South Dakota Living Will Template
This South Dakota Living Will Template is designed to be in compliance with the South Dakota Living Will statute, enabling you to specify your wishes regarding medical treatment in the event you are unable to communicate your medical care preferences. Please provide your details where indicated.
PERSONAL INFORMATION
Full Name: ___________________________________
Date of Birth: _______________________________
Address: _____________________________________
City: __________________ State: SD Zip Code: ___________
Phone Number: ________________________________
APPOINTMENT OF HEALTH CARE AGENT
I, _______________ [insert your name], appoint the following person as my Health Care Agent to make health care decisions for me if I become unable to make my own health care decisions.
Agent's Full Name: ________________________________
Agent's Relationship to Me: _________________________
Agent's Address: ___________________________________
Agent's City: ______________ State: SD Zip Code: ________
Agent's Phone Number: ______________________________
DIRECTIONS FOR HEALTH CARE
If I am in a condition that is both terminal and irreversible or in a persistent vegetative state, I direct that:
- Life-sustaining treatment designed to prolong my life be withheld or withdrawn, except as needed to provide comfort care.
- Even if my death is not imminent, I do no wish to receive nutrition and hydration provided artificially, such as through a feeding tube or intravenously, unless necessary as comfort care.
OPTIONAL: ORGAN AND TISSUE DONATION
I wish to donate only the following organs/tissues: __________________________________________________
OR
I wish to donate any needed organs or tissues.
SIGNATURE
I understand the nature and effect of this document and I am mentally competent to make this Living Will. I sign my name to this Living Will on this date:
Date: ___________ Signature: _______________________________
WITNESS DECLARATION
I declare that the person who signed or acknowledged this document is personally known to me and appears to be of sound mind and under no duress, fraud, or undue influence. I am not the person appointed as agent by this document. I am not related to the principal by blood, marriage, or adoption, and, to the best of my knowledge, I am not entitled to any part of the estate of the principal under a will now existing or by operation of law.
Date: ___________ Witness Signature: _______________________________
Witness Printed Name: _______________________________
Witness Address: ____________________________________
City: ______________ State: SD Zip Code: _____________
This document was created according to the guidelines of the South Dakota Living Will statute. It is recommended that you review this form with a legal advisor. Keep the original document in a safe but accessible place and provide a copy to your appointed health care agent, if applicable.