South Dakota Advance Directive Form

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A South Dakota advance directive is a document that lets a person designate someone else to be their health care agent and follow their treatment requests in case they become incapacitated. An advance directive allows a person to plan their healthcare choices in the event they cannot speak for themselves due to loss of consciousness, dementia, or other mental issues. In addition, it includes selections for organ donation.

Table of Contents

Laws

StatuteChapter 34-12D (Living Wills), Chapter 59-7 (Termination of Agency)

Signing Requirements (§ 59-7-2.1, § 34-12D-2) –  Two (2) witnesses or a notary public.

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How to Write

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Durable Power Of Attorney For Health Care

(1) South Dakota Principal Identity.  This document will define how a predetermined Health Care Agent may act to represent the medical decisions of the Party issuing it. Identify yourself as the South Dakota Health Care Principal behind this instrument of appointment.

(2) South Dakota Health Care Agent Name. The Party who shall receive the principal power to confer with South Dakota Physicians to determine your medical treatment must be named. Present his or her full name.

(3) Address Of Health Care Agent.

(4) South Dakota Successor Agent. As the South Dakota Principal behind this appointment, you have the option of naming a Successor Agent as well. This precautionary measure allows a Successor to your South Dakota Health Care Agent to be set up with the authorization needed to seize and use the principal power of deciding over your medical treatment and health care by automatically having the right to assume the South Dakota Health Care Agent role should it become vacant for any reason (i.e., revocation, unavailability, unwillingness, etc.). For this designation to be automatically made, the South Dakota Successor Agent’s full name must be presented to the appointment statement provided.

(5) South Dakota Successor Agent Address.

Artificial Nutrition/Hydration Directive

(6) South Dakota Health Care Agent’s Authority Over Nutrition. The South Dakota Health Care Agent shall have the ability to decide on a wide array of your medical needs when you are uncommunicative in the State Of South Dakota and diagnosed as either being in a permanent comatose condition or with a terminal condition that is either irreversible or incurable. One ability not automatically granted to the South Dakota Health Care Agent by default is the authority to decide upon whether you should receive artificial nutrition/hydration under these circumstances. Indicate if he or she (and the Successor Agent) should be granted the power to authorize the use of machines to keep you well-nourished and hydrated or to authorize the withholding of artificial feedings and hydration by initialing the first statement on this topic.

(7) Restriction Upon South Dakota Health Care Agent’s Authority Over Nutrition. If you have determined that your directions over if (or when) artificial feedings should be administered should be restricted from your South Dakota Health Care Agent’s principal powers, then initial the second statement.

(8) Specific Directives Over Artificial Nutrition. If you have instructions regarding the use of tubes or technology to deliver nutrients and water when you cannot eat or drink and cannot communicate, then initial the third directive after you have defined when machines and medical procedures can or cannot be used to deliver nutrients and water to your body.

South Dakota Principal Instructions For Agent

(9) Imposed Limitations On The Health Care Agent’s Power. Your South Dakota Health Care Agent may be forced to make very difficult decisions on your behalf. Some of these decisions may warrant that your concerns and instructions to your South Dakota Health Care Agent be documented. You may also place definitive restrictions or conditions on the South Dakota Health Care Agent’s granted principal powers

South Dakota Principal Signature

(10) Signature Date Of South Dakota Principal.

(11) South Dakota Principal Signature. To execute this document so that it will be recognized by South Dakota Medical Personnel, you must sign your name after entering the date. Perform this action as two Witnesses watch or as a Notary Public observes.

(12) Printed Name.

(13) South Dakota Principal Address.

Notarization

(14) Notary Public Verification. A Notary Public recognized by the State of South Dakota can be obtained and used to show the authenticity of your signature. He or she will complete the notarization area on display to show that testimony on your signature is given.

Statements Of Two Witnesses

(15) Witness Address. If two qualified South Dakota Witnesses have watched you sign this document then each one must complete a unique signature area to acknowledge the statement verifying that your signature was provided in good conscience. To begin, Witness 1 must provide his or her address once he or she is intent on acknowledging this statement.

(16) First Witness Signature. The First Witness can only verify your signing as authentically made by signing his or her own name to acknowledge the Witness statement.

(17) Printed Name Of First Witness.

(18) Second Witness’s Address. A separate area has been included so that the Second Witness attending your signing may also provide confirmation of its authenticity. After he or she has determined that the Witness statement is accurate, the Second Witness must provide his or her address.

(19) Signature Of Second Witness. The testimony provided by the Second Witness must be made with his or her signature.

(20) Printed Name Of Witness. 

South Dakota Living Will Declaration

(21) South Dakota Declarant. In addition to naming a South Dakota Health Care Agent, the Principal can make certain declarations applying to a terminal condition that can only result in death within a short amount of time. Such a declaration would be placed to action when the Principal or South Dakota Declarant loses the ability to communicate when death is near. To make this declaration, you must identify the South Dakota Declarant making it. Assuming you are the concerned Patient, document your full name to the first statement.

(22) Denial Of Life-Sustaining Treatment. If you become permanently unconscious (i.e., a lifelong comatose condition) or you are suffering from a terminal condition that will cause death, then you may declare that all life-sustaining treatments be removed from treatments so that natural death will occur. This means that life-support machines such as a breathing or dialysis machine will be detached and no longer administered. To make such a declaration to attending South Dakota Medical Professionals, you must initial your authorization to the appropriate statement.

(23) Requesting Life-Support. As the South Dakota Declarant, you also have the option to approve or authorize all life-sustaining treatments regardless of how invasive, uncomfortable, painful, or effective that treatment may be. Such attempts by South Dakota Physicians can considerably extend or even maintain your life but your authorization must be provided by initialing the second statement on this subject.

(24) South Dakota Declarant Instructions. The two previous options on how you wish South Dakota Physicians to proceed after diagnosing you with a terminal condition or as in a permanent coma (unconscious) are blanket statements that leave little maneuverability for individual scenarios or treatments. If you wish to apply specific statements such as desired trial periods of life-sustaining treatments, limitations on some treatment but complete acceptance of others, medical conditions when you believe this document should be applied or only taken into consideration, and other provisions concerning the use of medical technology to extend your life then use the area in the third directive choice to present these directives for the review of South Dakota Medical Staff. If providing such instruction, you must provide your initials of approval once they have been set as the content of this area.

Living Will Artificial Nutrition Directive

(25) Refusal Of Artificial Nutrition And Hydration. Naturally, if you are close to an end-of-life event as a result of enduring a terminal medical condition or are permanently unable to regain consciousness (i.e., a coma), then your body will have an increasingly difficult time intaking nutrients and water. Depending on your condition this may be a mechanical problem (i.e., a choking hazard) or the failure of certain organs (i.e., stomach). As a rule, South Dakota Physicians will apply whatever technology or medical procedures are available to keep your nourishment and hydration levels to an acceptable level. You, as the South Dakota Declarant, have the option to authorize that all artificially made or mechanically delivered nutrition and fluids are not given when you are unable to wake up or are close to death. Generally, this will cause dehydration and malnutrition in a relatively short period of time thus, bringing the time of death closer. To make this declaration produce your initials to the appropriate nutrition directive.

(26) Directive For Artificial Nutrition And Hydration. If you prefer to avoid states of malnutrition and/or dehydration when you are in a coma or approaching the end-stage of a terminal medical condition, then you may direct South Dakota Physicians to monitor your nutrition and fluid levels so that they can maintain healthy levels even if invasive measures or machines are necessary to do so. Your initials will be required for this directive to be included

South Dakota Declarant Signature

(27) Signature Date Of South Dakota Declarant. The calendar date when this paperwork is executed (signed) should be documented at the time of signing. Review the declarations made above and any attachments provided for accuracy before supplying this date.

(28) South Dakota Declarant Signature. South Dakota Health Care Providers will require that a signature that is provable as authentic is provided to execute this document. This means that an impartial Party such as two adult Witnesses and a registered Notary Public must be present at the signing. Make sure the appropriate Party(ies) are present and observing you then sign your name where requested

(29) Printed Name.

Witness Authentication

(30) Witness 1 Signature, Printed Name, And Address. Two distinct areas have been provided for the Witnesses’ use. Witness 1 must sign as well as print his or her name and address to establish that he or she was present at the time of your signing.

(31) Witness 2 Signature, Printed Name, And Address. The second South Dakota Witness will then review the statement made. After which he or she will sign this paperwork, supply the printed version of his or her name, and dispense his or her address to complete the Witness requirements placed on this South Dakota execution.

Notary Participation

(32) Notary Public. If you have elected a registered Notary Public to oversee this declaration’s execution, then you must surrender this document to him or her. The Notary Public will provide several facts surrounding your signing (i.e., date, location, the names of every Party present, etc.). Once the notarization process is completed and proof supplied, the Notary Public will return this paperwork with his or her stamp/seal. 

 

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