South Carolina Living Will Form

DECLARATIONOFADESIREFORANATURALDEATH

yearsofageandaresidentofanddomiciledintheCityof , Countyof

,StateofSouthCarolina,makethisDeclarationthis dayof

,20.

Iwillfullyandvoluntarilymakeknownmydesirethatnolife-sustainingproceduresbeusedtoprolongmydyingifmyconditionisterminalorifIaminastateofpermanentunconsciousness,andIdeclare:

IfatanytimeIhaveaconditioncertifiedtobeaterminalconditionbytwophysicianswhohavepersonallyexaminedme,oneofwhomismyattendingphysician,andthephysicianshavedeterminedthatmydeathcouldoccurwithinareasonablyshortperiodoftimewithouttheuseoflife-sustainingproceduresorifthephysicianscertifythatIaminastateofpermanentunconsciousnessandwheretheapplicationoflife-sustainingprocedureswouldserveonlytoprolongthedyingprocess,Idirectthattheproceduresbewithheldorwithdrawn,andthatIbepermittedtodienaturallywithonlytheadministrationofmedicationortheperformanceofanymedicalprocedurenecessarytoprovidemewithcomfortcare.

INSTRUCTIONSCONCERNINGARTIFICIALNUTRITIONANDHYDRATIONINITIALONEOFTHEFOLLOWINGSTATEMENTS

IfmyconditionisTERMINALandcouldresultindeathwithinareasonablyshorttime,

IdirectthatnutritionandhydrationBEPROVIDEDthroughanymedicallyindicatedmeans,includingmedicallyorsurgicallyimplantedtubes.

OR

IdirectthatnutritionandhydrationNOTBEPROVIDEDthroughanymedicallyindicatedmeans,includingmedicallyorsurgicallyimplantedtubes.

INITIALONEOFTHEFOLLOWINGSTATEMENTS

IfIaminaPERSISTENTVEGETATIVESTATEorotherconditionofpermanentunconsciousness,

IdirectthatnutritionandhydrationBEPROVIDEDthroughanymedicallyindicatedmeans,includingmedicallyorsurgicallyimplantedtubes.

OR

IdirectthatnutritionandhydrationNOTBEPROVIDEDthroughanymedicallyindicatedmeans,includingmedicallyorsurgicallyimplantedtubes.

Intheabsenceofmyabilitytogivedirectionsregardingtheuseoflife-sustainingprocedures,itismyintentionthatthisDeclarationbehonoredbymyfamilyandphysiciansandanyhealthfacilityinwhichImaybeapatientasthefinalexpressionofmylegalrighttorefusemedicalorsurgicaltreatment,andIaccepttheconsequencesfromtherefusal.

IamawarethatthisDeclarationauthorizesaphysiciantowithholdorwithdrawlife-sustainingprocedures.I

amemotionallyandmentallycompetenttomakethisDeclaration.

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APPOINTMENTOFANAGENT(OPTIONAL)

1. YoumaygiveanotherpersonauthoritytoREVOKEthisdeclarationonyourbehalf. Ifyouwishtodoso,pleaseenterthatperson'snameinthespacebelow.

NameofAgentwithPowertoRevoke:Address:

TelephoneNumber:

2. YoumaygiveanotherpersonauthoritytoENFORCEthisdeclarationonyourbehalf. Ifyouwishtodoso,pleaseenterthatperson'snameinthespacebelow.

NameofAgentwithPowertoEnforce Address:TelephoneNumber:

REVOCATIONPROCEDURES

THISDECLARATIONMAYBEREVOKEDBYANYONEOFTHEFOLLOWINGMETHODS.HOWEVER,AREVOCATIONISNOTEFFECTIVEUNTILITISCOMMUNICATEDTOTHEATTENDINGPHYSICIAN:

(1) BYBEINGDEFACED,TORN,OBLITERATED,OROTHERWISEDESTROYED,INEXPRESSIONOFYOURINTENTTOREVOKE,BYYOUORBYSOMEPERSONINYOURPRESENCEANDBYYOURDIRECTION. REVOCATIONBYDESTRUCTIONOFONEORMOREOFMULTIPLEORIGINALDECLARATIONSREVOKESALLOFTHEORIGINALDECLARATIONS;

(2) BYAWRITTENREVOCATIONSIGNEDANDDATEDBYYOUEXPRESSINGYOURINTENTTOREVOKE;

(3) BYYOURORALEXPRESSIONOFYOURINTENTTOREVOKETHEDECLARATION. ANORALREVOCATIONTOTHEATTENDINGPHYSICIANBYAPERSONOTHERTHANYOUISEFFECTIVEONLYIF:

(A)THEPERSONWASPRESENTWHENTHEORALREVOCATIONWASMADE;

(B) THEREVOCATIONWASCOMMUNICATEDTOTHEPHYSICIANWITHINAREASONABLETIME;

(C) YOURPHYSICALORMENTALCONDITIONMAKESITIMPOSSIBLEFORTHEPHYSICIANTOCONFIRMTHROUGHSUBSEQUENTCONVERSATIONWITHYOUTHATTHEREVOCATIONHASOCCURRED.TOBEEFFECTIVEASAREVOCATION,THEORALEXPRESSIONCLEARLYMUSTINDICATEYOURDESIRETHATTHEDECLARATIONNOTBEGIVENEFFECTORTHATLIFE-SUSTAININGPROCEDURESBEADMINISTERED;

(4)IFYOU,INTHESPACEABOVE,HAVEAUTHORIZEDANAGENTTOREVOKETHEDECLARATION,THEAGENTMAYREVOKEORALLYORBYAWRITTEN,SIGNED,ANDDATEDINSTRUMENT. ANAGENTMAYREVOKEONLYIFYOUAREINCOMPETENTTODOSO. ANAGENTMAYREVOKETHEDECLARATIONPERMANENTLYORTEMPORARILY;

(5) BYYOUREXECUTINGANOTHERDECLARATIONATALATERTIME.

SignatureofDeclarant

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AFFIDAVIT

STATEOFCOUNTYOF

We, and ,theundersignedwitnessestotheforegoingDeclaration,datedthe dayof ,20 ,atleastoneofusbeingfirstdulysworn,declaretotheundersignedauthority,onthebasisofourbestinformationandbelief,thattheDeclarationwasonthatdatesignedbythedeclarantasandforhisDECLARATIONOFADESIREFORANATURALDEATHinourpresenceandwe,athisrequestandinhispresence,andinthepresenceofeachother,subscribeournamesaswitnessesonthatdate.Thedeclarantispersonallyknowntous,andwebelievehimtobeofsoundmind.Eachofusaffirmsthatheisqualifiedasawitness*tothisDeclarationundertheprovisionsoftheSouthCarolinaDeathwithDignityActinthatheisnotrelatedtothedeclarantbyblood,marriage,oradoptioneitherasaspouse,linealancestor,descendantoftheparentsofthedeclarant,orspouseofanyofthem;nordirectlyfinanciallyresponsibleforthedeclarant'smedicalcare;norentitledtoanyportionofthedeclarant'sestateuponhisdecease,whetherunderanywillorasanheirbyintestatesuccession;northebeneficiaryofalifeinsurancepolicyofthedeclarant;northedeclarant'sattendingphysician;noranemployeeoftheattendingphysician;norapersonwhohasaclaimagainstthedeclarant'sdecedent'sestateasofthistime.Nomorethanoneofusisanemployeeofahealthfacilityinwhichthedeclarantisapatient.Ifthedeclarantisaresidentinahospitalornursingcarefacilityatthedateofexecutionof

thisDeclaration,atleastoneofusisanombudsmandesignatedbytheStateOmbudsman,OfficeoftheGovernor.

WitnessWitness*

Subscribedbeforemeby ,thedeclarant,andsubscribedandsworntobeforemeby thewitness(es),

this dayof ,20.

(SEAL)

SignatureofNotaryPublic

Notary Publicfor

My commissionexpires:

*Ifqualifiedasawitness,theNotaryPublicmayserveasawitness.SCCodeofLawsSec.44-77-10(Rev.6/91)(Page3of3)