Business Assistant/Business Assistant.iso/legal/gde757_1/lharc1.exe/5690.BLD

Text File | 1993-01-06 | 7.6 KB | 301 lines

#5690
@001 Please state the declarant's name:
@002 Please state the declarant's city of residence:
@003 Please state the declarant's county of residence:
@004 Please state the declarant's state of residence:
@005 Please state a designee, if any:
@006 Please state designee's city and state of residence:
#end control section
#5690
/* South Carolina living will 4090.arm*/

DECLARATION AS PROVIDED BY CODE OF SOUTH CAROLINA
LAWS [1976] SECTION 44-77-50


STATE OF SOUTH CAROLINA

COUNTY OF @003


           DECLARATION OF A DESIRE FOR A NATURAL DEATH



    I, @001, being at least eighteen years of age, and a

resident of and domiciled in the City of @002, County of @003,

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, 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 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be withheld or withdrawn, and that I be permitted to die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.



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 DECLARATION MAY BE REVOKED;


    (1) BY BEING DEFACED, TORN, OBLITERATED, OR OTHERWISE

DESTROYED, IN EXPRESSION OF THE DECLARANT'S INTENT TO REVOKE,

BY THE DECLARANT OR BY SOME PERSON IN THE PRESENCE OF AND BY THE

DIRECTION OF THE DECLARANT. REVOCATION BY DESTRUCTION OF ONE OR

MORE DECLARATIONS REVOKES ALL OF THE ORIGINAL DECLARATIONS. THE

REVOCATION OF THE ORIGINAL DECLARATION ACTUALLY NOT DESTROYED

BECOMES EFFECTIVE ONLY UPON COMMUNICATION TO THE ATTENDING

PHYSICIAN. THE ATTENDING PHYSICIAN SHALL RECORD IN THE

DECLARANT'S MEDICAL RECORDS THE TIME AND DATE WHEN THE PHYSICIAN

RECEIVED NOTIFICATION OF THE REVOCATION;

    (2) BY A WRITTEN REVOCATION SIGNED AND DATED BY THE

DECLARANT EXPRESSING HIS INTENT TO REVOKE, THE REVOCATION

BECOMES EFFECTIVE ONLY UPON COMMUNICATION TO THE ATTENDING

PHYSICIAN. THE ATTENDING PHYSICIAN SHALL RECORD IN THE

DECLARANT'S MEDICAL RECORD THE TIME AND DATE WHEN THE PHYSICIAN

RECEIVED NOTIFICATION OF THE WRITTEN REVOCATION;


(3) BY AN ORAL DECLARATION BY THE DECLARANT OF HIS

INTENT TO REVOKE THE DECLARATION. THE REVOCATION BECOMES

EFFECTIVE ONLY UPON COMMUNICATION TO THE ATTENDING PHYSICIAN BY

THE DECLARANT. HOWEVER, AN ORAL REVOCATION MADE BY THE DECLARANT

BECOMES EFFECTIVE UPON COMMUNICATION TO THE ATTENDING PHYSICIAN

BY A PERSON OTHER THAN THE DECLARANT 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) THE PHYSICAL OR MENTAL CONDITION OF THE

          DECLARANT MAKES IT IMPOSSIBLE FOR THE PHYSICIAN

          TO CONFIRM THROUGH SUBSEQUENT CONVERSATION WITH

          THE DECLARANT THAT THE REVOCATION HAS OCCURRED.


THE ATTENDING PHYSICIAN SHALL RECORD IN THE PATIENT'S MEDICAL

RECORD THE TIME, DATE, AND PLACE OF THE REVOCATION AND THE TIME,

DATE AND PLACE, IF DIFFERENT, OF WHEN HE RECEIVED NOTIFICATION

OF THE REVOCATION, THE ORAL EXPRESSION CLEARLY MUST INDICATE A

DESIRE THAT THE DECLARATION NOT BE GIVEN EFFECT OR THAT LIFE-

SUSTAINING PROCEDURES BE ADMINISTERED;

(4) BY A WRITTEN, SIGNED, AND DATED REVOCATION OR AN

ORAL REVOCATION BY A PERSON DESIGNATED BY THE DECLARANT IN THE

DECLARATION, EXPRESSING THE DESIGNEE'S INTENT PERMANENTLY OR

TEMPORARILY TO REVOKE THE DECLARATION. THE REVOCATION BECOMES

EFFECTIVE ONLY UPON COMMUNICATION TO THE ATTENDING PHYSICIAN BY

THE DESIGNEE. THE ATTENDING PHYSICIAN SHALL RECORD IN THE

DECLARANT'S MEDICAL RECORD THE TIME, DATE AND PLACE OF THE

REVOCATION AND THE TIMES, DATE AND PLACE, IF DIFFERENT, OF

WHEN THE PHYSICIAN RECEIVED NOTIFICATION OF THE REVOCATION. A

DESIGNEE MAY REVOKE ONLY IF THE DECLARANT IS INCOMPETENT TO DO

DO. IF THE DECLARATION WISHES TO DESIGNATE A PERSON WITH

AUTHORITY TO REVOKE THIS DECLARATION ON HIS BEHALF, THE NAME

AND ADDRESS OF THAT PERSON MUST BE ENTERED BELOW:




 @005
 NAME OF DESIGNEE

 ADDRESS: @006



________________________________________________________________
DECLARANT
@001


STATE OF ___________________

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 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

affirm 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 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

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 person who has a claim

against 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.




________________________________________________________________
Witness






________________________________________________________________
Witness


    Subscribed before me by @001, the

declarant, and subscribed to before me by ______________________

and _____________________, the witnesses, this _________________

day of ___________________, 19_______.




________________________________________________________________
Notary Public



Notary Public for _________________


My Commission Expires: