SOUTH CAROLINA DEPARTMENT OF MENTAL HEALTH
Columbia, South Carolina

 

 OFFICE OF THE STATE DIRECTOR OF MENTAL HEALTH   DIRECTIVE NO.    850-05
                                                                                                                                              (5-100)

TO:                All Organizational Components

SUBJECT:     Advance Directives

I..         Purpose:

The purpose of this directive is to implement the "Patient Self Determination Act" and the State's public policy to encourage the execution of advance health care directives.  The Patient Self Determination Act requires that each hospital and nursing facility receiving federal Medicare or Medicaid funds must provide information to every patient/resident, about the facility's policies concerning implementation of Advance Directives, and distribute a written description of State law concerning Advance Directives to the patient/resident.  It is also the declared policy of the State of South Carolina to promote the use of Advance Directives as a means of encouraging patient self-determination and avoiding uncertainty in a health care crisis.

II.         Policy:

While competent, individuals may anticipate the possibility of later incapacity and may prepare Advance Directives stating their desires regarding the provision or withholding of medical care in such event.  It is the Department's policy to encourage the use of advance health care directives and to honor Advance Directives.  However, no Departmental facility shall condition the provision of care or otherwise discriminate against an individual based on whether or not the individual has executed an advance health care directive.

III.       Advance Directives:

For purposes of the Patient Self Determination Act and this directive, "Advance Directive" means a written instruction such as a living will or health care power of attorney, recognized under State law (whether by statute or by the courts of the State) and relating to the provision of health care when the individual is incapacitated.

South Carolina provides by statute for two types of Advance Directives.

  1. Living Will. The Death with Dignity Act authorizes competent adults to express their wishes regarding the use or withholding of life-sustaining procedures, including artificial nutrition and hydration, in the event they are diagnosed with a terminal condition or are in a state of permanent unconsciousness and in the further event that they are incapacitated or otherwise unable to express their desires.  The Act creates a statutory form for this purpose entitled "Declaration of a Desire for a Natural Death." A copy is attached to this Directive as Appendix 1. This document and those similar in purpose are commonly referred to as a "living will."
     

  2. Health Care Power of Attorney.  Sections within the South Carolina Probate Code authorize competent adults to designate another person to make decisions on their behalf about their medical care in the event they become incapacitated.  The Code creates a statutory form for this purpose entitled "Health Care Power of Attorney." A copy is attached to this Directive as Appendix 2.

Individuals may also have prepared other forms of Advance Directives or put into writing their desires concerning certain types of medical care.  Subject to each individual's circumstances, the Department's medical staff shall consider any expression of a patient's desires which appears genuine. 

IV.       Do Not Resuscitate Orders:

 A Do Not Resuscitate Order is a written physician's order not to begin the otherwise automatic initiation of cardiopulmonary resuscitation in the event the consumer suffers cardiac or respiratory arrest.  It is appropriate in situations involving a consumer with a terminal condition or a patient in a state of permanent unconsciousness, and is generally entered with the consent of the consumer or the consumer's substitute decision maker, or in circumstances where resuscitative efforts are inappropriate or medically futile.  Although the entry of a Do Not Resuscitate Order involves advance planning for the withholding of specific health care procedures, and frequently involves consultation with the consumer, it is not considered an Advance Directive for purposes of the Patient Self Determination Act or this Directive.  Entry of a Do Not Resuscitate Order is, however, one means of effectuating a consumer's Advance Directive for the withholding of life-sustaining procedures when the conditions set forth in the Advance Directive are met.

 V.        Procedure:

A.    Providing Information.

  1. Each inpatient facility shall promulgate policies and procedures to ensure  that upon admission, adult consumers will be provided with a written statement of the facility's policy regarding the implementation of Advance Directives, and also be  provided with a written description of the State law in South Carolina  concerning Advance Directives.  A copy of  the written description of   State law is attached hereto as Appendix 3. Trained staff shall be made available to provide the consumer an explanation as requested.  The consumerís medical record shall be documented to reflect that the required information was provided.
     
  2. Each mental health center shall include information and instruction concerning Advance Directives in any ongoing client education programs.

B.       Requesting Information.

  1. Inpatient facility policies shall provide that upon admission of adult consumers, staff will inquire into the existence of Advance Directives previously executed by the consumer.  The consumer's medical record shall be documented as to the response to the inquiry.  If the consumer indicates that he or she has an Advance Directive, staff shall request a copy.
     

  2. In the event mental health center staff are aware that a consumer has executed  an Advance Directive, they shall request a copy and maintain it in the consumerís record.  In the event the center staff become aware of the consumerís subsequent admission to a hospital or nursing home, staff shall contact the facility to make them aware of, and supply a copy of, the consumerís Advance Directive.

C.       Providing Assistance.

          Both inpatient facilities and mental health centers shall assist apparently competent consumers who desire to prepare an Advance Directive.  Assistance shall include the following:

1.      Information.  The medical staff and other trained staff should endeavor to answer consumer's questions about Advance Directives and the effect of a particular Advance Directive in the consumer's individual circumstance.

  • Provision of approval forms.  Staff shall make available to those interested consumers copies of the approved State forms for Advance Directives

  •   Assistance in locating witnesses for execution. In South Carolina, Advance Directives require a minimum of two witnesses to the declarant's signature.  However, State law prohibits certain individuals (family members, prospective beneficiaries and attending medical personnel) from serving as witnesses.  If needed, staff shall assist in locating willing disinterested individuals to witness the consumerís execution of the form(s).

  •          Staff shall not serve as a witness to the declarant's signature if they are or have been directly involved in the patient' care.  Staff shall not accept appointment as an agent in a Health Care Power of Attorney or Declaration of a Natural Death.

    Staff need not provide assistance to a consumer in circumstances in which staff believe the consumer is unable to make an informed and understanding decision regarding the execution of an Advance Directive.

     D. Additional Guidelines.

                             1.         If the facility is made aware that the consumer has made an Advance                                 Directive, staff should request a certified copy, not the same as notarized.                                  Staff may make certified copies from the original by annotating a photocopy with
                                    the following language:

    I hereby certify that this document is a true and correct copy of the original thereof which I compared on the

               _____ day of ______________, 19___.

    _                                                

    (signature of employee)

    The certified copy of the Advance Directive(s) shall be placed in the consumerís  medical record.  If the consumer is transferred to any medical facility, the physician shall note on the transfer form the existence of the specific Advance Directive.  If the consumerís chart does not accompany the consumer, and the circumstances require it, the Advance Directive(s) shall be delivered to the medical facility to which the consumer has been transferred.

    2.                  If the consumer is transferred to any other Department of Mental Health facility, the Advance Directive(s) shall be sent to the receiving facility for inclusion in the consumerís chart at such facility.

    3.                  In the event it becomes necessary, an inpatient facility may retain the original of the consumerís Advance Directive(s) as long as the consumer remains in the facility.  In the event the consumer is discharged from the facility, the original of the consumerís Advance Directive(s) shall be returned to other responsible party acting on the consumerís behalf.

    VI.  Staff Training/Community Education:

    Each inpatient facility shall provide at least annually for staff education on Advance Directives.  Mental health centers shall provide clinical staff with information concerning Advance Directives and the provisions of the Directive.   In addition, the Department and its inpatient facilities and mental health centers  shall seek appropriate opportunities to provide community education concerning Advance Directives.

    This directive rescinds and replaces SCDMH Directive  No. 804-97 entitled Advance Directives.Ē

    March 2, 2005


    APPENDIX 1

         DECLARATION OF A DESIRE FOR A NATURAL
    DEATH

    STATE OF SOUTH CAROLINA                                   COUNTY OF______________

    I, __________________________( ____ / ____/ ____ ),Declarant, being at least eighteen
                                                           Social Security Number

    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 __________________________, 19____.

         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.

                                                                                        OR
    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

    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.

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

         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.


    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 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.
                                                                             _________________________________
                                                                                                Signature of Declarant


    AFFIDAVIT

    STATE OF__________________                       COUNTY OF ____________________

    We, ____________________and ____________________the undersigned witnesses to the foregoing Declaration, dated the _______ day of ____________________ ,  19 ___ 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 his 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 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 before me by________________________, the declarant, and subscribed and sworn to before me by _______________________________________________________
    the witness(es), this _____ day of _____________________, 19______.

                                                                                      ________________________________
                                                                                     Signature of Notary Public

                                            (SEAL)

                                                                                     Notary Public for  __________________

                                                                                      My commission expires, _____________

    *If qualified as a witness, the Notary Public may serve as a witness.                 SC Code of Laws Sec. 44-77-10 (Rev. 6191)


      APPENDIX 2

    HEALTH CARE POWER OF ATTORNEY
    Printable .pdf

    A health care power of attorney executed on or after January 1, 2007 must be substantially in the following form (S. C. Code Section 62-5-504 (D):

    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 ACKNOWLEDGMENT THAT THE SIGNATURE ON THE POWER OF ATTORNEY IS YOURS.

    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.

    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.

    HEALTH CARE POWER OF ATTORNEY

    (S.C. STATUTORY FORM)

    1. DESIGNATION OF HEALTH CARE AGENT

    I, __________, hereby appoint:
    (Principal)
    (Agent's Name) _____________________________________

    (Agent's Address) ___________________________________

    Telephone: home: ___________ work: ____________ mobile:_______________
    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:

    Address: __________________________________

    Telephone: home:_________ work:__________ mobile:_________

    b. Second Alternate Agent:

    Address:_______________________________________

    Telephone: home:_________ work:__________ mobile:_________

    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 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 Information 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.

    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.

    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 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:

    _______________________________________________________

    _______________________________________________________

    _______________________________________________________

    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)

    (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 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) ____ 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 ITEM 8, YOUR AGENT WILL NOT HAVE AUTHORITY TO DIRECT THAT NUTRITION AND HYDRATION NECESSARY FOR 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 prior 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:

    _________________________________________________________

    Principal's Signature:_________________________________________

    Print Name of Principal:______________________________________

    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 financially responsible for the principal's medical care. I am not entitled to any portion of the principal'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 Health Care Agent by this document.

    Witness No. 1

    Signature:_____________________________ Date:____________

    Print Name:_________________________ Telephone:__________

    Address:_______________________________________________

    ______________________________________________________

    Witness No. 2

    Signature:_____________________________ Date:____________

    Print Name:___________________________ Telephone:________

    Address:_______________________________________________

    ______________________________________________________

    (This portion of the document is optional and is not required to create a valid health care power of attorney.)

    STATE OF SOUTH CAROLINA

    COUNTY OF___________________________________________

    The foregoing instrument was acknowledged before me by Principal on ________________, 20 ___________.

    Notary Public for South Carolina____________________________

    My Commission Expires:__________________________________"

     


    APPENDIX 3

         YOUR RIGHT TO MAKE
    DECISIONS ABOUT
    YOUR HEALTH CARE

         

    January 25, 1993


    YOU HAVE THE RIGHT TO MAKE HEALTH CARE DECISIONS THAT AFFECT YOU.

    You have the right to make all decisions about the health care you receive. If you do not want certain treatments, you can tell your doctor, either in person or in writing, that you do not want them. If you want to refuse treatment but You do not have someone to name as Your agent,, you can sign a living will.

    Most patients can express their wishes to their doctor, but some who are badly injured, unconscious, or very ill cannot.  People need to know your wishes about health care in case you become unable to speak effectively for yourself.  You can express your wishes in a health care power of attorney or a living will.

    In a living will you tell your doctor that you do not want to receive certain treatment.  In a health care power of attorney you name an agent who will tell the doctor what treatment should or should not be provided.

    The decision to sign a health care power of attorney or living will is very personal and very important.  This pamphlet answers some frequently asked questions about health care powers of attorney and living wills.

    These documents will be followed only if you are unable, due to illness or injury, to make decisions for yourself. While you are pregnant, however, these documents will not cause life support to be withheld.

    If you do not have a living will or health care power of attorney that tells what you want done, you do not know what decisions will be made or who will make them. Decisions may be made by certain relatives designated by South Carolina law, by a person appointed by the court, or by the court itself. The best way to make sure your wishes are followed is to state your wishes in a health care power of attorney, or sometimes, a living will. It you want to refuse treatment but you do not have someone to name as your agent, you can sign a living will.

    It You have questions about signing a. health care power of attorney or living will, you should talk to your doctor: your minister, priest, rabbi, or other religious counselor or your attorney. Finally, it is very important that you   discuss your feelings about life support with your family. A health care power of attorney, also should be discussed with the people you intend to name as your agent and alternate agents to make sure that they are willing to serve.  It is also important to make sure that your agents know your wishes.

    Are there forms for living wills and health care Powers of attorney in South Carolina?

    Yes. The South Carolina legislature has approved forms for both a living will and a health care power of attorney. The living will form that the legislature approved is called a "Declaration of a Desire for Natural Death."  You may be able to get these forms from the person who gave you this brochure.  If not, you may call:

    Your local Council an Aging South Carolina Commission on Aging 1 (800) 868-9095

    Joint legislative Committee on Aging (803) 734-2995

    Governor's Office, Ombudsman Division (803) 734-0457

    How are a Health Care Power of Attorney and a Living Will different?

    *  The agent named in a health care power of attorney can make all of the decisions about your health care that need to be made. A living will affects only life support.

    *  A living will affects life support only in certain circumstances. A living will only tells the doctor what to do if you are permanently unconscious or if you are terminally ill and close to death. A health care power of attorney is not limited to these situations.

    "Permanently unconscious" means that you are in a persistent vegetative state in which your body functions but your mind does not. This is different from a coma, because a person in a coma usually wakes up, but a permanently unconscious person does not.

    *  A living will can only say  what treatment you don't want. In a health care power of attorney you can say what treatment you do want as well as what you do not want.

    * With a living will. you must decide what should be done in the future, without knowing exactly what the circumstances will be when the decision is put into effect. With a health care power of attorney, the agent can make decisions when the need arises, and will know what the circumstances are.

    * An Ombudsman from the Governor's Office must be a witness if you sign a living will when you are in a hospital or nursing home. An Ombudsman does not have to be a witness if you sign a health care power of attorney in a hospital or nursing home.

    I want to be allowed to die a natural death and not be kept alive by medical treatment heroic measures, or artificial means. How can I make sure this happens?

    The best way to be sure you are allowed to die a natural death is to sign a health care power of  attorney that states the circumstances in which you would not want treatment. In the South Carolina form, you should specify your wishes in Items 6 and 7.

    You may not have a person that you can trust to carry out your desire for a natural death. It not, a living will can ensure that you are allowed to die a natural death. However, it will only do so if you are permanently unconscious or terminally ill and close to death.

    Which document should I sign if I want to be treated with all available life-sustaining procedures?

    You should sign a Health Care Power of Attorney, and  not a living will. The South Carolina Health Care Power of Attorney form allows you to say either that you go or that you do not want life-sustaining treatment. A living will only allows you to say that you do not want life-sustaining procedures.

    What if I have an old health care power of attorney or living will, or signed one in another state?

    If you previously signed a living will or health care power of attorney, even in another state, it is probably valid. However, it may be a good idea to sign the most current forms. For example, the current South Carolina living will form covers artificial nutrition and hydration whereas older forms did not.

    How is a health care power of attorney different from a durable power of Attorney?

    A health care power of attorney is a specific type of durable power of attorney that names an agent only to make health care decisions.  A durable power of attorney may or may not allow the agent to make health care decisions. It depends on what the document says. The agent may only be able to make decisions about property and financial matters.

    What are the requirements for signing a living will?

    You Must be eighteen years old to sign a living will, Two persons must witness your signing the living will form. A notary public must also sign the living will. If you sign a living will while you are a patient in a hospital or a resident in a nursing home, a representative from the Governor's Office (the Ombudsman) must witness your signing.

    There are certain people who cannot witness your living will. The living will form says who cannot be a witness. You should read the living ,will form carefully to be sure your witnesses are qualified.

    What are the requirements for signing a health care power of attorney?

    You must have two witnesses sign "the document. The form tells you who cannot be witnesses. (These are the same people who cannot witness a living will.) Unlike a living will, the health care power of attorney may be signed in a hospital or in a nursing home without having someone from the Ombudsman's office present. It is not necessary to have a notary sign your health care power of attorney.

    Whom should I appoint as my agent? What if my agent cannot serve?

    You should appoint a person you trust and who knows how you feel about health care. You also should name at least one alternate, who will make decisions if your agent is unable or unwilling to make these decisions. You should talk to the people you choose as your agent and alternate agents to be sure they are willing to serve. Also, they should know how you feet about health care.

    Is them anything I need to know about completing the living will or health care power of attorney form?

    Each form contains spaces for you to state your wishes about things like whether you want life support and tube feeding. If you do not put your initials in either blank, tube feeding may be provided, depending upon your condition. Be sure to read the forms carefully and follow the instructions.

    Where should I keep my health care power of attorney or living will?

    Keep the original in a safe place where your family members can get it. You also should give a copy to as many of the following people as you are comfortable with: your family members. your doctor. your lawyer, your minister or priest, or your agent. Do not put your only copy of these documents in your safe deposit box.

    What if I change my mind after I have signed a living will or health care power attorney?

    You may revoke (cancel) your living will or health care power of attorney any time. The forms contain instructions for doing so. You must tell your doctor and anyone else who has a copy that you have changed your mind and you want to revoke your living will or health care power of attorney.