This is a required section in which the Declarant (the person the Living Will is prepared for) states his/her intention to make a Living Will. Press [Ctrl+F1] for more information.
This required section states the circumstances under which life-sustaining procedures or treatment will be withheld or withdrawn, and includes an optional "coma" provision. Press [Ctrl+F1] for more information.
This is a required section in which the Declarant states whether artificially administered nutrition and hydration should be withheld or withdrawn. Press [Ctrl+F1] for more information.
This is an optional section which enables the Declarant to state whether artificially administered nutrition and hydration should be withheld or withdrawn if the Declarant is in a coma. Press [Ctrl+F1] for more information.
This is a required section which provides an opportunity for the Declarant to request that the provisions of this document be honored. Press [Ctrl+F1] for more information.
This optional section designates an "Agent" to make health care decisions if the Declarant is unable to do so. Press [Ctrl+F1] for more information.
This optional section states what effect should be given to the Living Will if the Declarant is pregnant. Press [Ctrl+F1] for more information.
This is an optional section which allows for additional specific instructions and requests. Press [Ctrl+F1] for more information.
This recommended provision provides that the inclusion of an invalid request or instruction does not invalidate the other provisions. Press [Ctrl+F1] for more information.
This is a required section which gives the Declarant the right to revoke the Living Will at any time. Press [Ctrl+F1] for more information.
This required section provides the signature line for the Declarant who must sign in the presence of witnesses and a Notary Public. Press [Ctrl+F1] for more information.
This is a required section in which the witness states that he/she meets all of the state requirements for being a witness to a Living Will. Press [Ctrl+F1] for more information.
This required section provides signature lines for the witnesses in accordance with state law requirements. Press [Ctrl+F1] for more information.
This is a required section in which a public official (such as a Notary Public) acknowledges the signatures of the Declarant and of the witnesses. Press [Ctrl+F1] for more information.
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Living Will
LIW_SC
The Living Will is a document under which a competent adult, prior to becoming unconscious or incompetent, declares his/her intention that withholding or withdrawal of life-sustaining procedures should be withheld or withdrawn under certain circumstances.
Enter the Declarant's city or edit the information as desired.
A Living Will is prepared for a "Declarant". Enter the Declarant's name or edit the information as desired. A Living Will directs the Declarant's physician to withdraw or withhold life-sustaining procedures if the Declarant is in a terminal condition with no hope of recovery. Press [Ctrl+F1] for more information.
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! Declaration Section (1 of 14)
DECLARATION OF A DESIRE FOR A NATURAL DEATH
STATE OF SOUTH CAROLINA
COUNTY OF _________________________
I, !, 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 _______________, 19___.
A Living Will is prepared for a "Declarant". In this required section, the Declarant states his/her intentions regarding life-sustaining procedures or treatment during terminal and/or coma circumstances. Press [Ctrl+F1] for more information.
A Living Will is prepared for a "Declarant". Enter the Declarant's name or edit the information as desired. A Living Will directs the Declarant's physician to withdraw or withhold life-sustaining procedures if the Declarant is in a terminal condition with no hope of recovery. Press [Ctrl+F1] for more information.
Enter the Declarant's city or edit the information as desired.
Enter the Declarant's county or edit the information as desired.
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! Life Support Section (2 of 14)
I willfully and voluntarily make known my desire that no life-sustaining procedures be used to prolong my dying if my condition is terminal,
! [Optional COMA provision] 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 will occur within a relatively short period of time without the use of life-sustaining procedures,
! [automatically included if COMA checkbox is marked] 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.
This required section describes the circumstances under which you want to have life-sustaining procedures or treatment withheld or withdrawn if you become terminally ill or permanently unconscious. Press [Ctrl+F1] for more information.
Enter an X if you want to have life-sustaining procedures or treatment withheld or withdrawn if you become permanently unconscious. Press [Ctrl+F1] for more information.
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! Nutrition Section (3 of 14)
[The selected provision must be initialed when the Living Will is signed. Access Document Information for an explanation of Artificial Nutrition/Hydration.]
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,
_________ (initials) I direct that nutrition and hydration BE PROVIDED through any medically indicated means, including medically or surgically implanted tubes.
_________ (initials) I direct that nutrition and hydration NOT BE PROVIDED through any medically indicated means, including medically or surgically implanted tubes.
This required section states whether or not you desire artificial nutrition and hydration to be provided if you are terminally ill. Press [Ctrl+F1] for more information.
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! Optional Nutrition/Coma Section (4 of 14)
[The selected provision must be initialed when the Living Will is signed. Access Document Information for an explanation of a Permanent Coma.]
[include only if COMA checkbox is marked] INITIAL ONE OF THE FOLLOWING STATEMENTS:
If I am in a persistent vegetative state, or other condition of permanent unconsciousness,
_________ (initials) I direct that nutrition and hydration BE PROVIDED through any medically indicated means, including medically or surgically implanted tubes.
_________ (initials) I direct that nutrition and hydration NOT BE PROVIDED through any medically indicated means, including medically or surgically implanted tubes.
Enter an X to include a section that states whether or not you desire artificial nutrition and hydration to be provided if you are in a permanently unconscious condition. Press [Ctrl+F1] for more information.
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! Right of Refusal Section (5 of 14)
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.
This required section states the Declarant's request that the Living Will be followed. It also notes the Declarant's basic right to make medical decisions, including the right to refuse treatment.
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! Optional Agent Section (6 of 14)
APPOINTMENT OF AN AGENT.
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.
Agent Name: !
Agent Address:
Street 1: !
Street 2: !
City: !,
State: !
Zip Code: !
! Country: !
Phone: Home: ! Work: !
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.
Agent Name: !
Agent Address:
Street 1: !
Street 2: !
City: !,
State: !
Zip Code: !
! Country: !
Phone: Home: ! Work: !
Enter an X to include a section that allows you to designate "Agents" for the limited purposes of revoking and enforcing your Living Will. Press [Ctrl+F1] for more information.
Enter the revoking Agent's name or use the P.I. Manager to select and paste a record. This person will have the authority to revoke this declaration on your behalf.
Enter the revoking Agent's street address or edit the information as desired.
Enter the revoking Agent's extended street address or edit the information as desired.
Enter the revoking Agent's city or edit the information as desired.
Enter the revoking Agent's state/province or edit the information as desired.
Enter the revoking Agent's zip/postal code or edit the information as desired.
Enter an X to include the revoking Agent's country, if outside the United States.
Enter the country or edit the information as desired.
Enter a home phone number where the revoking Agent may be reached.
Enter a work phone number where the revoking Agent may be reached.
Enter the enforcing Agent's name or use the P.I. Manager to select and paste a record. This person will have the authority to enforce this declaration on your behalf.
Enter the enforcing Agent's street address or edit the information as desired.
Enter the enforcing Agent's extended street address or edit the information as desired.
Enter the enforcing Agent's city or edit the information as desired.
Enter the enforcing Agent's state/province or edit the information as desired.
Enter the enforcing Agent's zip/postal code or edit the information as desired.
Enter an X to include the enforcing Agent's country, if outside the United States.
Enter a home phone number where the enforcing Agent may be reached.
Enter a work phone number where the enforcing Agent may be reached.
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! Optional Pregnancy Section (7 of 14)
If I have been diagnosed as pregnant and that diagnosis is known to my physician, this document shall have no force or effect during the course of my pregnancy.
! [Optional additional sentence] However, if at any point it is determined that it is not possible that the fetus could develop to the point of live birth with continued application of life-sustaining procedures, it is my preference that this document be given effect at that point.
! [Optional additional sentence] If life-sustaining procedures will be physically harmful or unreasonably painful to me in a manner that cannot be alleviated by medication, I request that my desire for personal physical comfort be given consideration in determining whether this document shall be effective if I am pregnant.
Enter an X to include a pregnancy section which states that this Living Will will not be enforced if you are pregnant. Certain exceptions to this statement are presented. Press [Ctrl+F1] for more information.
Enter an X to provide an exception to the invalidity of the Living Will if you are pregnant. This exception permits enforcement of the Living Will if the fetus could not develop to the point of live birth with the continued application of life-sustaining procedures.
Enter an X to provide an exception to the invalidity of the Living Will if you are pregnant. This exception requests that pain or physical harm to you be considered in determining whether life-sustaining procedures or treatment should be withheld or withdrawn.
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! Optional Other Specific Requests Section (8 of 14)
Other specific requests:
Enter an X to include a paragraph that allows you to state other specific requests or instructions.
Use this space to state any other specific requests or instructions.
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! Optional Severability Section (9 of 14)
If any provision in this document is held to be invalid, such invalidity shall not affect the other provisions which can be given effect without the invalid provision, and to this end the directions in this document are severable.
It is recommended that this severability provision be included to prevent one invalid provision from invalidating the entire document. However, if you do not want to include it, press the spacebar to deselect the checkbox. Press [Ctrl+F1] for information regarding the reasons for including a severability paragraph.
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! Revocation Section (10 of 14)
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 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.
This required section states how this document may be revoked. Press [Ctrl+F1] for more information.
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! Declarant Signature Section (11 of 14)
________________________________________
Signature
Declarant Name: !
Declarant Address:City: !
State: !
! Country: !
! SSN: !
! Birthdate: !
This required section provides a signature line for the Declarant, and requests additional information regarding the Declarant.
Enter the Declarant's state/province or edit the information as desired.
Enter an X to include the Declarant's country, if outside the United States.
Enter the country or edit the information as desired.
Enter an X to include the Declarant's social security number (SSN). By providing the SSN, the health care providers will be assisted in maintaining their Living Will files. Press [Ctrl+F1] for more information.
Enter the Declarant's social security number or edit the information as desired.
Enter an X to include the Declarant's date of birth. By providing the date of birth, the health care providers will be assisted in maintaining their Living Will files. Press [Ctrl+F1] for more information.
Using the format MM/DD/YYYY, enter the Declarant's date of birth or edit the information as desired.
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! Affidavit Section (12 of 14)
[CAREFULLY REVIEW THE RESTRICTIONS ON WHO MAY BE A WITNESS. IF THE DOCUMENT IS NOT PROPERLY WITNESSED, IT MAY NOT BE ENFORCEABLE.]
AFFIDAVIT
STATE OF SOUTH CAROLINA
COUNTY OF _________________________
We, _________________________ and _________________________, the undersigned witnesses to the foregoing Declaration, dated the _____ day of _______________, 19___, 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/her DECLARATION OF A DESIRE FOR A NATURAL DEATH in our presence and we, at his/her request and in his/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 him/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 or marriage, 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/her 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 patient in a hospital or skilled or intermediate care nursing 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.
This is a required section in which the witnesses attest to being eligible as witnesses under the South Carolina Living Will statute.
This required section provides signature lines for the witnesses, and requests additional information regarding the witnesses.
Enter the FIRST witness' name or use the P.I. Manager to select and paste a record. The witness information may be left blank and be completed when the document is signed. Review the limits on who may be a witness. If the document is not properly witnessed, it may not be enforceable. Press [Ctrl+F1] for more information.
Enter the first witness' street address or edit the information as desired.
Enter the first witness' extended street address or edit the information as desired.
Enter the first witness' city or edit the information as desired.
Enter the first witness' state/province or edit the information as desired.
Enter the first witness' zip/postal code or edit the information as desired.
Enter an X to include the country in which the first witness resides, if outside the United States.
Enter the country or edit the information as desired.
Enter the name of the SECOND witness or use the P.I. Manager to select and paste a record. The following information regarding the name and address of the witness may be left blank and be completed when the document is signed.
Enter the second witness' street address or edit the information as desired.
Enter the second witness' extended street address or edit the information as desired.
Enter the second witness' city or edit the information as desired.
Enter the second witness' state/province or edit the information as desired.
Enter the second witness' zip/postal code or edit the information as desired.
Enter an X to include the country in which the second witness resides, if outside the United States.
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! Notary Section (14 of 14)
[This is a required section in which a Notary Public acknowledges that the Declarant and Witnesses signed the document.]
Subscribed before me by !, the Declarant, and subscribed and sworn to before me by _________________________________ and _________________________________, the witnesses, this _____ day of _______________, 19___.
______________________________________
Notary Public
Notary Public for ____________________
My commission expires: ______________
This is a required section in which a Notary Public acknowledges that the witnesses and the Declarant signed this document.
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