34-12D-3. Declaration--Sample form.
A declaration may, but need not, be in the following form:
LIVING WILL DECLARATION
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 living will 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 living will remains valid and in effect until and unless you revoke it. Review this living will periodically to make sure it continues to reflect your wishes. You may amend or revoke this living will at any time by notifying your physician and other health care providers. You should give copies of this living will 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.
TO MY FAMILY, HEALTH CARE PROVIDER, AND ALL THOSE CONCERNED WITH MY CARE:
I, __________ direct you to follow my wishes for care if I am in a terminal condition, my death is imminent, and I am unable to communicate my decisions about my medical care.
With respect to any life-sustaining treatment, I direct the following:
(Initial only one of the following options. If you do not agree with either of the following options, space is provided below for you to write your own instructions.)
_ If my death is imminent or I am permanently unconscious, I choose not to prolong my life. If life sustaining treatment has been started, stop it, but keep me comfortable and control my pain.
_ Even if my death is imminent or I am permanently unconscious, I choose to prolong my life.
_ I choose neither of the above options, and here are my instructions should I become terminally ill and my death is imminent or I am permanently unconscious:
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
Artificial Nutrition and Hydration: food and water provided by means of a tube inserted into the stomach or intestine or needle into a vein.
With respect to artificial nutrition and hydration, I direct the following:
(Initial only one)
_ If my death is imminent or I am permanently unconscious, I do not want artificial nutrition and hydration. If it has been started, stop it.
_ Even if my death is imminent or I am permanently unconscious, I want artificial nutrition and hydration.
Date: _________________________________________________________
(your signature)
___________________________________________________________________
(your address)(type or print your signature)
The declarant voluntarily signed this document in my presence.
Witness ____________________
Address ____________________
Witness ____________________
Address ____________________
On this the ______ day of ________, ______, the declarant, _______________, and witnesses _______________, and _______________ personally appeared before the undersigned officer and signed the foregoing instrument in my presence. Dated this ______ day of ________, ______.
______________________________________ Notary Public
My commission expires: ____________________________.
Source: SL 1991, ch 273, §3; SL 2007, ch 193, §2.
Structure South Dakota Codified Laws
Title 34 - Public Health and Safety
Section 34-12D-1 - Definition of terms.
Section 34-12D-2 - Declaration--Requirements as to execution.
Section 34-12D-3 - Declaration--Sample form.
Section 34-12D-4 - Multiple documents--Resolving conflicts--Participation by attorney in fact.
Section 34-12D-5 - When declaration becomes operative.
Section 34-12D-6 - Decisions regarding life-sustaining treatment--Rights of qualified patient.
Section 34-12D-7 - Entry of declaration into medical record.
Section 34-12D-8 - Revocation of declaration--Medical record to contain revocation.
Section 34-12D-10 - Treatment of pregnant woman notwithstanding declaration.
Section 34-12D-13 - Immunity from civil or criminal liability, and from professional discipline.
Section 34-12D-14 - Withdrawal or withholding of treatment neither suicide or homicide.
Section 34-12D-15 - Withdrawal or withholding of treatment--Effect upon life insurance or annuity.
Section 34-12D-16 - Insurer or health-care provider may not prohibit or require declaration.
Section 34-12D-18 - Patients able to make decisions regarding medical care--Effect upon rights.
Section 34-12D-19 - Health care provider not required to deviate from accepted medical standards.
Section 34-12D-20 - Mercy-killing, euthanasia, suicide, and assisted suicide not condoned.
Section 34-12D-21 - Assumption as to valid declaration permissible.
Section 34-12D-25 - Cause of action for compensatory and punitive damages for assisting suicide.
Section 34-12D-26 - Attorney's fees to plaintiff in assisted suicide action.
Section 34-12D-27 - Licensing board notified of assisted suicide violation.
Section 34-12D-28 - Revocation of license for assisted suicide violation.
Section 34-12D-29 - Licensed health care professional defined.