South Dakota Do Not Resuscitate Form

Information you will need

• What's the patient's last name?
• What's the patient's first name?
• What's the patient's middle initial?
• What's the patient's date of birth?
• What are the patient’s CPR orders?
• Does the patient have an advance health care directive?
• What's the patient's diagnosis?
• What's the goals of care?
• What are the patient’s treatment orders?
• What are the patient’s additional orders?
• Based on the health care provider’s medical judgement, will artificially administered nutrition and hydration be unable to prolong life?
• Based on the health care provider’s medical judgement, will artificially administered nutrition and hydration be more burdensome than beneficial?
• Based on the health care provider’s medical judgement, will artificially administered nutrition and hydration cause significant physical discomfort?
• What's the name of the medical provider who spoke to the patient?
• Is the patient's authorized representative the basis for these orders?
• Is the patient's declaration the basis for these orders?
• What's the name of the patient or their representative?
• What's the representative's relationship to the patient? (if applicable)
• What's the representative's address? (if applicable)
• What's the representative's phone number? (if applicable)
• What's the medical provider's name?
• What's the medical provider's phone number?
• What month was the patient born?
• What day was the patient born?

…and 15 more fields in the PDF.

Completed by the provider.

The form includes a witness section.