Health Care Power Of Attorney Form - South Carolina (Page 5 of 7) in pdf

not apply.

7. STATEMENT OF DESIRES CONCERNING LIFE-SUSTAINING TREATMENT

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

(INITIAL ONLY ONE OF THE FOLLOWING 3 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.

8. 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 in situations where life-sustaining treatment is

being withheld or withdrawn pursuant to Item 7, (INITIAL ONLY ONE OF THE FOLLOWING

THREE PARAGRAPHS):

(a) _____ GRANT OF DISCRETION TO AGENT. I do not want my life to be prolonged by tube

feeding if my agent believes the burdens of tube feeding 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 this decision.

(b) _____ DIRECTIVE TO WITHHOLD OR WITHDRAW TUBE FEEDING. I do not want my life

prolonged by tube feeding.

within the standards of accepted medical practice, without regard to my condition, the chances I have for

recovery, or the cost of the procedure, and without regard to whether other forms of life-sustaining

treatment are being withheld or withdrawn.

IF YOU DO NOT INITIAL ANY OF THE STATEMENTS IN ITEM 8, YOUR AGENT WILL NOT

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Health Care Power Of Attorney Form - South Carolina Page 5