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South Dakota Health Care Power of Attorney Form

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South Dakota Health Care Power of Attorney Form Page 2
South Dakota Health Care Power of Attorney Form
G. To make anatomical gifts of part or all of my body for medical purposes, authorize an autopsy, and direct the disposition of my
remains, to the extent permitted by law;
H. To take any other action needed to do what I authorize here, including (but not limited to) granting any waiver or release from
liability required by any hospital, doctor, or other health care provider; signing any documents relating to refusals of treatment or
the leaving of a facility against medical advice, and pursuing any legal action in my name, and at the expense of my estate to
force compliance with my wishes as determined by my Agent, or to week actual or punitive damages for the failure to comply.
3. Statement of Desires, Special Instructions, and Limitations
A. The powers granted above do not include the following powers or are subject to the following rules or
limitations.
B. With respect to any Life-Sustaining Treatment, I direct the following: (initial
only one of the following paragraphs)
_____ Reference To Living Will. I specifically direct my Agent to follow any health care declaration or
“living will” executed by me.
_____ Grant of Discretion To Agent. I do not want my life to prolonged nor do I want life-sustaining treatment if my Agent
believes the burdens of the treatment outweigh the expected benefits. I want my Agent to consider the relief of suffering, the
expense involved and the quality as well as the possible extension of my life in making decisions concerning life-sustaining
treatment.
_____ Directive To Withhold or Withdraw Treatment. I do not want my life to be prolonged and I do
not want life-sustaining treatment:
a. If I have a condition that is incurable or irreversible and, without the administration of life-sustaining
treatment, expected to result in imminent death;
OR
b. If I am in a coma or persistent vegetative state which is reasonably concluded to be irreversible.
_____ Directive For Maximum Treatment. I want my life to be prolonged to the greatest extent
possible without regard to my condition, the changes I have for recovery, or the cost
the procedures.
_____ Directive In My Own Words.
South Dakota Health Care Power of Attorney Form