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South Dakota Durable Power of Attorney for Health Care Form


South Dakota Durable Power of Attorney for Health Care Form
Durable Power of Attorney for Health Care – Sample Form
A health care power of attorney pursuant to SDCL 59-7-2.5 et seq. may, but need not be, in the
following form:
DURABLE POWER OF ATTORNEY FOR HEALTH CARE
I, ____________________________, being an adult of sound mind, hereby appoint
(name of principal)
__________________________, of _________________________________________
(name of agent) (his/her address and telephone number)
as my attorney-in-fact (“agent”) to consent to, to reject, or to withdraw consent for medical
procedures, treatment, or intervention. In the event the person I appoint above is unable,
unwilling or unavailable to act as my health care agent, I appoint as my successor agent:
__________________________, of ________________________________________
(name of successor agent) (his/her address and telephone number)
My agent (or any successor agent) may make any health care decisions for me which I could
make individually if I had decisional capacity (except for any limitations given below). All such
decisions shall be made in accordance with accepted medical standards and the agent (or any
successor agent) may not authorize the withholding or withdrawal of comfort care from me.
My agent (or any successor agent) may authorize the withholding of life-sustaining treatment as
set forth in my living will or advance directive (except for any limitations given therein) if I have
executed one.
In the event I am unable to communicate verbally or nonverbally, demonstrate no purposeful
movement or motor ability, and am unable to interact purposefully with environmental
stimulation and (1) I have an incurable and irreversible condition such that, in accordance with
accepted medical standards, death is imminent if life-sustaining treatment is not administered, or
(2) I am in a coma or I have a condition of permanent unconsciousness that, in accordance with
accepted medical standards, will last indefinitely without significant improvement: (Initial only
one of the following three options and if you do not agree with either of the first two options,
space is provided below for you to write your own instructions.)
______ I authorize my agent (or any successor agent) to direct the withholding of artificial
nutrition or hydration from me.
______ I do not authorize my agent (or any successor agent) to direct the withholding of
artificial nutrition or hydration from me.
______ I authorize the following: __________________________________________________
South Dakota Durable Power of Attorney for Health Care Form
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