Fillable Printable Health Care Power of Attorney - South Carolina

Health Care Power of Attorney - South Carolina

Diocese of Charleston

South Carolina

Health Care Power of Attorney

Roman Catholic Faith-Based

Dear Friends in Christ,

As faithful Catholics, we share a common belief that ultimately we shall be together,

united with the Lord Jesus. But in our complex world of advanced medical technology and life-

prolonging treatments, we can easily become distracted and confused by the many choices

presented to us. It is likely that many of us will face difficult decisions alongside our loved ones.

Our faith teaches that we are held in the embrace of a loving God and that one day we shall see

Him face to face. We also know that human life is a precious gift from God, and should not be

treated lightly. We will not live forever; yet as believers, we fix our eyes not on what is seen, but

on what is unseen. "For what is seen is temporary, but what is unseen is eternal" (2 Corinthians

4:18).

The medical field has been greatly blessed with advances in science and technology

which may alleviate suffering from sickness but also may present distressing questions regarding

use of such technology in order to sustain human life. As we face the reality of death, this may

lead some to express support of euthanasia or assisted suicide. These expressions represent a

false understanding of the gift of life and personal freedom. The Church teaches that life is a gift

from God and that we are stewards of that gift, not masters.

We need treatments at the end of our lives that are morally sound and that respect both

the dignity of the human person, made in the image of God, and our destiny to live with Him

forever in heaven. Our Church's moral teachings address many of the concerns that burden us in

this complex culture. Consequently, we have consulted with professionals in Catholic bioethics

and law to assist in preparing this Health Care Power of Attorney for the state of South Carolina.

You are neither legally nor morally required to have an Advanced Medical Directive.

However, we have offered you this document to assist you in making sure that your care and

treatment is consistent with the Catholic faith and your wishes.

May Mary, the Mother of God, intercede for us now and at the hour of our death.

In the Lord's Peace,

Most Rev. Robert E. Guglielmone

Bishop of Charleston

South Carolina Health Care Power of Attorney

(Roman Catholic Faith-Based)

South Caro lina

Health Care Power of Attorney

(Roman Catholic Faith-Based)

INFORMATION ABOUT THIS DOCUMENT

THIS IS AN IMPORTANT LEGAL DOCUMENT. BEFORE SIGNING THIS DOCUMENT,

YOU SHOULD KNOW THESE IMPORTANT FACTS:

1. THIS DOCUMENT GIVES THE PERSON YOU NAME AS YOUR AGENT THE

POW ER T O MAKE HEA LT H CAR E DEC IS IO NS FOR YOU IF YOU CANNOT MAKE THE

DECISIONS FOR YOURSELF. THIS POWER INCLUDES THE POWER TO MAKE

DECISIONS ABOUT LIFE-SUSTAINING TREATMENT. UNLESS YOU STATE

OTHERWISE, YOUR AGENT WILL HAVE THE SAME AUTHORITY TO MAKE

DECISIONS ABOUT YOUR HEALTH CARE AS YOU WOULD HAVE.

2. THIS POWER IS SUBJECT TO ANY LIMITATIONS OR STATEMENTS OF YOUR

DESIRES THAT YOU INCLUDE IN THIS DOCUMENT. YOU MAY STATE IN THIS

DOCUMENT ANY TREATMENT YOU DO NOT DESIRE OR TREATMENT YOU WANT

TO BE SURE YOU R E CEIVE. YOUR A GENT WILL BE OB LIGATED TO F O LLOW YOUR

INST RUCT IO NS W HEN MAK IN G DEC ISIONS ON YOUR BEHALF. YOU MAY ATT ACH

ADDITIONAL PAGES IF YOU NEED MORE SPACE TO COMPLETE THE STATEMENT.

3. AFTER YOU HAVE SIGNED THIS DOCUMENT, YOU HAVE THE RIGHT TO

MAKE HEALTH CARE DECISIONS FOR YOURSELF IF YOU ARE MENTALLY

COMPETENT TO DO SO. AFTER YOU HAVE SIGNED THIS DOCUMENT, NO

TREATMENT MAY BE GIVEN TO YOU OR STOPPED OVER YOUR OBJECTION IF

YOU ARE MENTALLY COMPETENT TO MAKE THAT DECISION.

4. YOU HAVE THE RIGHT TO REVOKE THIS DOCUMENT, AND TERMINATE

YOUR AGENT'S AUTHORITY, BY INFORMING EITHER YOUR AGENT OR YOUR

HEALTH CARE PROVIDER ORALLY OR IN WRITING.

5. IF THERE IS ANYTHING IN THIS DOCUMENT THAT YOU DO NOT

UNDERSTAND, YOU SHOULD ASK A SOCIAL WORKER, LAWYER, OR OTHER

PERSON TO EXPLAIN IT TO YOU.

6. THIS POWER OF ATTORNEY WILL NOT BE VALID UNLESS TWO PERSONS

SIGN AS WITNESSES. EACH OF THESE PERSONS MUST EITHER WITNESS YOUR

SIGNING OF THE POWER OF ATTORNEY OR WITNESS YOUR ACKNOWLEDGMENT

THAT THE SIGNATURE ON THE POWER OF ATTORNEY IS YOURS.

South Carolina Health Care Power of Attorney

(Roman Catholic Faith-Based)

THE FOLLOWING PERSONS MAY NOT ACT AS WITNESSES:

A. YOUR SPOUSE, YOUR CHILDREN, GRANDCHILDREN, AND OTHER

LINEAL DESCENDANTS; YOUR PARENTS, GRANDPARENTS, AND OTHER LINEAL

ANCESTORS; YOUR SIBLINGS AND THEIR LINEAL DESCENDANTS; OR A SPOUSE

OF ANY OF THESE PERSONS.

B. A PER SON W HO IS D IREC T LY F INANC IALLY R ES PONS IBLE FOR YOUR

MEDICAL CARE.

C. A PERSON WHO IS NAMED IN YOUR WILL, OR, IF YOU HAVE NO

WILL, WHO WOULD INHERIT YOUR PROPERTY BY INTESTATE SUCCESSION.

D. A BENE FIC IARY OF A LIFE INSURA NC E POLICY ON YOUR LIFE.

E. THE PERSONS NAMED IN THE HEALTH CARE POWER OF ATTORNEY

AS YOUR AGENT OR SUCCESSOR AGENT.

F. YOUR PHYSICIAN OR AN EMPLOYEE OF YOUR PHYSICIAN.

G. ANY PERSON WHO WOULD HAVE A CLAIM AGAINST ANY PORTION

OF YOUR ESTATE (PERSONS TO WHOM YOU OWE MONEY).

IF YOU ARE A PATIENT IN A HEALTH FACILITY, NO MORE THAN ONE WITNESS

MAY BE AN EMPLOYEE OF THAT FACILITY.

7. YOUR AGENT MUST BE A PERSON WHO IS 18 YEARS OLD OR OLDER AND

OF SOUND MIND. IT MAY NOT BE YOUR DOCTOR OR ANY OTHER HEALTH CARE

PROVIDER THAT IS NOW PROVIDING YOU WITH TREATMENT; OR AN EMPLOYEE

OF YOUR DOCTOR OR PROVIDER; OR A SPOUSE OF THE DOCTOR, PROVIDER, OR

EMPLOYEE; UNLESS THE PERSON IS A RELATIVE OF YOURS.

8. YOU SHOULD INFORM THE PERSON THAT YOU WANT HIM OR HER TO BE

YOUR HEALTH CARE AGENT. YOU SHOULD DISCUSS THIS DOCUMENT WITH

YOUR AGENT AND YOUR PHYSICIAN AND GIVE EACH A SIGNED COPY. IF YOU

ARE IN A HEALTH CARE FACILITY OR A NURSING CARE FACILITY, A COPY OF

THIS DOCUMENT SHOULD BE INCLUDED IN YOUR MEDICAL RECORD.

South Carolina Health Care Power of Attorney

(Roman Catholic Faith-Based)

South Caro lina

Health Care Power of Attorney

(Roman Catholic Faith-Based)

1. DESIGNATION OF HEALTH CARE AGENT

I __________________________ , hereby appoint ____________________________________

(principal’s name) (agent’s name)

______________________________________________________________________________

(address)

Home Telephone: ___________ Work Telephone: _______________Cell number___________

as my agent to make health care decisions for me as authorized in this document.

SUC CES SOR AGENT: If an a g ent nam ed by m e di es , beco mes le gally dis abled, resigns, refuses

to act, becomes unavailable, or if an agent who is my spouse is divorced or separated from me, I

name the following as successor to my agent, each to act alone and successively, in the order

named.

A. First Alternate Agent: ____________________________________________

Address: ______________________________________________________

Telephone: _____________________

B. Second Alternate Agent: __________________________________________

Address: ______________________________________________________

Telephone: _____________________

2. EFFECTIVE DATE AND DURABILITY

By this document I intend to create a durable power of attorney effective upon, and only during,

any period of mental incompetence, except as provided in Section 5 below.

South Carolina Health Care Power of Attorney

(Roman Catholic Faith-Based)

3. FAITH-BASED STATEMENT

I believe that all life is a gift from God. I direct that all medical decisions for me be made

accordin g to m y Catholic religious beliefs and in conformit y to Catholic moral teaching as found

in the Ethical and Religious Directives for Catholic Health Care Services promulgated by the

United States Conference of Catholic Bishops. All provisions of this document shall be

interpreted in accordance with this Section 3.

4. PROTECTION FROM LIABILITY FOR PEOPLE RELYING ON THIS DOCUMENT

No person who may act in reliance upon the representations of my attorney-in-fact for the scope

of authority granted to the attorney-in-fact shall incur any liability as to me or to my estate as a

result of permitting the attorney-in-fact to exercise this authority, nor is any such person who

deals with m y attorne y-in-fact responsible to determine or ensure the prop er application of funds

or property.

5. HIPAA AUTHORIZATION

When considering or making health care decisions for me, all individually identifiable health

information and medical records shall be released without restriction to my health care agent(s)

and/ or my altern at e heal t h care a gen t(s ) nam ed abov e including, but not limited to, (i) diagnosti c,

treatment, other health care, and related insurance and financial records and information

asso ciated w ith any pas t, present , or fut ure ph ysi cal o r ment al health condi tion including, but not

limited to, diagnosis or treatment of HIV/AIDS, sexually transmitted disease(s), mental illness,

and/or drug or alcohol abuse and (ii) any written opinion relating to my health that such health

care agent(s) and/or alternate health care agent(s) may have requested. Without limiting the

generality of the foregoing, this release authority applies to all health information and medical

records governed by the Health Insurance Portability and Accountability Act of 1996 (HIPAA),

42 USC 1320d and 45 CFR 160-164; is effective whether or not I am mentally competent; has no

expiration date; and shall terminate only in the event that I revoke the authority in writing and

deliver it to my health care provider.

6. ADVANCE DIRECTIVES: GENER A L PR ESUM PT ION FOR LIFE

A. Life Preservation. I direct my health care provider(s) to provide health care, and

health care agent(s) to make health care decisions, consistent with my general desire for the use

of medical treatment that would preserve m y life. I do not authorize any action or omission that

is intended to cause or hasten my death.

B. Life-Sustaining Procedures. The term "Life-Sustaining Procedures" as used in

this document refers to the definition of Life-Sustaining Procedures provided in S.C. Code Ann.

Section 62-5-504(A)(6), which is as follows:

"Life-Sustaining Procedure means a medical procedure or intervention which

serves only to prolong the dying process. Life-Sustaining Procedures do not

South Carolina Health Care Power of Attorney

(Roman Catholic Faith-Based)

include the administration of medication or other treatment for comfort care or

alleviation of pain."

I intend for Life-Sustaining Procedures to be administered only as specifically provided

in this document.

C. Food and Water. I intend for the term Life-Sustaining Procedures to exclude the

providing of nutrition and hydration. I specifically direct my health care provider(s) and health

care agent(s) to cause nutrition and hydration to be provided to me in all instances and by any

methods necessary, including but not limited to oral, intravenous or tube.

D. CPR. I intend for the term Life-Sustaining Procedures to exclude the

administration of cardiopulmonary resuscitation (CPR). I specifically direct my health care

provider(s) and health care agent(s) to administer CPR to me in all instances.

E. Medication. I specifically direct that medication and/or other treatment for

comfort care or alleviation of pain be provided to me in all instances. However, I do not

authorize the administration of any medication or other treatment for the intended purpose of

causing or hastening my death.

F. Nursing Care. I specifically direct that I be provided basic nursing care and

procedures to provide comfort care.

G. Abortion/Stem Cells. I do not authorize any treatments that are derived from any

tissue, organ or other substance from an unborn, newborn or stillborn child, including but not

limited to embryonic stem cells. However, this prohibition does not apply if such are derived

from an ectopic pregnancy.

H. Attempted Suicide. The instructions in this document are intended to be followed

even if suicide is attempted or alleged to be attempted.

I. Discrimination. I direct that medical treatment and care be provided to me to

preserve my life as described herein without discrimination based on my age or physical or

mental disability or the purported or perceived quality of my life.

J. Pregnancy. S.C. Code Ann. Section 62-5-504(G) provides that Life-Sustaining

Procedures may not be withheld or withdrawn if I am pregnant. In accordance with that

provision, I specifically direct that all lifesaving procedures, including Life-Sustaining

Procedures, be used for me in order to allow my child to be born alive. This direction is to

remain in force even if I am determined to be brain dead.

7. AGENT'S POWERS

I grant to my agent authority to make decisions for me regarding my health care, however in

accordance with the terms, conditions and limitations contained in this document. In exercising

this authority, my agent shall follow my desires as stated in this document.

South Carolina Health Care Power of Attorney

(Roman Catholic Faith-Based)

8. ORGAN DONATION (INITIAL ONLY ONE CHOICE)

My agent [may ________ or may not __________] consent to the donation of all or any of my

tissue or organs for purposes of transplantation.

9. OTHER ADVANCE DIRECTIVES

A. Revocation of Prior Living Will. I hereby revoke any prior advance directives

under the South Carolina Death with Dignity Act (S.C. Code Ann. Section 44-77-10, et seq.),

such as a Living Will or Declaration for Desire of a Natural Death. The advanced directives

contained in this document shall be control and be effective.

B. Agent’s Power Limited. My agent shall not have the power to revoke this

Section 9, or make any decisions for me inconsistent with this Section 9.

C. Terminal Condition. S.C. Code Ann. Section 44-77-20(4) defines "Terminal

Condition" as an incurable or irreversible condition that, within reasonable medical judgment,

could cause death within a reasonably short period of time if Life-Sustaining Procedures are not

used.

If at an y time I have a condition certified to be a Terminal Condition by two (2) physicians who

have personally examined me, one of whom is my attending physician, and the physicians have

determined that my death could occur within a rea sonabl y short p eriod of ti me without the use of

Life-Sustaining Procedures and where the applicat ion of Life-Sustaining Procedures would serve

only to prolong the dying process:

(Initial only one choice below.)

________ I direct that the Life-Sustaining Procedures be withheld or withdrawn.

________ I direct that the maximum amount of Life-Sustaining Procedures be administered.

[The remainder of this page intentionally left blank.]

South Carolina Health Care Power of Attorney

(Roman Catholic Faith-Based)

D. Permanent Unconsciousness. S.C. Code Ann. Section 44-77-20(7) defines

"Permanent Unconsciousness" as a medical diagnosis, consistent with accepted standards of

medical practice, that a person is in a persistent vegetative state or some other irreversible

condition in which the person has no neocortical functioning, but only involuntary vegetative or

primitive reflect functions controlled by the brain stem.

If at any time I have been diagnosed as being in a state of Permanent Unconsciousness by two

(2) physicians who have personally examined me, one of whom is my attending physician, and

the physicians have determined that my death could occur within a reasonably 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:

(Initial only one choice below.)

________ I direct that the Life-Sustaining Procedures be withheld or withdrawn.

________ I direct that the maximum amount of Life-Sustaining Procedures be administered.

10. ADMINISTRATIVE PROVISIONS

A. I revoke any prior Health Care Power of Attorney and any provisions relating to

health care of any other prior power of attorney.

B. This power of attorney is intended to be valid in any jurisdiction in which it is

presented.

11. MISCELLANEOUS PROVISIONS:

(Do not leave these lines blank. Either write in them or cross through them. Do not write in

anything that conflicts with another provision in this document.)

______________________________________________________________________________

South Carolina Health Care Power of Attorney

(Roman Catholic Faith-Based)

12. UNAVAILABILITY OF AGENT

If at any relevant time the Agent or Successor Agents named herein are unable or unwilling to

make decisions concerning m y health care, and those decisions are to be made by a guardian, by

the Probate Court, or by a surrogate pursuant to the Adult Health Care Consent Act, it is my

intention that the guardian, Probate Court, or surrogate make those decisions in accordance with

my directions as stated in this document. Pursuant to S.C. Code Ann. Section 62-5-501(B), this

power of attorney shall not terminate upon the appointment of a guardian and/or conservator, and

any such guardian and/or conservator shall be bound by the provisions of this document.

BY SIGNING HERE I INDICATE THAT I UNDERSTAND THE CONTENTS OF THIS

DOCUMENT AND THE EFFECT OF THIS GRANT OF POWERS TO MY AGENT.

I sign my name to this Health Care Power of Attorney on this _____ day of ________, ______.

My current home address is:

____________________________________________________________

Street, City, State

____________________________________

Signature of Principal

[The remainder of this page is intentionally left blank.]

South Carolina Health Care Power of Attorney

(Roman Catholic Faith-Based)

WITNESS STATEMENT

I declare, on the basis of information and belief, that the person who signed or acknowledged this

document (the principal) is personally known to me, that he/she signed or acknowledged this

Health Care Power of Attorney in my presence, and that he/she appears to be of sound mind and

under no duress, fraud, or undue influence. I am not related to the principal by blood, marriage,

or adoption, either as a spouse, a lineal ancestor, descendant of the parents of the principal, or

spouse of any of them. I am not dir ectl y fin anci ally respo nsib le fo r the pri ncipal 's medi cal car e. I

am not entitled to any portion of the principal's estate upon his decease, whether under any will

or as an heir by intestate succession, nor am I the beneficiary of an insurance policy on the

principal's life, nor do I have a claim against the principal's estate as of this time. I am not the

principal's attending physician, nor an employee of the attending physician. No more than one

witness is an employee of a health facilit y in which the principal is a patient. I am not appointed

as Health Care Agent or Successor Health Care Agent by this document.

Witness No. 1

Signature: ________________________________ Date: ________________

Print Name: ________________________________

Telephone: ________________________________

Address: __________________________________________________________

Witness No. 2

Signature: ________________________________ Date: ________________

Print Name: ________________________________

Telephone: ________________________________

Address: __________________________________________________________

(The notary portion of the document is optional and is not required to create a valid health care

power of attorney.)

STATE OF SOUTH CAROLINA

COUNTY OF ___________________

The foregoing instrument was acknowledged before me by Principal on ________________.

________________________________

Notary Public for South Carolina My commission expires: ____________