Fillable Printable Health Care Power of Attorney Statutory Form - South Carolina

Health Care Power of Attorney Statutory Form - South Carolina

SOUTH CAROLINA STATUTES

SECTION 62-5-504. Definitions.

(A) As used in this section:

(1) "Agent" or "health care agent" means an individual designated in a health care

power of attorney to make health care decisions on behalf of a principal.

(2) "Declaration of a desire for a natural death" or "declaration" means a

document executed in accordance with the South Carolina Death with Dignity Act

or a similar document executed in accordance with the law of another state.

(3) "Health care" means a procedure to diagnose or treat a human disease,

ailment, defect, abnormality, or complaint, whether of physical or mental origin.

It also includes the provision of intermediate or skilled nursing care; services for

the rehabilitation of injured, disabled, or sick persons; and placement in or

removal from a facility that provides these forms of care.

(4) "Health care power of attorney" means a durable power of attorney executed

in accordance with this section.

(5) "Health care provider" means a person, health care facility, organization, or

corporation licensed, certified, or otherwise authorized or permitted by the laws of

this State to administer health care.

(6) "Life-sustaining procedure" means a medical procedure or intervention which

serves only to prolong the dying process. Life-sustaining procedures do not

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

alleviation of pain. The principal shall indicate in the health care power of

attorney whether the provision of nutrition and hydration through medically or

surgically implanted tubes is desired.

(7) "Permanent unconsciousness" means 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 reflex functions

controlled by the brain stem.

(8) "Nursing care provider" means a nursing care facility or an employee of the

facility.

(9) "Principal" means an individu al who executes a health care power of attorney.

A principal must be eighteen years of age or older and of sound mind.

(10) "Separated" means that the principal and his or her spouse are separated

pursuant to one of the following:

(a) entry of a pendente lite order in a divorce or separate maintenance

action;

(b) formal signing of a written property or marital settlement agreement;

permanent order approving a property or marital settlement agreement

between the parties.

(B) (1) A health care power of attorney is a durable power of attorney pursuant to

Section 62-5-501. Sections that refer to a durable power of attorney or judicial

interpretations of the law relating to durable powers of attorney apply to a health

care power of attorney to the extent that they are not inconsistent with this

section.

(2) This section does not affect the right of a person to execute a durable power of

attorney relating to health care pursuant to other provisions of law but which does

not conform to the requirements of this section. If a durable power of attorney for

health care executed under Section 62-5-501 or under the laws of another state

does not conform to the requirements of this section, the provisions of this section

do not apply to it. However, a court is not precluded from determining that the

law applicable to nonconforming durable powers of attorney for health care is the

same as the law set forth in this section for health care powers of attorney.

(3) To the extent not inconsistent with this section, the provisions of the Adult

Health Care Consent Act apply to the making of decisions by a health care agent

and the implementation of those decisions by health care providers.

(4) In determining the effectiveness of a health care power of attorney, mental

incompetence is to be determined according to the standards and procedures for

inability to consent under Section 44-66-20(6), except that certification of mental

incompetence by the agent may be substituted for certification by a second

physician. If the certifying physician states that the principal's mental

incompetence precludes the principal from making all health care decisions or all

decisions concerning certain categories of health care, and that the principal's

mental incompetence is permanent or of extended duration, no further

certification is necessary in regard to the stated categories of health care decisions

during the stated duration of mental incompetence unless the agent or the

attending physician believes the principal may have regained capacity.

(a) be substantially in the form set forth in subsection (D) of this section;

(b) be dated and signed by the principal or in the principal's name by

another person in the principal's presence and by his direction;

signing of the health care power of attorney or the principal's

acknowledgment of his signature on the health care power of attorney.

Each witness must state in an affidavit as set forth in subsection (D) of this

section that, at the time of the execution of the health care power of

attorney, to the extent the witness has knowledge, the witness is not

related to the principal by blood, marriage, or adoption, either as a spouse,

lineal ancestor, descendant of the parents of the principal, or spouse of any

of them; not directly financially responsible for the principal's medical

care; not entitled to any portion of the principal's estate upon his decease

under a will of the principal then existing or as an heir by intestate

succession; not a beneficiary of a life insurance policy of the principal;

and not appointed as health care agent or successor health care agent in th e

health care power of attorney; and that no more than one witness is an

employee of a health facility in which the principal is a patient, no witness

is the attending physician or an employee of the attending physician, or no

witness has a claim against the principal's estate upon his decease;

(d) state the name and address of the agent. A health care agent must be an

individual who is eighteen years of age or older and of sound mind. A

health care agent may not be a health care provider, or an employee of a

provider, with whom the principal has a provider-patient relationship at

the time the health care power of attorney is executed, or an employee of a

nursing care facility in which the principal resides, or a spouse of the

health care provider or employee, unless the health care provider,

employee, or spouse is a relative of the principal.

(2) The validity of a health care power of attorney is not affected by the

principal's failure to initial any of the choices provided in Section 4, 6, or 7 of the

Health Care Power of Attorney form or to name successor agents. If the principal

fails to indicate either of the statements in Section 7 concerning provision of

artificial nutrition and hydration, the agent does not have authority to direct that

nutrition and hydration necessary for comfort care or alleviation of pain be

withheld or withdrawn.

(D) A health care power of attorney must be substantially in the following form:

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

POWER TO MAKE HEALTH CARE DE CISIONS FOR YOU IF YOU CANNOT

MAKE THE DECISION 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 STATE M ENTS OF

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

IN THIS DOCUMENT ANY TREATMENT YOU DO NOT DESIR E OR

TREATMENT YOU WANT TO BE SURE YOU RECEIVE. YOUR AGENT WILL BE

OBLIGATED TO FOLLOW YOUR INSTRUCTIONS WHEN MAKING DECISIONS

ON YOUR BEHALF. YOU MAY ATTACH 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 OBJEC TION

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 INFO RMING 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 OT HER

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.

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 DESCE NDANTS; OR A

SPOUSE OF ANY OF THESE PERSONS.

B. A PERSON WHO IS DIRECTLY FINANCIALLY RES PONSIBLE 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 BENEFICIARY OF A LIFE INSURANCE 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 WOUL D HAVE A C LAIM 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 PROVI DER; OR A SPOUSE OF THE

DOCTOR, PROVIDER, OR EMPL OYEE; UNLESS THE PERSON IS A RELATIVE

OF YOURS.

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

YOUR HEALTH CARE AGENT. YOU SHOULD DIS CUSS 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.

HEALTH CARE POWER OF ATTORNEY

(S.C. STATUTORY FORM)

1. DESIGNATION OF HEALTH CARE AGENT

I, ___________________________________________, hereby appoint:

(Principal)

_____________________________________________

(Agent)

_____________________________________________

(Address)

Home Telephone: _______________ Work Telephone: ______________ as my agent to

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

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.

3. AGENT'S POWERS

I grant to my agent full authority to make d ecisions for me regarding my health care. In

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

otherwise expressed by me or known to my agent. In making any decision, my agent

shall attempt to discuss the proposed decision with me to determine my desires if I am

able to communicate in any way. If my agent cannot determine the choice I would want

made, then my agent shall make a choice for me based upon what my agent believes to be

in my best interests. My agent's authority to interpret my desires is intended to be as

broad as possible, except for any limitations I may state below.

Accordingly, unless specifically limited by Section E, below, my agent is authorized as

follows:

A. To consent, refuse, or withdraw consent to any and all types of medical care,

treatment, surgical procedures, diagnostic procedures, medication, and the use of

mechanical or other procedures that affect any bodily function, including, but not limited

to, artificial respiration, nutritional support and hydration, and cardiopulmonary

resuscitation;

B. To authorize, or refuse to authorize, any medication or procedure intended to relieve

pain, even though such use may lead to physical damage, addiction, or hasten the

moment of, but not intentionally cause, my death;

C. To authorize my admission to or discharge, even against medical advice, from any

hospital, nursing care facility, or similar facility or service;

D. To take any other action necessary to making, documenting, and assuring

implementation of decisions concerning my health care, including, but not limited to,

granting any waiver or release from liability required by any hospital, physician, nursing

care provider, or other health care provider; signing any documents relating to refusals of

treatment or the leaving of a facility against medical advice, and pursuing any legal

action in my name, and at the expense of my estate to force compliance with my wishes

as determined by my agent, or to seek actual or punitive damages for the failure to

comply.

E. The powers granted above do not include the following powers or are subject to the

following rules or limitations:

________________________________________________________________________

4. ORGAN DONATION (INITIAL ONLY ONE)

My agent may ___; may not ___ consent to the donation of all or any of my tissue or

organs for purposes of transplantation.

5. EFFECT ON DECLARATION OF A DESIRE FOR A NATUR AL DEATH (LIVING

WILL)

I understand that if I have a valid Declaration of a Desire for a Natural Death, the

instructions contained in the Declaration will be given effect in any situation to which

they are applicable. My agent will have authority to make decisions concerning my health

care only in situations to which the Declaration does not apply.

6. STATEMENT OF DESIRES AND SPECIAL PROVISIONS

With respect to any Life-Sustaining Treatment, I direct the following:

(INITIAL ONLY ONE OF THE FOLLOWING 4 PARAGRAPHS)

(1) ___ GRANT OF DISCRETION TO AGENT. I do not want my life to be prolonged

nor do I want life-sustaining treatment to be provided or continued if my agent believes

the burdens of the treatment outweigh the expected benefits. I want my agent to consider

the relief of suffering, my personal beliefs, the expense involved and the quality as well

as the possible extension of my life in making decisions concerning life-sustaining

treatment.

(2) ___ DIRECTIVE TO WITHHOLD OR WITHDRAW TREATMENT. I do not want

my life to be prolonged and I do not want life-sustaining treatment:

a. if I have a condition that is incurable or irreversible and, without the administration of

life-sustaining procedures, expected to result in death within a relatively short period of

time; or

b. if I am in a state of permanent unconsciousness.

(3) ___ DIRECTIVE FOR MAXIMUM TREATMENT. I want my life to be prolonged

to the greatest extent possible, within the standards of accepted medical practice, without

regard to my condition, the chances I have for recovery, or the cost of the procedures.

(4) ___ DIRECTIVE IN MY OWN WORDS:

________________________________________________________________________

7. STATEMENT OF DESIRES REGARDING TUBE FEEDING

With respect to Nutrition and Hydration provided by means of a nasogastric tube or tube

into the stomach, intestines, or veins, I wish to make clear that (INITIAL ONLY ONE)

___ I do not want to receive these forms of artificial nutrition and hydration, and they

may be withheld or withdrawn under the conditions given above.

___ I do want to receive these forms of artificial nutrition and hydration.

IF YOU DO NOT INITIAL EITHER OF THE ABOVE STATEMENTS, YOUR

AGENT WILL NOT HAVE AUTHORITY TO DIRECT THAT NUTRITION AND

HYDRATION NECESSARY FOR COMFORT CARE OR ALLEVIATION OF PAIN

BE WITHDRAWN.

8. SUCCESSORS

If an agent named by me dies, becomes legally disabled, 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 successors 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: ______________________________________________________________

9. 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.

10. UNAVAILABILITY OF AGENT

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

unwilling to make decisions concerning my 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.

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 ___, 19___. My

current home address is:

Signature: _______________________________________________________________

Name: __________________________________________________________________

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

directly financially responsible for the principal's medical care. 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 facility 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: _________

Residence Address: ___________________________________________

______________________________________________________________

Witness No. 2

Signature: _____________________________ Date: ______________

Print Name: ____________________________ Telephone: _________

Residence Address: ___________________________________________

______________________________________________________________

(E) A health care agent has, in addition to the powers set forth in the health care power of

attorney, the following specific powers:

(1) to have access to the principal's medical records and information to the same extent

that the principal would have access, including the right to disclose the contents to others;

(2) to contract on the principal's behalf for placement in a health care or nursing care

facility or for health care related services, without the agent incurring personal financial

liability for the contract;

(3) to hire and fire medical, social service, and other support personnel responsible for the

principal's care.

(F)(1) The agent is not entitled to compensation for services performed under the health

care power of attorney, but the agent is entitled to reimbursement for all reasonable

expenses incurred as a result of carrying out the health care power of attorney or the

authority granted by this section.

(2) The agent's consent to health care or to the provision of services to the principal does

not cause the agent to be liable for the costs of the care or services.

(G) If a principal has been diagnosed as pregnant, life-sustaining procedures may not be

withheld or withdrawn pursuant to the health care power of attorney during the course of

the principal's pregnancy. This subsection does not otherwise affect the agent's authority

to make decisions concerning the principal's obstetrical and other health care during the

course of the pregnancy.