[Health Care Directive] South Dakota

Using these Materials

BEFORE YOU BEGIN

1. Check to be sure that you have the materials for each state in which you may receive health care.

2. These materials include:
   • Instructions for preparing your advance directive, please read all the instructions.
   • Your state-specific advance directive forms, which are the pages with the gray instruction bar on the left side.

ACTION STEPS

1. You may want to photocopy or print a second set of these forms before you start so you will have a clean copy if you need to start over.

2. When you begin to fill out the forms, refer to the gray instruction bars — they will guide you through the process.

3. Talk with your family, friends, and physicians about your advance Be sure the person you appoint to make decisions on your behalf understands your wishes.

4. Once the form is completed and signed, photocopy the form and give it to the person you have appointed to make decisions on your behalf, your family, friends, health care providers, and/or faith leaders so that the form is available in the event of an emergency.

5. South Dakota does not maintain an Advance Directive However you may record a durable power of attorney for health care (Part I of this form) at your county’s register of deeds. Be aware that, if you do record your advance directive, you will also need to record any revocation you make.

6. You may also want to save a copy of your form in an online personal health records application, program, or service that allows you to share your medical documents with your physicians, family, and others who you want to take an active role in your advance care planning.

INTRODUCTION TO YOUR SOUTH DAKOTA ADVANCE DIRECTIVE

This packet contains a legal document, a South Dakota Advance Directive, that protects your right to refuse medical treatment you do not want, or to request treatment you do want, in the event you lose the ability to make decisions yourself. You may complete Part I, Part II, or both, depending on your advance-planning needs. You must complete Part III.

Part I contains a South Dakota Durable Power of Attorney for Health Care. This part lets you name someone, your “agent,” to make decisions about your medical care—including decisions about life-sustaining procedures—if you can no longer speak for yourself. The durable power of attorney for health care is especially useful because it appoints someone to speak for you any time you are unable to make your own medical decisions, not only at the end of life.

 Your durable power of attorney for health care goes into effect when your doctor determines in good faith that you are no longer able to make or communicate your health care decisions.

Part II contains a South Dakota Declaration, which is your state’s living will. Your declaration lets you state your wishes about health care in the event that you can no longer make your own health care decisions and you are terminally ill.

Your living will go into effect when your doctor determines that you are no longer able to participate in your medical decisions, you are terminally ill—which includes permanent unconsciousness—and your death is imminent.

Part III contains the signature and witnessing provisions so that your document will be effective.

Following the advance directive is a South Dakota Organ Donation Form.

This document does not expressly address mental illness. If you would like to make advance care plans regarding mental illness, you should talk to your physician and an attorney about an advance directive tailored to your needs.

Note: This document will be legally binding only if the person completing it is an individual of sound mind who is 18 years or older.

COMPLETING YOUR SOUTH DAKOTA ADVANCE DIRECTIVE

How do I make my South Dakota Advance Directive legal?

If you complete part II, the directive, you must sign or have someone sign for you at your direction your document in the presence of two adult witnesses. Although not required, you may also have your document notarized.

While there are no legal requirements for witnessing your signature if you only complete Part I, your durable power of attorney for health care, you should have it witnessed in the manner required for Part II to be sure that your wishes are honored in the event someone challenges your document.

Whom should I appoint as my agent?

Your agent—also called an “attorney-in-fact”—is the person you appoint to make decisions about your health care if you become unable to make those decisions yourself. Your agent may be a family member or a close friend whom you trust to make serious decisions. The person you name as your agent should clearly understand your wishes and be willing to accept the responsibility of making health care decisions for you.

You can appoint a second person as your alternate agent. The alternate will step in if the first person you name as an agent is unable, unwilling, or unavailable to act for you.

Should I add personal instructions to my South Dakota Durable Power of Attorney for Health Care?

One of the strongest reasons for naming an agent is to have someone who can respond flexibly as your health care situation changes and deal with situations that you did not foresee. If you add instructions to this document it may help your agent carry out your wishes, but be careful that you do not unintentionally restrict your agent’s power to act in your best interest. In any event, be sure to talk with your agent about your future medical care and describe what you consider to be an acceptable “quality of life.”

What if I change my mind?

You can revoke Part I, your durable power of attorney for health care, at any time and in any manner that expresses your intent, such as executing a written revocation, destroying all copies of your document, or stating your revocation orally. It is important that you notify your agent of your revocation, as he or she will not be held liable for acting as your agent if he or she is unaware of your revocation. If you recorded your durable power of attorney for health care with the register of deeds, you must also record any revocation with the register of deeds.

You can revoke Part II, your declaration, at any time and in any manner that expresses your intent, such as executing a written revocation, destroying all copies of your document, or stating your revocation orally. Your revocation becomes effective on communication to your health care provider.

What other important facts should I know?

Your agent cannot withhold or withdraw comfort care.

Artificial nutrition and hydration will not be withheld or withdrawn unless you specifically state that you want it withheld or withdrawn in your advance directive or you expressly authorize your agent to direct the withholding of artificial nutrition or hydration.

Life-sustaining treatment and artificial nutrition and hydration will not be withheld from you if you are pregnant, unless it is reasonably medically certain that such treatment will not permit the development and live birth of the unborn child, or will be physically harmful to you, or will prolong severe pain which cannot be alleviated by medication.

SOUTH DAKOTA ADVANCE DIRECTIVE – PAGE 1 OF 5

PART I. DURABLE POWER OF ATTORNEY FOR HEALTH CARE

3) I have discussed my wishes with my agent and my successor agent, and authorize him/her to make all and any health care decisions for me, including decisions to withhold or withdraw any form of life I expressly authorize my agent (and successor agent) to make decisions for me regarding the withholding or withdrawal of artificial nutrition and hydration in all medical circumstances.

4) This power of attorney becomes effective when I can no longer make my own medical decisions, and is not affected by physical disability or mental incompetence. The determination of whether I can make my own medical decisions is to be made by my agent, or if he or she is unable, unwilling or unavailable to act, by my successor agent, unless the attending physician determines that I have decisional capacity.

SOUTH DAKOTA ADVANCE DIRECTIVE – PAGE 2 OF 5

5) When making health care decisions for me, my agent should think about what action would be consistent with past conversations we have had, my treatment preferences as expressed in this document, my religious and other beliefs and values, and how I have handled medical and other important issues in the If what I would decide is still unclear, then my agent should make decisions for me that my agent believes are in my best interest, considering the benefits, burdens, and risks of my current circumstances and treatment options.

I give the following instructions to help guide my agent:

SOUTH DAKOTA ADVANCE DIRECTIVE – PAGE 3 OF 5

PART II. DECLARATION

Notice

This is an important legal document. A living will directs the medical treatment you are to receive in the event you are in a terminal condition and are unable to participate in your own medical decisions. This living will may state what kind of treatment you want or do not want to receive.

Prepare this document carefully. If you use this form, read it completely. You may want to seek professional help to make sure the form does what you intend and is completed without mistakes.

This document will remain valid and in effect until and unless you revoke it. Review this document periodically to make sure it continues to reflect your wishes. You may amend or revoke this document at any time by notifying your physician and other health care providers. You should give copies of this document to your family, your physician and your health care facility.

This form is entirely optional. If you choose to use this form, please note that the form provides signature lines for you, the two witnesses whom you have selected and a notary public.

SOUTH DAKOTA ADVANCE DIRECTIVE – PAGE 4 OF 5

TO MY FAMILY, HEALTH CARE PROVIDER, AND ALL THOSE CONCERNED WITH MY CARE:

With respect to artificial nutrition and hydration, I direct the following:

(Artificial nutrition and hydration means food and water provided by means of a tube inserted into the stomach or intestine or needle into a vein.)

(initial only one):

SOUTH DAKOTA ADVANCE DIRECTIVE – PAGE 5 OF 5

PART III. EXECUTION

WITNESSES

The declarant voluntarily signed this document in my presence.

NOTARY (OPTIONAL)

SOUTH DAKOTA ORGAN DONATION FORM – PAGE 1 OF 1

Initial the line next to the statement below that best reflects your wishes. You do not have to initial any of the statements. If you do not initial any of the statements, your attorney for health care, proxy, or other agent, or your family, may have the authority to make a gift of all or part of your body under South Dakota law.

You Have Filled Out Your Health Care Directive, Now What?

1. Your South Dakota Advance Directive is an important legal Keep the original signed document in a secure but accessible place. Do not put the original document in a safe deposit box or any other security box that would keep others from having access to it.

2. Give photocopies of the signed original to your agent and alternate agent, doctor(s), family, close friends, clergy, and anyone else who might become involved in your health If you enter a nursing home or hospital, have photocopies of your document placed in your medical records.

3. Be sure to talk to your agent(s), doctor(s), clergy, family, and friends about your wishes concerning medical treatment. Discuss your wishes with them often, particularly if your medical condition changes.

4. South Dakota does not maintain an Advance Directive However you may record a durable power of attorney for health care (Part I of this form) at your county’s register of deeds. Be aware that, if you do record your advance directive, you will also need to record any revocation you make as well.

5. You may also want to save a copy of your form in an online personal health records application, program, or service that allows you to share your medical documents with your physicians, family, and others who you want to take an active role in your advance care planning.

6. If you want to make changes to your documents after they have been signed and witnessed, you must complete a new document.

7. Remember, you can always revoke your South Dakota document.

8. Be aware that your South Dakota document will not be effective in the event of a medical emergency. Ambulance and hospital emergency department personnel are required to provide cardiopulmonary resuscitation (CPR) unless they are given a separate directive that states These directives called “prehospital medical care directives” or “do not resuscitate orders” are designed for people whose poor health gives them little chance of benefiting from CPR. These directives instruct ambulance and hospital emergency personnel not to attempt CPR if your heart or breathing should stop.

Currently not all states have laws authorizing these orders. We suggest you speak to your physician if you are interested in obtaining one.