Carolina and Federal Laws on this subject but there is an opportunity to limit the South Carolina Health Care Agent’s authority over your medical decisions. All additional thoughts, restrictions, requests, or conditions that you wish applied to the Health Care Agent’s ability to represent you should be discussed in Statement “E” in the space found after the words “…Does Not Include the Following Powers Or Are Subject To The Following Rules Or Limitations.” This item can be found at the end of Article “4. Agent’s Power” and should be supplied with your direct instructions. If you require more room, then draw up all the provisions you wish included in a separate document, name it, date it, then supply its title to this space.   

 

Step 21 – Establish Your Standing On Being A South Carolina Organ donor

Article “5. Organ Donation” contains a single statement with two empty spaces. Notice that each pace corresponds to a phrase needed to complete the statement. You must initial the statement that completes this statement as an accurate representation of your intent. If you wish to grant your South Carolina Health Care Agent with the authority to make anatomical donations in your name (after death) then initial the space immediately following the term “My Agent May.” If you do not wish to grant your Health Care Agent, the right to donate your organs or tissues after death then initial the blank space between the term “May Not” and “Consent To The Donation…” In the example below the South Carolina Principal Declarant has determined that his or her Agent may make anatomical gifts after the death of the Principal.   

 

Step 22 – Weigh Your Agent’s Power With That Of Your Living Will

If you have issued a South Carolina Living Will (or intend to) while also designating a Health Care Agent, then there may come a time when your South Carolina Health Care Agent disagrees with the Living Will. This can cause confusion with South Carolina Medical Personnel responsible for your care, therefore Article “7. Statement Of Desires Concerning Life-Sustaining Treatment” presents three-letter items (A through C) of which one must be chosen by providing your initials. Item “A” becomes a “Grant Of Discretion To The Agent” meaning that the person you chose as your South Carolina Health Care Agent will carry more weight in authority than your South Carolina Living Will. If you have determined that you wish to set a “Directive To Withhold Or Withdraw Treatment” where your living will supersede the Agent’s opinions regarding your preferences, then select item “B.” Notice the language in this item will reiterate that found in your living will. This will mean that even if your South Carolina Health Care Agent does not believe with-drawing or denying life support systems to prolong your life when you are in a terminal condition or permanently unconscious is the correct course of action if South Carolina Medical Personnel diagnose you in either or both conditions, then your living will shall take effect. The third option sets your “Directive For Maximum Treatment” regardless of the contents of your living will or the opinion of your South Carolina Health Care Agent. If you wish the statement made by the item labeled “C” to be your stance then initial the blank line corresponding to the words “Directive For Maximum Treatment.” 

 

Step 23 – Dispense Your Position On Tube Feedings

Article “8 Statement Of Desires Regarding Tube Feeding” addresses the issue of maintaining your body when incapacitated or unconscious for either extended periods of time or permanently. In such a state, you will not be able to feed yourself or drink water to prevent starvation or dehydration. While, as a rule of thumb, South Carolina Medical Personnel will seek to prevent starvation or dehydration in their Patient, South Carolina Doctors will require your authorization to medically deliver nutrition and/or water to your system. If you have other directives forbidding medically administered nutrition/liquids and your Agent disagrees with their content, then South Carolina Doctors will need clarification on the next step. If you have determined that your Health Care Agent’s discretion and decision-making should override your living will then initial the line corresponding to the letter “(A)” and the “Grant Of Discretion” statement.    If you intend to refuse tube feeding under any circumstances, then initial “(B)” just before the words “Directive To Withhold Or Withdraw Tube Feeding.”
You can authorize all tube feedings to be administered as needed and determined by South Carolina Doctors by initialing “(C)” just before the label “Directive For Provision Of Tube Feeding.”

 

Step 24 – Name The Date And Location Of The South Carolina Appointment

This designation of your South Carolina Health Care Agent must be dated to be effective. Furthermore, you must sign it before two Witnesses on the date that it is being executed. Therefore, refer to the statement beginning with the words “I Sign My Name To This Health Care Power Of Attorney…” then record the two-digit calendar “Day OF” the month you are signing this paperwork, the name of the month this signature is executed, and the corresponding year for this date across the three empty lines that follow this term.  Continue through this final statement to produce your full address after the words “My Current Home Address Is”.

 

Step 25 – Execute Your South Carolina Power Of Attorney

To place this document in effect, continue to the blank line labeled “Signature” then sign your name on it while two Witnesses watch. In addition to your signature, present your name in print on the blank line placed directly underneath your “Signature” line. 

 

Step 26 – Prove Your Act Of Signing With Two South Carolina Witnesses

The two Witnesses present while you sign the above document must fulfill their roles by reading the “Witness Statement.” Once completed and ready to show agreement with the contents of this statement, the first Witness must continue to the “Witness No. 1” section, sign the “Signature” line provided, then deliver the current date as a month, day, and year. Witness No. 1 must also print his or her name on the “Print Name” line and disclose his or her “Telephone” number to the adjacent blank line. The “Address” line in the “Witness No. 1” section requires that his or her home address by reported. Once this is recorded, Witness No. 1 must give this document to the other Witness in attendance. The “Witness No. 2” section provides a unique “Signature” and “Date” line that requires the Second Witness to sign his or her name then document the date of this action. Witness No. 2 should provide his or her printed name and “Telephone” number to the next two available lines. Finally, Witness No. 2 must proceed one line down the supply his or her “Address.” 

 

Step 25 – Work With A South Carolina Doctor To Complete The POST

The South Carolina Physician Orders For Scope Of Treatment puts your medical preferences when faced with a life-threatening condition, persistent unconsciousness, or undergoing a cardiac arrest in writing with the written support of a South Carolina Physician who incorporates your wishes into formal orders of treatment. Generally, this will be printed then kept in your medical records so that future South Carolina Medical Personnel have access to this material. Thus, the first section will serve to deliver your Patient information to Reviewers beginning with a presentation of your last name, first name, and middle initial in the boxes labeled “Patient Last Name” and “Patient First Name/MI”  Your birthday is the next item that must be displayed with your name. The “Patient Date Of Birth” text box should be supplied with this information while the adjacent box should be furnished with your telephone number or that of the South Carolina Health Care Agent working on your behalf. Be advised, if you are filling this out as part of your directives, then make sure your phone number is presented in the “Patient/Legal Representative Phone Number.” If possible, the last four digits of the Patient’s social security number should be dispensed to the box labeled “Social Security Number Last 4 Digits.” This is optional but will aid in identifying you to South Carolina Medical Providers. The Patient’s “Gender” must be reported in the next box by marking the checkbox labeled “M,” “F,” or “Other.”  Finally, the “Patient Mailing Address” box must display the home address of the Patient (You). This information is generally required when seeking to verify a Patient’s identity. One final piece of information that can be delivered regarding the Patient can be found to the left of his or her address. The South Carolina Doctor will be expected to document any prevalent, lifelong, or terminal medical condition that you have been diagnosed with in this box. If no such prognosis has been issued, then this area can be left blank.  

 

Step 26 – Present The Proper South Carolina Physician Response To Cardiopulmonary Arrest

The first section of the South Carolina POST presents the scenario of your heart and/or lungs stopping. This can result in death very quickly and it will be important to make sure South Carolina Responders and Doctors are aware of your wishes in this scenario. One of two checkboxes in “A Cardiopulmonary Resuscitation (CPR)” must be selected to display your determined preference. The first checkbox, labeled “Attempt Resuscitation/CPR,” should be marked if you wish South Carolina Doctors and Medical Responders to attempt to restart your heart and/or lungs through any means available.    If you do not wish South Carolina Medical Personnel to attempt resuscitation of your heart/lungs when either or both have ceased functioning, then select the checkbox labeled “Do Not Attempt Resuscitation/DNR”

Step 27 – Inform South Carolina Doctors Of Approved Medical Interventions

In “B Medical Interventions,” you will be able to inform South Carolina Doctors of the level of medical treatment and interventions you authorize if you are incapacitated but not in need of CPR. You can inform South Carolina Doctors and Medical Responders that they will have your authorization to administer “Full Treatment” for your medical condition(s) even if a transfer to a hospital or invasive treatments are needed. The goal will be to treat your medical condition and prolong your life.  If you wish to avoid being hospitalized or having invasive treatments administered(i.e., intubation) but will authorize South Carolina Doctors and Medical Responders to treat your medical condition with noninvasive methods then select the “Limited Treatment” checkbox. You may also use “B Medical Interventions” to limit South Carolina Doctors and Medical Responders to provide “Comfort Measures Only” by selecting the third checkbox. 

 

Step 28 – Authorize Or Deny The Use Of Antibiotics

You may approve of the use of “Antibiotics” by marking the first checkbox in “C.” This allows South Carolina Doctors to treat your condition and any infections by administering antibiotics with the purpose of prolonging your life.  Part “C Antibiotics” gives you the option request that South Carolina Doctors limit the administration of antibiotics only to times when you develop an infection, and this will be the best way to treat it. Select the second checkbox in “C Antibiotics” to make this statement to South Carolina Doctors.  Select the third checkbox in “C Antibiotics” if you have determined that the only reason South Carolina Doctors may administer antibiotics is to treat pain and discomfort. The final area of “C Antibiotics” will accept any “Additional Orders” the South Carolina Doctor completing this form and the Declarant have deemed appropriate to include. If no other information is needed on the topic of antibiotics this area may be left blank or populated with the word “None.”

 

Step 29 – Discuss Authorization Of Artificial Nutrition And Liquid

Part “D Artificially Administered Nutrition And Fluids” is set to document your level of authorization for receiving artificial nutrition and fluids to prolong your life. If you approve of receiving long-term nutrition through a tube or intravenously, then select the first checkbox in the left-hand column. Similarly, if you approve of “Long-Term Fluids” artificially administered when necessary to prevent your dehydration then select the first checkbox in the right-hand column.  You can use the second checkbox in the left-hand column of “Section D” to inform South Carolina Doctors that you will accept medically delivered nutrition for a “Trial Period…” by marking the second checkbox down the left-hand column. Similarly, you may authorize a “Trial Period Of IV Fluids” by selecting the second checkbox down the right-hand column. You can deny the administration of feeding tubes for nutrition and/or IV Fluids by selecting the third box down the left-hand column and/or the third box on the right-hand column. If you wish to have the decision to receive nutrition artificially made on an as-needed basis then select the “Decide When/If The Situation Arises” on the left. You may also elect to have the decision to keep you hydrated made at the time of need by marking the fourth checkbox down the right-hand column. The words “Additional Orders” label a space on the left in “Section D Artificially Administered Nutrition And Fluids” where you can provide any instructions or preferences regarding the administration of artificial nutrition. The “Additional Orders” space below the right-hand column is provided so that you may include specific instructions regarding medically administered fluids. 

 

Step 30 – South Carolina Physician Approval Must Be Presented

“Section E Signature Of Physician, Advanced Practice Registered Nurse, Or Physician Assistant” seeks several items from the South Carolina Medical Professional completing this form with you. He or she must provide a formal statement that your directives are appropriate by signing his or her name underneath the box labeled “Physician/APRN/PA Signature” then print his or her name in the adjacent box. The final box of the first row beneath the statement displays three checkboxes labeled “Physician,” “APRN,” and “PA.” The South Carolina Medical Professional will check the appropriate box to define his or her role.  The second row beneath the authorization statement has been set to display the South Carolina Medical Professional’s signature “Date,” “Physician/APRN/PA Phone Number,” and the “Physician/APRN/PA License #” After completing the signature area, the South Carolina Medical Professional must indicate “Who Participated In Discussion” by checking each box labeled with a definition of the parties present. In the example below, the checkbox labeled “Patient With Decision-Making Capacity” has been marked while the checkboxes “Legal Representative” and “Other” have been left blank. “Section F Signature Of Patient Or Legal Representative” requires your “Signature” produced on the first row. Additionally, your status must be defined. Thus, if you are the Patient, report the word “Self” in the “Relationship” box or if you are the Patient’s Health Care Agent, record the term Health Care Agent or Health Care Attorney-in-Fact  The second row seeks your printed name in the “Print Name” box, your signature “Date” in the second box, and your “Phone Number” in the third box.  

 

Step 31 – Identify The South Carolina Facilitator Of This POST

The box labeled “Print Name” in “Section G Facilitator Assisting With POST Form Completion.” If you are completing this form in an administrative function or if you are physically aiding the Patient, then print your name in the “Print Name” of “Section G.” Also, make sure to record the “Date” of this document’s completion and the “Phone Number” where you can be reached regarding the contents presented above. 

 

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