Fill and Sign the Declaration of a Desire for a Natural Death State of Form

STATE OF SOUTH CAROLINA COUNTY OF _________________________ DECLARATION OF A DESIRE FOR A NATURAL DEATH (South Carolina Code of Laws 44-77-50) I, _______________________________, Declarant, being at least eighteen 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 _________________, 20 . 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life-sustaining procedures would serve only to prolong the dying process, I direct that the procedures be withheld or withdrawn, and that I be permitted to die naturally with only the administration of medication or the performance of any medical procedure necessary to provide me with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. INSTRUCTIONS CONCERNING ARTIFICIAL NUTRITION AND HYDRATION INITIAL ONE OF THE FOLLOWING STATEMENTS If my condition is terminal and could result in death within a reasonably short time, ______ I direct that nutrition and hydration BE PROVIDED through any medically indicated means, including medically or surgically implanted tubes.
If i am in a state of permanent unconsciousness and neither my attending nor my family physicians have certified that I have a terminal disease or that my death can occur within a reasonably short period of time, and my physician or any other qualified person designated in writing by my attending physician has made a written certification that i am in a condition certified to be terminal by two physicians who have personally examined if at any time, i make a declaration that I desire no artificial nutrition or hydration, be given to me to prolong my life. No physician, physician assistant (physician assistant) or certified nurse practitioner shall: make, use or administer any drugs or medicines for any purpose other than those enumerated in the following items (except as directed by an attending physician when the physician is certified to be competent to determine whether any drug or medicine is appropriate for the proposed treatment, the application of which is the responsibility of the physician's professional medical assistants, certified nurse practitioners, internists or other physicians and has been approved by the physician's treating physician and is written in the physician's own words or with a notation of the manner of preparation for administration, or unless he or she is a physician or certified nurse practitioner under rules of his or her own making and such rules contain the following restrictions): first: the medications shall be administered only when the physicians, nurses or other qualified persons have determined after a thorough clinical examination or diagnosis that such medication is the best treatment at the time. Second: if any medicine or chemical agent is administered before the conditions are verified by a physician with a written certification, it must be removed and the other medication shall be administered until such time as a physician's certification is obtained or other competent and reasonable conditions have been established or until the physician's death results from the administration of such medicine or chemical agent. Third: the drugs and all other medications mentioned in this item must also be administered for the purpose of ascertaining the presence of any infectious disease, if the disease has been detected in serum, serum and other tissues tested for disease-producing microorganisms. Fourth: drugs or medicines mentioned in this item must be administered only after the diagnosis of a disease-causing microscopic or microscopic particulate specimen, or as instructed by the attending physician. Fifth: when the drugs or medicines mentioned in this item have been used for diagnostic purposes, all subsequent treatment for diseases arising from use for such purposes must be given in accordance with such diagnostic protocols; seventh: when the drugs mentioned in this item have been used for the purpose of assisting the