SOUTH CAROLINA DEPARTMENT OF MENTAL HEALTH
Columbia, South Carolina

TO:            All Organizational Components

SUBJECT: Advance Directives

I.      Purpose:

The purpose of this directive is to implement the "Patient Self Determination Act" and the State's public policy to encourage the execution of advance health care directives. The Patient Self Determination Act requires that each hospital and nursing facility receiving federal Medicare or Medicaid funds must provide information to every patient/resident, about the facility's policies concerning implementation of Advance Directives, and distribute a written description of State law concerning Advance Directives to the patient/resident. It is also the declared policy of the State of South Carolina to promote the use of Advance Directives as a means of encouraging patient self-determination and avoiding uncertainty in a health care crisis.

II.     Policy:

While competent, individuals may anticipate the possibility of later incapacity and may prepare Advance Directives stating their desires regarding the provision or withholding of medical care in such event. It is the Department's policy to encourage the use of advance health care directives and to honor Advance Directives. However, no Departmental facility shall condition the provision of care or otherwise discriminate against an individual based on whether or not the individual has executed an advance health care directive.

III.     Advance Directives:

For purposes of the Patient Self Determination Act and this directive, "Advance Directive" means a written instruction such as a living will or health care power of attorney, recognized under State law (whether by statute or by the courts of the State) and relating to the provision of health care when the individual is incapacitated.

South Carolina provides by statute for two types of Advance Directives

A.   Living Will.   The Death with Dignity Act authorizes competent adults to
       express their wishes regarding the use or withholding of life-sustaining
       procedures, including artificial nutrition and hydration, in the event they are
       diagnosed with a terminal condition or are in a state of permanent
       unconsciousness and in the further event that they are incapacitated or
       otherwise unable to express their desires. The Act creates a statutory form
       for this purpose entitled "Declaration of a Desire for a Natural Death." A
       copy is attached to this Directive as Appendix 1. This document and those
       similar in purpose are commonly referred to as a "living will."

B.   Health Care Power of Attorney. Sections within the South Carolina
       Probate Code authorize competent adults to designate another person to
       make decisions on their behalf about their medical care in the event they
       become incapacitated. The Code creates a statutory form for this purpose
       entitled "Health Care Power of Attorney." For competent adults wishing to
       express their desires concerning future mental health treatment, the
       Department has developed a form entitled "Statement of Desires Regarding
       Mental Health Treatment and Care" for use as an addendum to the statutory
       "Health Care Power of Attorney" form. A copy of both forms are attached to
       this Directive as Appendices 2 and 3.

Individuals may also have prepared other forms of Advance Directives or put into writing their desires concerning certain types of medical care. Subject to each individual's circumstances, the Department's medical staff shall consider any
expression of a patient's desires which appears genuine.

IV.     Do Not Resuscitate Orders:

A.   Do Not Resuscitate Order is a written physician's order not to begin the
       otherwise automatic initiation of cardiopulmonary resuscitation in the event
       the patient suffers cardiac or respiratory arrest. It is appropriate in situations
       involving a patient with a terminal condition or a patient in a state of
       permanent unconsciousness, and is generally entered with the consent of the
       patient or the patient's substitute decision maker, or in circumstances where
       resuscitative efforts are inappropriate or medically futile. Although the entry
       of a Do Not Resuscitate Order involves advance planning for the withholding
       of specific health care procedures, and frequently involves consultation with
       the patient, it is not considered an Advance Directive for purposes of the
       Patient Self Determination Act or this Directive. Entry of a Do Not
       Resuscitate Order is, however, one means of effectuating a patient's Advance
       Directive for the withholding of life-sustaining procedures when the conditions
       set forth in the Advance Directive are met.

V.     Procedure:

A.   Providing Information.

1.     Each inpatient facility shall promulgate policies and procedures to ensure that
        upon admission, adult patients will be provided with a written statement of
        the facility's policy regarding the implementation of Advance Directives, and
        also be provided with a written description of the State law in South Carolina
        concerning Advance Directives. A copy of the written description of State
        law is attached hereto as Appendix 4. Trained staff shall be made available
        to provide the patient an explanation as requested. The patient's medical
        record shall be documented to reflect that the required information was
        provided.

2.     Each mental health center shall include information and instruction concerning
        Advance Directives in any ongoing client education programs.

B.      Requesting Information.

1.     Inpatient facility policies shall provide that upon admission of adult patients,
        staff will inquire into the existence of Advance Directives previously
        executed by the patient. The patient's medical record shall be documented
        as to the response to the inquiry. If the patient indicates that he or she has an
        Advance Directive, staff shall request a copy.

2.     In the event mental health center staff are aware that a client has executed an
        Advance Directive, they shall request a copy and maintain it in the client's |
        record. In the event the center staff become aware of the client's subsequent
        admission to a hospital or nursing home, staff shall contact the facility to make
        them aware of, and supply a copy of, the client's Advance Directive.

C.     Providing Assistance.

Both inpatient facilities and mental health centers shall assist apparently competent patients and clients who desire to prepare an Advance Directive. Assistance shall include the following:

1.      Information. The medical staff and other trained staff should endeavor to
         answer patients and clients questions about Advance Directives and the
         effect of a particular Advance Directive in the patient's or client's individual
         circumstances.

2.      Provision of approved forms. Staff shall make available to those
         interested patients and clients copies of the approved State forms for
         Advance Directives, as well as the addendum to the Health Care Power of
         Attorney entitled "Statement of Desires Regarding Mental Health Treatment
         and Care" (Appendix 3).

3.      Assistance in locating witnesses for execution. In South Carolina,
         Advance Directives require a minimum of two witnesses to the declarant's
         signature. However, State law prohibits certain individuals (family members,
         prospective beneficiaries and attending medical personnel) from serving as
         witnesses. If needed, staff shall assist in locating willing disinterested
         individuals to witness the patient's/client's execution of the form(s).

         Staff shall not serve as a witness to the declarant's signature if they are or
         have been directly involved in the patient's care. Staff shall not accept
         appointment as an agent in a Health Care Power of Attorney or Declaration
         of a Desire for a Natural Death.

Staff need not provide assistance to a patient/client in circumstances in which staff believe the patient/client is unable to make an informed and understanding decision regarding the execution of an Advance Directive.

D.      Additional Guidelines.

1. If the facility or center is made aware that the patient has made an
    Advance Directive, staff should request a certified copy. Staff may
    make certified copies from the original by annotating a photocopy
    with the following language:

I hereby certify that this document is a true and correct
copy of the original thereof which I compared on the
_____  day of _______________, 19 _____.
___________________________
          (signature of employee)

    The certified copy of the Advance Directive(s) shall be placed in the
    client's or patient's medical record. If the patient is transferred to any
    medical facility, the physician shall note on the transfer form the
    existence of the specific Advance Directive. If the patient's chart
    does not accompany the patient, and the circumstances require it,
    the Advance Directive(s) shall be delivered to the medical facility to
    which the patient has been transferred.

2. If the patient is transferred to any other Department of Mental
    Health facility, the Advance Directive(s) shall be sent to the receiving
    facility for inclusion in the patient's chart at such facility.

3. In the event it becomes necessary, an inpatient facility may retain the
    original of the patient's Advance Directive(s) as long as the patient
    remains in the facility. In the event the patient is discharged from the
    facility, the original of the patient's Advance Directive(s) shall be
    returned to other responsible party acting on the patient's behalf.

   VI.            Staff Training /Community Education:

Each inpatient facility shall provide at least annually for staff education on Advance Directives.  Mental health centers shall provide clinical staff with information concerning Advance Directives and the provisions of this Directive.  In addition, the Department, its inpatient facilities and mental health centers shall seek appropriate opportunities to provide community education concerning Advance Directives.

This directive rescinds and replaces SCDMH Directive No. 757-91, "Patient Self Determination Act."

                                                                           
                                                                                    John Morris. M.S.W.
                                                                                    Acting State Director of Mental Health

Date:     March 19, 1997

    APPENDIX 1

     DECLARATION OF A DESIRE FOR A NATURAL
DEATH

STATE OF SOUTH CAROLINA                                   COUNTY OF______________

I, __________________________( ____ / ____/ ____ ),Declarant, being at least eighteen
                                                       Social Security Number

years of age and a resident of and domiciled in the City of ______________________, County
of __________________________, State of South Carolina, make this Declaration this
____day of __________________________, 19____.

     I willfully and voluntarily make known my desire that no life-sustaining procedures be used to prolong my dying if my condition is terminal or if I am in a state of permanent unconsciousness, and I declare:

     If at any time I have a condition certified to be a terminal condition by two 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 or if the physicians certify that I am in a state of permanent unconsciousness and where the application of life-sustaining procedures would serve only to prolong the dying process, I direct that the procedures be withheld or withdrawn, and that I be permitted to die naturally with only the administration of medication or the performance of any medical procedure necessary to Provide me with comfort care.

     In the absence of my ability to give directions regarding the use of life-sustaining procedures, it is my intention that this Declaration be honored by my family and physicians and any health facility in which I may be a patient as the final expression of my legal right to refuse medical or surgical treatment, and I accept the consequences from the refusal.

      I am aware that this Declaration authorizes a physician to withhold or withdraw life-sustaining procedures. I am emotionally and mentally competent to make this Declaration.

APPOINTMENT OF AN AGENT (OPTIONAL)

1. You may give another person authority to REVOKE this declaration on your behalf. If you
    wish to do so, please enter that person's name in the space below.

Name of Agent with Power to Revoke:________________________________________
Address:_______________________________________________________________
Telephone Number:_______________________________________________________

2. You may give another person authority to ENFORCE this declaration on your behalf. If you
     wish to do so, please enter that person's name in the space below.

Name of Agent with Power to Enforce: ________________________________________
Address:_______________________________________________________________
Telephone Number: ______________________________________________________

REVOCATION PROCEDURES

THIS DECLARATION MAY BE REVOKED BY ANY ONE OF THE FOLLOWING METHODS. HOWEVER, A REVOCATION IS NOT EFFECTIVE UNTIL IT IS COMMUNICATED TO THE ATTENDING PHYSICIAN:

(1)   BY BEING DEFACED. TORN, OBLITERATED, OR OTHERWISE DESTROYED,
       IN EXPRESSION OF YOUR INTENT TO REVOKE, BY YOU OR 13Y SOME
       PERSON IN YOUR PRESENCE AND BY YOUR DIRECTION. REVOCATION
       BY DESTRUCTION OF ONE OR MORE OF MULTIPLE ORIGINAL
       DECLARATIONS REVOKES ALL OF THE ORIGINAL DECLARATIONS:

(2)   BY A WRITTEN REVOCATION SIGNED AND DATED BY YOU EXPRESSING
       YOUR INTENT TO REVOKE;

(3)   BY YOUR ORAL EXPRESSION OF YOUR INTENT TO REVOKE THE
       DECLARATION, AN ORAL REVOCATION TO THE ATTENDING PHYSICIAN
       BY A PERSON OTHER THAN YOU IS EFFECTIVE ONLY IF:
       (A)   THE PERSON WAS PRESENT WHEN THE ORAL REVOCATION WAS
               MADE;
       (B)   THE REVOCATION WAS COMMUNICATED TO THE PHYSICIAN
               WITHIN A REASONABLE TIME;
       (C)   YOUR PHYSICAL OR MENTAL CONDITION MAKES IT IMPOSSIBLE
                FOR THE PHYSICIAN TO CONFIRM THROUGH SUBSEQUENT
                CONVERSATION WITH YOU THAT THE REVOCATION HAS
                OCCURRED. TO BE EFFECTIVE AS A REVOCATION, THE ORAL
                EXPRESSION CLEARLY MUST INDICATE YOUR DESIRE THAT THE
                DECLARATION NOT BE GIVEN EFFECT OR THAT LIFE-SUSTAINING
                PROCEDURES BE ADMINISTERED;

(4)  IF YOU, IN THE SPACE ABOVE, HAVE AUTHORIZED AN AGENT TO REVOKE
      THE DECLARATION, THE AGENT MAY REVOKE ORALLY OR 13Y A WRITTEN,
      SIGNED, AND DATED INSTRUMENT. AN AGENT MAY REVOKE ONLY IF YOU
      ARE INCOMPETENT TO DO SO. AN AGENT MAY REVOKE THE
      DECLARATION PERMANENTLY OR TEMPORARILY;

(5)  By YOUR EXECUTING ANOTHER DECLARATION AT A LATER TIME.
                                                                         _________________________________
                                                                                            Signature of Declarant

AFFIDAVIT

STATE OF__________________                       COUNTY OF ____________________

We, ____________________and ____________________the undersigned witnesses to the foregoing Declaration, dated the _______ day of ____________________ ,  19 ___ at least one of us being first duly sworn, declare to the undersigned authority, on the basis of our beat information and belief, that the Declaration was on that date signed by the declarant as and for his DECLARATION OF A DESIRE FOR A NATURAL DEATH in our presence and we, at his request and in his presence, and in the presence of each other, subscribe our names as witnesses on that date. The declarant is personally known to us, and we believe him to be of sound mind. Each of us affirms that he is qualified as a witness* to this Declaration under the provisions of the South Carolina Death with Dignity Act in that he is not related to the declarant by blood, marriage, or adoption either as a spouse, lineal ancestor, descendant of the parents of the declarant, or spouse of any of them; nor directly financially responsible for the declarant's medical care; nor entitled to any portion of the declarant's estate upon his decease, whether under any will or as an heir by intestate succession; nor the beneficiary of a life insurance policy of the declarant; nor the declarant's attending physician; nor an employee of the attending physician; nor a person who has a claim against the declarant's decedent's estate as of this time. No more than one of us is an employee of a health facility in which the declarant is a patient, If the declarant is a resident in a hospital or nursing care facility at the date of execution of this Declaration, at least one of us is an ombudsman designated by the State Ombudsman, Office of the Governor.

_______________________________                ________________________________
Witness                                                                 Witness*

     Subscribed before me by________________________, the declarant, and subscribed and sworn to before me by _______________________________________________________
the witness(es), this _____ day of _____________________, 19______.

                                                                                  ________________________________
                                                                                 Signature of Notary Public

                                        (SEAL)

                                                                                 Notary Public for  __________________

                                                                                  My commission expires, _____________

*If qualified as a witness, the Notary Public may serve as a witness.                 SC Code of Laws Sec. 44-77-10 (Rev. 6191)

APPENDIX 2

HEALTH CARE POWER OF ATTORNEY
(South Carolina Statutory Form, Code of Laws Section 62-5-504)

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
         decisions 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 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 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
         acknowledgement 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 linear
         descendants: your parents. grandparents. and other linear
         ancestors: your siblings and their linear descendants: or a
         spouse of any of these persons.

B.     A person who is directly financially responsible 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 would have a claim against any portion of your
          estate (persons to whom you owe money).

      If you are 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 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.

HEALTH CARE POWER OF ATTORNEY
(South Carolina Statutory Form, Code of Laws Section 62-5-504)

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 decisions 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 desire 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, surgical
              procedures, diagnostic procedures, medication. and the use of treatment, 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 NATURAL 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.

OR

(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.

OR

(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.

OR

(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.

OR

________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: ____________________________________________________________________
       Print 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/her 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: _______________________________________________________________
        ______________________________________________________________________________

legis.4/8/92

APPENDIX  3

STATEMENT OF DESIRES REGARDING MENTAL HEALTH TREATMENT AND CARE

ADDENDUM TO THE SOUTH CAROLINA
HEALTH CARE POWER OF ATTORNEY FORM

OF __________________________________
(Name of Principal)

This statement is effective for THREE YEARS from the date
signed, unless sooner revoked or replaced.

I have experienced past mental health treatment.

(Optional) I am aware that I have a mental illness that has been diagnosed as _____________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________

(Optional) The name of my doctor or other mental health practitioner is:   ________________
_______________________________________________________________________

     My doctor's telephone number is: __________________________________________

With respect to the following forms of mental health treatment or care, I wish to make clear my desires as follows:

1.   Regarding admission to a hospital:

      If I become unable to give or withhold informed consent for mental health treatment, my
      wishes regarding admission to a hospital for mental health treatment are as follows:    
      [Instruction: Choose section A. or B. or C. or D.]

      A.____ I leave the decision of my admission to a hospital for mental health treatment to
                   my health care agent named in my Health Care Power of Attorney.

      B.____ I consent to being admitted to a hospital for mental health treatment.

      C.____ I do not consent to being admitted to a hospital for mental health treatment.

      D.____ I consent to being admitted to a hospital for mental health treatment, except
                   that I do not consent to admission to: _____________________________
                   _________________________________________________________

2.   Regarding Psychotropic Medications:

      If I become unable to give or withhold informed consent for mental health treatment,
      MY wishes regarding receiving psychotropic medication are as follows: [Instruction:
      Choose section A. or B. or C. or D. and complete ONLY that section. Filling out
      section E. is optional-]

      A.____ I leave the decision of the administration of psychotropic medications to my
                   health care agent named in my Health Care Power of Attorney.

      B.____ I consent to the administration of any psychotropic medication prescribed by
                  my treating physician.

      C.____ I do not consent to the administration of any psychotropic medication.

      Optional)       My reasons for refusing all psychotropic medications are:
                           _______________________________________________
                            _______________________________________________

      D.____ I consent to the administration of psychotropic medications except I
                   expressly do not consent to the following medication(s) administered
                   to me:
                   ___________________________________________________

       (Optional)      My understanding of the risks and benefits of these specific
                             medications is:
                            _______________________________________________
                            _______________________________________________

       (Optional)      My reasons for refusing these specific medications are:
                            _______________________________________________
                            _______________________________________________

       E.____ Other instructions and preferences regarding the administration of
                   psychotropic medications: _______________________________
                   ___________________________________________________
                   ___________________________________________________

3.   Regarding electroconvulsive (shock) therapy:

      If I become unable to give or withhold informed consent for mental health treatment
      my wishes regarding receiving electro-convulsive therapy are as follows: [Instruction:
      Choose either Section A. or B. or C. or D. and complete ONLY that section.]

      A. ____  I leave the decision regarding the administration of electroconvulsive therapy
                     to my health care agent named in my Health Care Power of Attorney.

      B. ____ I consent to the administration of electroconvulsive therapy prescribed by
                   my treating physician.

      C. ____I do not consent to the administration of electroconvulsive therapy.

       (Optional)    My reasons for refusing electroconvulsive therapy are:   ______________
                          ________________________________________________________
                          ________________________________________________________

       D.____ I consent to the administration of electroconvulsive therapy under the following
                    conditions (Circle 1. or 2., below and fill in the blanks):

1. for the following number of treatments only:

2. with the number of treatments to be determined by

Dr. ___________________________

Address: _______________________
______________________________

4. Regarding seclusion or restraint:

    If while hospitalized my behavior becomes threatening to myself or others, my preference
    regarding staff's response to my behavior is as follows: [Instruction: Choose either
    Section A. or B. Filling out Section C. is optional.]

    A. ____That I be placed in a seclusion room until I have regained self-control and the
                 threatening behavior appears at an end.

    B.____ That I be placed in mechanical restraints until I have regained self-control and
                 the threatening behavior appears at an end.

    C.____ Other instructions or preferences regarding the use of seclusion or restraint:
                 ________________________________________________________
                 ________________________________________________________

5. Additional instructions and statements of desires regarding my mental health treatment:
     _______________________________________________________________
     _______________________________________________________________
     _______________________________________________________________
     _______________________________________________________________

6. I may attach a statement of instructions or requests concerning personal matters or issues
    which I would like followed in the event I become unable to manage my affairs or clearly
    communicate my wishes.

    THIS ADDENDUM IS EFFECTIVE FOR THREE YEARS FROM THE DATE
    SIGNED, UNLESS SOONER REVOKED OR REPLACED. THE EXPIRATION
    OR REVOCATION OF THIS ADDENDUM SHALL NOT REVOKE MY
    SOUTH CAROLINA HEALTH CARE POWER OF ATTORNEY FORM.

BY SIGNING THIS ADDENDUM BELOW 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 Addendum to Health Care Power of Attorney on this _______day of _____________, 19____. My current home address is: ______________________________
_________________________________________________________________________
Signature: _________________________________________________________________
Print 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 Addendum to 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/her 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 care 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: ________________________________________________________
_______________________________________________________________________

(Optional)    PHYSICIAN'S REVIEW:

I reviewed the foregoing Statement of Desires Regarding Mental
Health Treatment and Care with ________________________and
                                                          (Name of Principal)
am aware of its provisions.

________________________                         ________________
                      Physician                                                     Date

APPENDIX 4

     YOUR RIGHT TO MAKE
DECISIONS ABOUT
YOUR HEALTH CARE

     

January 25, 1993

YOU HAVE THE RIGHT TO MAKE HEALTH CARE DECISIONS THAT AFFECT YOU.

You have the right to make all decisions about the health care you receive. If you do not want certain treatments, you can tell your doctor, either in person or in writing, that you do not want them. If you want to refuse treatment but You do not have someone to name as Your agent,, you can sign a living will.

Most patients can express their wishes to their doctor, but some who are badly injured, unconscious, or very ill cannot.  People need to know your wishes about health care in case you become unable to speak effectively for yourself.  You can express your wishes in a health care power of attorney or a living will.

In a living will you tell your doctor that you do not want to receive certain treatment.  In a health care power of attorney you name an agent who will tell the doctor what treatment should or should not be provided.

The decision to sign a health care power of attorney or living will is very personal and very important.  This pamphlet answers some frequently asked questions about health care powers of attorney and living wills.

These documents will be followed only if you are unable, due to illness or injury, to make decisions for yourself. While you are pregnant, however, these documents will not cause life support to be withheld.

If you do not have a living will or health care power of attorney that tells what you want done, you do not know what decisions will be made or who will make them. Decisions may be made by certain relatives designated by South Carolina law, by a person appointed by the court, or by the court itself. The best way to make sure your wishes are followed is to state your wishes in a health care power of attorney, or sometimes, a living will. It you want to refuse treatment but you do not have someone to name as your agent, you can sign a living will.

It You have questions about signing a. health care power of attorney or living will, you should talk to your doctor: your minister, priest, rabbi, or other religious counselor or your attorney. Finally, it is very important that you   discuss your feelings about life support with your family. A health care power of attorney, also should be discussed with the people you intend to name as your agent and alternate agents to make sure that they are willing to serve.  It is also important to make sure that your agents know your wishes.

Are there forms for living wills and health care Powers of attorney in South Carolina?

Yes. The South Carolina legislature has approved forms for both a living will and a health care power of attorney. The living will form that the legislature approved is called a "Declaration of a Desire for Natural Death."  You may be able to get these forms from the person who gave you this brochure.  If not, you may call:

Your local Council an Aging South Carolina Commission on Aging 1 (800) 868-9095

Joint legislative Committee on Aging (803) 734-2995

Governor's Office, Ombudsman Division (803) 734-0457

How are a Health Care Power of Attorney and a Living Will different?

*  The agent named in a health care power of attorney can make all of the decisions about your health care that need to be made. A living will affects only life support.

*  A living will affects life support only in certain circumstances. A living will only tells the doctor what to do if you are permanently unconscious or if you are terminally ill and close to death. A health care power of attorney is not limited to these situations.

"Permanently unconscious" means that you are in a persistent vegetative state in which your body functions but your mind does not. This is different from a coma, because a person in a coma usually wakes up, but a permanently unconscious person does not.

*  A living will can only say  what treatment you don't want. In a health care power of attorney you can say what treatment you do want as well as what you do not want.

* With a living will. you must decide what should be done in the future, without knowing exactly what the circumstances will be when the decision is put into effect. With a health care power of attorney, the agent can make decisions when the need arises, and will know what the circumstances are.

* An Ombudsman from the Governor's Office must be a witness if you sign a living will when you are in a hospital or nursing home. An Ombudsman does not have to be a witness if you sign a health care power of attorney in a hospital or nursing home.

I went to be allowed to die a natural death and not be kept alive by medical treatment heroic measures, or artificial means. How can I make sure this happens?

The best way to be sure you are allowed to die a natural death is to sign a health care power of  attorney that states the circumstances in which you would not want treatment. In the South Carolina form, you should specify your wishes in Items 6 and 7.

You may not have a person that you can trust to carry out your desire for a natural death. It not, a living will can ensure that you are allowed to die a natural death. However, it will only do so if you are permanently unconscious or terminally ill and close to death.

Which document should I sign if I want to be treated with all available life-sustaining procedures?

You should sign a Health Care Power of Attorney, and  not a living will. The South Carolina Health Care Power of Attorney form allows you to say either that you go or that you do not want life-sustaining treatment. A living will only allows you to say that you do not want life-sustaining procedures.

What if I have an old health care power of attorney or living will, or signed one in another state?

If you previously signed a living will or health care power of attorney, even in another state, it is probably valid. However, it may be a good idea to sign the most current forms. For example, the current South Carolina living will form covers artificial nutrition and hydration whereas older forms did not.

How is a health care power of attorney different from a durable power of Attorney?

A health care power of attorney is a specific type of durable power of attorney that names an agent only to make health care decisions.  A durable power of attorney may or may not allow the agent to make health care decisions. It depends on what the document says. The agent may only be able to make decisions about property and financial matters.

What are the requirements for signing a living will?

You Must be eighteen years old to sign a living will, Two persons must witness your signing the living will form. A notary public must also sign the living will. If you sign a living will while you are a patient in a hospital or a resident in a nursing home, a representative from the Governor's Office (the Ombudsman) must witness your signing.

There are certain people who cannot witness your living will. The living will form says who cannot be a witness. You should read the living ,will form carefully to be sure your witnesses are qualified.

What are the requirements for signing a health care power of attorney?

You must have two witnesses sign "he document. The form tells you who cannot be witnesses. (These are the same people who cannot witness a living will.) Unlike a living will, the health care power of attorney may be signed in a hospital or in a nursing home without having someone from the Ombudsman's office present. It is not necessary to have a notary sign your health care power of attorney.

Whom should I appoint as my agent? What if my agent cannot serve?

You should appoint a person you trust and who knows how you feel about health care. You also should name at least one alternate,who will make decisions if your agent is unable or unwilling to make these decisions. You should talk to the people you choose as your agent and alternate agents to be sure they are willing to serve. Also, they should know how you feet about health care.

Is them anything I need to know about completing the living will or health care power of attorney form?

Each form contains spaces for you to state your wishes about things like whether you want life support and tube feeding. If you do not put your initials in either blank, tube feeding may be provided, depending upon your condition. Be sure to read the forms carefully and follow the instructions.

Where should I keep my health care power of attorney or living will?

Keep the original in a safe place where your family members can get it. You also should give a copy to as many of the following people as you are comfortable with: your family members. your doctor. your lawyer, your minister or priest, or your agent. Do not put your only copy of these documents in your safe deposit box.

What if I change my mind after I have signed a living will or health care power attorney?

You may revoke (cancel) your living will or health care power of attorney any time. The forms contain instructions for doing so. You must tell your doctor and anyone else who has a copy that you have changed your mind and you want to revoke your living will or health care power of attorney.