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Health Care Directive

How would you like to protect yourself in a medical emergency?

How would you like to protect yourself in a medical emergency?

Frequently Asked Questions

In South Carolina, the Death With Dignity Act allows a person to make a declaration stating that no life-sustaining procedures be used to prolong dying if the person's condition is terminal or if the person is in a state of permanent unconsciousness.What is a Living Will?A Living Will allows you to have a say in the type of health care treatment you receive should you find yourself unable to act for yourself. A Living Will is also commonly known as a Health Care Directive.What is a Medical Power of Attorney?A Medical Power of Attorney allows you to appoint someone to make health care decisions on your behalf should you find yourself unable to act for yourself.What is the difference between a Living Will and a Last Will and Testament?A Living Will deals with the type of health care treatment you will receive while alive. In contrast, a Last Will determines how your estate will be dispersed after you pass. Both documents are part of a strong estate plan.

Your Health Care Directive

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Advance Directive For Health Care
(Living Will and Health Care Proxy)

I understand that this document, my Advance Directive for Health Care, will be used to make my wishes known about what medical treatment or other care I would or would not want if become too sick to speak for myself.

I understand that I am not required to have an Advance Directive.

I understand that I can change my mind about these directions by tearing up this document and

  1. writing a new one, or
  2. telling someone at least 19 years of age of my wishes and asking him or her to write them down.

After I have executed my Advance Directive, I will tell my doctor, family and friends that I have an Advance Directive and where I will be keeping it.


SECTION 1. LIVING WILL

I, _________________________, being of sound mind and at least 19 years old, would like to make the following wishes known. I direct that my family, my doctors and health care workers, and all others follow the directions I have put in this Advance Directive.

I understand that these directions will only be used if I am not able to speak for myself.

Definitions:

For the purposes of this document, the following definitions apply:

  1. "Terminally Ill or Injured" means that my doctor and another doctor have decided that I have a condition that cannot be cured and that I will likely die in the near future from this condition.
  2. "Life Sustaining Treatment" includes drugs, machines, or medical procedures that would keep me alive but would not cure me. I know that even if I choose not to have life sustaining treatment, I will still get medicines and treatments that ease my pain and keep me comfortable unless otherwise directed.
  3. "Artificially provided food and hydration" means being given nutrients (food) and water through a tube or an IV to keep me alive if I can no longer chew or swallow on my own or with someone helping me.
  4. "Permanent unconsciousness" is when my doctor and another doctor agree that, within a reasonable degree of medical certainty, I can no longer think, feel anything, knowingly move, or be aware of being alive. They believe this condition will last indefinitely without hope for improvement and have watched me long enough to make that decision. At least one of these doctors must be qualified to make such a diagnosis.

IF I BECOME TERMINALLY ILL OR INJURED:

  • I DO want to have life sustaining treatment if I am terminally ill or injured.   _____ (my initials)
  • I DO want to have artificially provided food and hydration if I am terminally ill or injured.   _____ (my initials)

IF I BECOME PERMANENTLY UNCONSCIOUS:

  • I DO want to have life sustaining treatment if I become permanently unconscious.   _____ (my initials)
  • I DO want to have artificially provided food and hydration if I become permanently unconscious.   _____( my initials)

OTHER DIRECTIONS
The above are all my directions. I have no further directions. _____ (my initials)


SECTION 2. IF I NEED SOMEONE TO SPEAK FOR ME

I understand that I may use this document to name a person I would like to make medical or other decisions for me if I become too sick to speak for myself. I understand that such a person is called a health care proxy.

I know that I do not have to name a health care proxy, and that the directions in my Advance Directive for Health Care will be followed even if I do not name a health care proxy.

I want ____________________ to be my health care proxy. I have spoken with ____________________ about my wishes. ____________________'s contact information is:
____________________
____________________,  in Alabama, ____________________
Phone number: ____________________

If ____________________ is not able, not willing, or not available to be my health care proxy, _______________________ is my next choice. _______________________'s contact information is:
_______________________
_______________________, in Alabama, __________
Phone number: __________

I DO want my health care proxy to make decisions about whether I am given food and water through a tube or an IV. _____ (my initials)

I understand that I can instruct my health care proxy:

  1. to follow only my directions as they are listed in this document, or
  2. to follow my directions as they are listed in this document, and to make any decisions about things I have not covered in this document, or
  3. to make the final decision, even though it could mean doing something different from what I have listed in this document.

I have considered the options available to me as listed above and I have decided to reject choices 2 and 3 in favour of choice 1. I want my health care proxy to  follow only the directions listed on this form.  _____ (my initials)

In accordance with the Health Insurance Portability and Accountability Act of 1996, 42 USC 1320d ("HIPAA"), I authorize my health care proxy to review and receive any information regarding my physical or mental health, including medical and hospital records.


SECTION 3. THE THINGS LISTED IN THIS DOCUMENT ARE WHAT I WANT

I understand the following:

  • I understand that more options are available to me with respect to my future health care than those that are articulated in this document, and I confirm that the directions I have given were decided upon after much careful consideration in full awareness of the other options.  _______ (my initials)
  • If my doctor or hospital does not want to follow the directions I have listed, they must see that I get to a doctor or hospital who will follow my instructions.
  • If I am pregnant, or if I become pregnant, the choices I have made in this document will not be followed until after the birth.

EFFECT OF COPY
A copy of this Living Will Declaration has the same effect as the original.

SEVERABILITY
If any part of any provision of this instrument is ruled invalid or unenforceable under applicable law, such part will be ineffective to the extent of such invalidity only, without in any way affecting the remaining parts of such provisions or the remaining provisions of this instrument.


SECTION 4. SIGNATURE

Name:

_________________________

Date of Birth:

December 2, 2016

Signature:

______________________________

Date signed:

2nd day of December, 2016


SECTION 5. WITNESSES

First Witness:

I, _____________________________, am witnessing the signing of this Advance Directive for Health Care because I believe the Principal, _________________________, to be of sound mind. I did not sign _________________________'s signature.  I am not the health care proxy named herein. I am not related to _________________________ by blood, adoption, or marriage and I am not entitled to any part of her estate. I am at least 19 years of age and I am not directly responsible for paying for _________________________'s health care.

Name:

______________________________

Signature:

______________________________

Date:

______________________________



Second Witness:

I, _____________________________, am witnessing the signing of this Advance Directive for Health Care because I believe the Principal, _________________________, to be of sound mind. I did not sign _________________________'s signature.  I am not the health care proxy named herein. I am not related to _________________________ by blood, adoption, or marriage and I am not entitled to any part of her estate. I am at least 19 years of age and I am not directly responsible for paying for _________________________'s health care.

Name:

______________________________

Signature:

______________________________

Date:

______________________________


SECTION 6. SIGNATURE OF PROXY

I, ____________________, am willing to serve as the health care proxy for _________________________ as specified in this Advance Directive.

Signature: _________________________ Date: __________


Signature of Second Choice for Proxy:
I, _______________________, am willing to serve as the health care proxy for _________________________ as specified in this Advance Directive, if ____________________ cannot serve.

Signature: _________________________ Date: _____________


RECORD OF COPIES

Record of people and institutions to whom I have given a signed copy of this document:

1. ____________________________________  Date: ____________________
2. ____________________________________  Date: ____________________
3. ____________________________________  Date: ____________________
4. ____________________________________  Date: ____________________
5. ____________________________________  Date: ____________________

Health Care Directive

What is a Health Care Directive?

A Health Care Directive is comprised of a Living Will and Medical Power of Attorney.

A directive allows you to plan your medical treatment in advance should there ever comes a time when you are unable to express your personal health care wishes.

A Health Care Directive is also known as:

  • Advance Directive
  • Personal Directive
  • Advance Decision
  • Medical Directive
  • Living Will

What is a Medical Power of Attorney?

A Medical Power of Attorney is a document used to appoint someone to make medical decisions on your behalf.

A Medical Power of Attorney is also known as:

  • Health Care Power of Attorney
  • Health Care Proxy
  • Durable Power of Attorney for Health Care
  • Health Care Representative

What is a Living Will?

A Living Will is a document that you use to indicate your medical wishes in the event you are incapacitated or cannot consent to your health care treatment.

Living Will vs. Last Will and Testament

If you are unable to express your health care wishes in the future, hospitals and family will reference your Living Will as a statement of your medical wishes.

Alternatively, a Last Will and Testament is a document used to indicate how you would like your assets divided or children cared for after your death. You cannot specify medical treatment preferences with a Last Will.

Why should I create a Health Care Directive?

Without a Living Will, the burden of making your medical decisions falls on your family members. Creating a personal directive not only gives you control of your medical wishes but it saves your family from making tough treatment choices on your behalf.

Additionally, appointing a Medical Power of Attorney allows you to discuss your treatment wishes with someone you trust prior to any unforeseen medical circumstance so they can make health care decisions in your best interest.

Choosing a Medical Power of Attorney/Health Care Proxy

When appointing someone as your Medical Power of Attorney, you should choose someone who is trustworthy, has your best interests in mind, and will make your health care decisions according to your intended wishes.

What medical decisions can I make with a Living Will?

Every state has its own limits as to what you are legally permitted to include in your directive. While you may specify instructions for a variety of medical situations and describe your feelings towards quality of life, keep in mind health care providers will only be allowed to carry out certain procedures according to your state laws.

Here are some of the main treatment choices you will want to specify in your Living Will:

Life Support

Life Support means any life-sustaining procedures done to a patient to restore function to an organ through medical intervention.

Common forms of life support include CPR (Cardiopulmonary Resuscitation), defibrillators, assisted breathing, dialysis, and artificially administered food and water.

DNR is short for "Do Not Resuscitate", which means you do not wish to receive life support or resuscitation if an organ fails.

Comfort Care

Comfort care means healthcare professionals will use any means possible to relieve your pain, including administering medication or creating a comfortable environment for you to rest in.

Quality of Life

Many people define quality of life in their Living Will to notify their family and health care professionals as to what they may want in extreme health situations (life or death) and what constitutes a quality life for them.

When does my Health Care Directive come into effect?

The terms of your directive are binding once you sign the document. It comes into use when you have been found to be incapable of making your own medical decisions. Typically, this may be when you are incapacitated, in a coma, or in a vegetative state.

Can I make changes to my Health Care Directive?

You can make changes to your personal directive if you destroy your current one, notify your health care representative or hospital of your changes, and create and distribute a new directive. It's important to let everyone in your family know where you keep your advance directive so they can easily find it during an emergency.

Related Documents:

  • Power of Attorney: A document used to grant someone the authority to act on your behalf, such as tending to your finances or maintaining property.
  • Last Will and Testament: A document specifying how you would like your estate divided upon your death.
  • Child Medical Consent: A form granting a guardian the authorization to make medical decisions on behalf of your child.
  • Medical Records Release: A form requesting your medical records be released to you or a third party.

Related Articles:

Frequently Asked Questions:

Health Care Directive FAQ
Sample Health Care Directive

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