Declaration Of A Desire For A Natural Death Form
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4STATE OF SOUTH CAROLINA
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DECLARATION OF A DESIRE FOR A
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NATURAL DEATH
COUNTY OF _____________
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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only to prolong the dying process, I direct that the procedures be withheld or withdrawn, and that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
1. If my condition is terminal and could result in death within a reasonably short time,
A._____________I direct that nutrition and hydration BE PROVIDED through any medically
indicated means, including medically or surgically implanted tubes.
B._____________I direct that nutrition and hydration NOT BE PROVIDED through any
medically indicated means, including medically or surgically implanted tubes.
The following line is not part of the standard South Carolina form. It has been added at the
request of many people as a point of clarification. If you do want it to apply, please initial the
line below:
C._____________Nevertheless, I do want treatment to ensure my comfort and to relieve pain
and suffering and minimal intravenous fluids to avoid discomfort.
INITIAL ONE OF THE FOLLOWING STATEMENTS
2. If I am in a persistent vegetative state or other condition of permanent unconsciousness,
A._____________I direct that nutrition and hydration BE PROVIDED through any medically
indicated means, including medically or surgically implanted tubes.
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