South Carolina Living Will Template
This Living Will is specifically designed to comply with the provisions of the South Carolina Death with Dignity Act. It allows the undersigned to provide clear directives regarding their health care preferences in circumstances where they are no longer able to communicate those wishes due to incapacity.
Personal Information
Full Name: _______________________________________________
Date of Birth: ____________________________________________
Address: _________________________________________________
City: ____________________________ State: SC Zip: ___________
Phone: _________________________ Email: ___________________
Health Care Instructions
In the event that I am unable to make my own health care decisions because of incapacity, the following are my directions to my health care providers:
- Life-Sustaining Treatment: In the situation where I am terminally ill or in a persistent vegetative state and where my attending physician has determined that there is no reasonable expectation of my recovery, I direct that:
- All treatments that might only prolong the moment of my death be withheld or discontinued, including artificially provided nourishment and fluids.
- Life-sustaining treatments be administered if it is believed that such treatments could lead to a significant improvement in my condition and quality of life.
- Pain Relief: I wish to receive medication to relieve pain and suffering, even if such medication might hasten the moment of death.
- Other Directions: ________________________________________________________________________
Designation of Health Care Agent
I hereby designate the following person as my Health Care Agent to make health care decisions for me in case I am not able to make such decisions for myself.
Name: _____________________________________________________
Relationship: ______________________________________________
Address: __________________________________________________
City: __________________________ State: SC Zip: ______________
Alternate Phone: ________________ Primary Phone: _________________
If my primary Health Care Agent is unable, unwilling, or unavailable to act as my agent, I designate the following person as my alternate Health Care Agent:
Name: _____________________________________________________
Relationship: ______________________________________________
Address: __________________________________________________
City: __________________________ State: SC Zip: ______________
Alternate Phone: ________________ Primary Phone: _________________
Signatures
This Living Will is made voluntarily and without any coercion. I am of sound mind and fully understand the nature and purpose of this document.
_______________________________ ________________
Signature of Principal Date
State of South Carolina
County of _____________________
This document was acknowledged before me on (date) _______________ by (name of principal) ____________________________________.
__________________________________ _______________
Signature of Notary Public Date
My commission expires: __________________