Declaration of a Desire for a Natural Death
STATE OF SOUTH CAROLINA DECLARATION OF A DESIRE FOR A NATURAL DEATH County of the information supplied in the interview I, the information supplied in the interview, Declarant, being at least eighteen years of age and a resident of and domiciled in South Carolina, make this Declaration on the information supplied in the interview. 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. 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 without life-sustaining procedures, or if the physicians certify that I am in a state of permanent unconsciousness and life-sustaining procedures would serve only to prolong the dying process, I direct that the procedures be withheld or withdrawn and that I be permitted to die naturally with medication or procedures necessary to provide comfort care. INSTRUCTIONS CONCERNING ARTIFICIAL NUTRITION AND HYDRATION If my condition is terminal and could result in death within a reasonably short time: the information supplied in the interviewI direct that nutrition and hydration BE PROVIDED through any medically indicated means, including medically or surgically implanted tubes.the information supplied in the interview the information supplied in the interviewI direct that nutrition and hydration NOT BE PROVIDED through any medically indicated means, including medically or surgically implanted tubes.the information supplied in the interview If I am in a persistent vegetative state or other condition of permanent unconsciousness: the information supplied in the interviewI direct that nutrition and hydration BE PROVIDED through any medically indicated means, including medically or surgically implanted tubes.the information supplied in the interview the information supplied in the interviewI direct that nutrition and hydration NOT BE PROVIDED through any medically indicated means, including medically or surgically implanted tubes.the information supplied in the interview In the absence of my ability to give directions, it is my intention that this Declaration be honored as the final expression of my legal right to refuse medical or surgical treatment, and I accept the consequences of 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 NOT COMPLETED. This standalone Living Will does not appoint an agent. Use the separate health-care-agent product if appointment authority is wanted. REVOCATION PROCEDURES THIS DECLARATION MAY BE REVOKED BY ANY ONE OF THE METHODS PERMITTED BY SOUTH CAROLINA CODE SECTION 44-77-80. A REVOCATION IS NOT EFFECTIVE UNTIL IT IS COMMUNICATED TO THE ATTENDING PHYSICIAN. Signature Signature: Date: the information supplied in the interview Address: the information supplied in the interview AFFIDAVIT STATE OF COUNTY OF We, the undersigned witnesses, declare that the Declaration was signed by the declarant in our presence and that we subscribed our names at the declarant's request, in the declarant's presence, and in the presence of each other. We believe the declarant to be of sound mind. Witness 1: Witness 2: If the declarant is a patient in a hospital or resident in a nursing care facility when the Declaration is executed, at least one witness must be the designated ombudsman required by South Carolina law. Subscribed and sworn before me: Notary Public: My commission expires: