South Carolina Living Will Template
This Living Will is designed to be compliant with the South Carolina Death with Dignity Act. It is a legal document that outlines your wishes regarding medical treatment if you become unable to communicate or make decisions due to a terminal illness or incapacitation. By completing this document, you can ensure your healthcare preferences are known and respected.
Personal Information:
- Full Name: ____________________________
- Date of Birth: ____________________________
- Address: ____________________________
- City: ____________________________
- State: South Carolina
- Zip Code: ____________________________
- Phone Number: ____________________________
Instructions for Health Care
Please indicate your preferences for the medical treatments listed below in the event that you are in a terminal condition and unable to communicate your health care wishes. For each item, check "Yes" if you want the treatment to be provided or continued, and "No" if you do not.
- Life-prolonging treatments (e.g., use of ventilator, dialysis, etc.): Yes [ ] No [ ]
- Artificial nutrition and hydration (feeding tube): Yes [ ] No [ ]
- Antibiotics or antiviral medications: Yes [ ] No [ ]
- Pain relief treatment, even if it may hasten death: Yes [ ] No [ ]
Power of Attorney for Health Care
You may appoint someone as your health care agent to make decisions for you if you are unable to do so. This person will be responsible for ensuring that the health care preferences you have indicated in this document are carried out.
- Health Care Agent's Full Name: ____________________________
- Relationship to You: ____________________________
- Phone Number: ____________________________
- Alternate Phone Number: ____________________________
By signing below, I affirm that this Living Will reflects my wishes regarding my health care and that I am of sound mind and not under any undue influence or duress.
Signature: ____________________________ Date: ____________________________
Witness Signature: ____________________________ Date: ____________________________
Witness Name (Print): ____________________________
This document was executed in accordance with South Carolina law, and it is intended to be valid in any jurisdiction to the extent allowed by law.