South Dakota Comfort One (DNR) vs. Living Wills: Key Differences Explained

When an ambulance crew in Sioux Falls or Rapid City responds to a 911 call for cardiac arrest, paramedics do not have time to read a multi-page estate planning binder or wait for two attending physicians to certify that a patient is in an irreversible coma. If the family hands the emergency medical technicians a standard Living Will, the crew is still legally obligated to initiate chest compressions, defibrillation, and endotracheal intubation. In South Dakota, preventing unwanted emergency resuscitation outside of a hospital setting requires a completely separate statutory medical order governed by state public health rules.

Understanding the legal and clinical distinctions in South Dakota Comfort One (DNR) vs. Living Wills: key differences explained empowers patients and families across Sioux Falls, Rapid City, Aberdeen, and Pierre to build a seamless end-of-life care plan. Unlike states that merge all advance directives into a single statute, South Dakota divides end-of-life planning across four separate statutory chapters: Comfort One EMS Directives (S.D. Codified Laws § 34-12F-1), Living Will Declarations (S.D. Codified Laws § 34-12D-2), Durable Powers of Attorney for Health Care (S.D. Codified Laws § 59-7-2.1), and Medical Orders for Scope of Treatment (MOST) (S.D. Codified Laws § 34-12H-1).

Comfort One (DNR) vs. Living Wills: Core Legal Differences

The fundamental difference between a Comfort One directive and a Living Will is who signs the document, when it takes effect, and which medical personnel must follow it. A Living Will is a legal declaration signed by a competent adult (with two adult witnesses or a notary public) instructing hospital physicians on whether to withhold or withdraw life-sustaining treatment and artificial nutrition/hydration only after the patient is diagnosed with a terminal condition or permanent unconsciousness under S.D. Codified Laws § 34-12D-5.

By contrast, Comfort One is South Dakota's official statewide pre-hospital EMS Cardiopulmonary Resuscitation (CPR) Directive governed by S.D. Codified Laws § 34-12F-2 and S.D. Admin. R. 44:05:06. It is an actionable medical order that must be co-signed by the patient (or their authorized health care agent/surrogate) and a licensed physician, physician assistant (PA), or certified nurse practitioner (CNP). It is effective the moment it is signed and specifically directs emergency medical services (EMS) personnel not to perform CPR if your heart or breathing stops.

Micro-Niches: EMT Rules, Terminal Illness, and Nursing Homes

To prevent gaps in care between your home, an ambulance, and an intensive care unit at Sanford USD Medical Center or Avera McKennan in Sioux Falls or Monument Health in Rapid City, your documents must address four clinical realities:

EMT & Paramedic Requirements and the Comfort One Bracelet

Under S.D. Codified Laws § 34-12F-4 and S.D. Admin. R. 44:05:06, South Dakota EMTs, paramedics, and first responders are legally required to comply with a Comfort One directive-and are granted full civil and criminal immunity under S.D. Codified Laws § 34-12F-4-only when the original directive or official state-approved identification is apparent and immediately available at the scene. When Comfort One is verified, EMS personnel withhold chest compressions, defibrillation (electric shock), endotracheal intubation, mechanical ventilation, and cardiotonic drugs, while still providing oxygen, airway suctioning, hemorrhage control, pain medication, and emotional support. For patients who leave home, the South Dakota Department of Health, Office of Rural Health and EMS, Pierre issues an official gold-plated brass Comfort One bracelet engraved with a unique registry number that paramedics recognize immediately without needing paper forms.

Terminal Illness Protocols & Artificial Nutrition Elections

Under South Dakota's Living Will statute (S.D. Codified Laws § 34-12D-1), a 'terminal condition' includes both an incurable, irreversible condition where death is imminent without life-sustaining treatment and a state of permanent coma or unconsciousness. Crucially, S.D. Codified Laws § 34-12D-2 requires a South Dakota Living Will to separately state the declarant's preference regarding artificial nutrition and hydration (feeding tubes and IV fluids) apart from general life-sustaining machines. Regardless of what you elect, S.D. Codified Laws § 34-12D-9 mandates that health care providers always administer medication to alleviate pain and maintain comfort, hygiene, and human dignity. Note also that under S.D. Codified Laws § 34-12D-10, life-sustaining treatment and nutrition cannot be withheld from a pregnant patient if it is probable the fetus will develop to live birth, unless such treatment would be physically harmful to the woman or prolong severe pain that cannot be alleviated by medication.

Nursing Home & Assisted Living Admissions (S.D. Codified Laws § 34-12F-6 & MOST)

When a patient with a Comfort One directive is admitted to a South Dakota nursing home, hospice, or hospital, S.D. Codified Laws § 34-12F-6 authorizes the facility to implement the Comfort One directive directly as a physician's order upon admission. Additionally, for nursing home residents or terminally ill patients who want to specify broader medical orders beyond just CPR-such as whether to be transferred to the hospital, receive IV antibiotics, or use non-invasive BiPAP breathing support-South Dakota enacted S.D. Codified Laws § 34-12H-2, creating the portable Medical Order for Scope of Treatment (MOST).

Combining Comfort One with a Medical POA for Complete Protection

Neither a Comfort One DNR nor a Living Will names a person to speak for you during non-terminal surgeries, dementia care, or nursing home placement. To avoid a contested court guardianship in the Second Judicial Circuit Court, Minnehaha County, Sioux Falls, the Seventh Judicial Circuit Court, Pennington County, Rapid City, or the Sixth Judicial Circuit Court, Hughes County, Pierre-where, as the Supreme Court of South Dakota explained in In re Guardianship and Conservatorship of Blare, 589 N.W.2d 211 (SD Supreme Court 1999), a court-appointed guardian is an agent of the court rather than a self-chosen attorney-in-fact-you must also execute a separate Durable Power of Attorney for Health Care under S.D. Codified Laws § 59-7-2.1 and S.D. Codified Laws § 34-12C-1. As reflected in Klein v. Sanford USD Medical Center, 872 N.W.2d 802 (SD Supreme Court 2015), South Dakota's health care consent statutes under S.D. Codified Laws § 34-12C-1 et seq. rely heavily on clear capacity determinations and documented agent authority. Under S.D. Codified Laws § 34-12D-4, if you have both a Living Will and a Health Care Power of Attorney, your Living Will guides your agent unless you expressly grant your agent authority to override it.

Step-by-Step Process in South Dakota

Follow these four steps to put a legally valid, coordinated end-of-life plan in place in South Dakota:

Step 1: Execute a South Dakota Living Will and Durable Medical POA

Work with a South Dakota estate planning attorney to draft Form SDCL 34-12D-3, South Dakota, Department of Health, Living Will Declaration (making sure to initial your separate election for artificial nutrition and hydration under S.D. Codified Laws § 34-12D-2) and Form SDCL 59-7-2.1, South Dakota, Legislature, Durable Power of Attorney for Health Care. Sign both documents in the presence of either two adult witnesses or a notary public.

Step 2: Complete the Comfort One or MOST Form with Your Medical Provider

Comfort One forms are not downloadable by the general public because they require clinical informed consent. Request Form Comfort One EMS Cardiopulmonary Resuscitation Directive, South Dakota, Department of Health, Official EMS DNR Order and Bracelet Application (or, if diagnosed with a terminal condition, Form MOST, South Dakota, Department of Health, Medical Order for Scope of Treatment Pursuant to SDCL Chapter 34-12H) during an appointment with your physician, PA, or nurse practitioner.

Step 3: Register with the SD Department of Health & Order Your Bracelet

Mail the completed Comfort One application-along with a check or money order for $45.50 if ordering the optional Comfort One bracelet-to the South Dakota Department of Health, Office of Rural Health and EMS, Pierre at 600 East Capitol Avenue, Pierre, SD 57501 (phone: 605-773-3361) so your directive and bracelet number are entered into the statewide Comfort One database.

Step 4: Display the Directive at Home and Upload to Hospital Portals

Place your original Comfort One or MOST form on your refrigerator or bedroom wall where 911 paramedics can see it immediately, wear your Comfort One bracelet when away from home, and upload your Living Will and Medical POA to your Sanford MyChart, AveraChart, or Monument Health electronic medical record under S.D. Codified Laws § 34-12D-7.

How Much Does it Cost in South Dakota?

Putting Comfort One, a Living Will, and a Medical Power of Attorney in place in South Dakota involves minimal state fees and predictable legal costs:

• Comfort One Form & State Registry Fee: There is $0 state fee to obtain and register the paper Comfort One directive through your physician and the South Dakota Department of Health.
• Official Comfort One Bracelet Fee: Ordering the optional hypoallergenic gold-plated brass Comfort One bracelet from the Office of Rural Health / EMS costs a flat $45.50 (payable by check or money order to Office of Rural Health - EMS).
• Medical Office Visit Co-Pay: Completing a Comfort One or MOST form with your doctor, PA, or nurse practitioner is typically covered under Medicare Part B Advance Care Planning billing codes (CPT 99497) or a standard office co-pay of $0 to $50.
• South Dakota Estate Planning Attorney Fees: Hiring a South Dakota elder law or estate planning lawyer to draft a customized Living Will Declaration and Durable Power of Attorney for Health Care typically costs $150 to $450 as standalone documents, or is bundled into a comprehensive estate plan ranging from $800 to $2,500.

To ensure your Living Will, HIPAA release, and Durable Power of Attorney for Health Care comply with every requirement of Title 34 and Title 59, connect with an experienced South Dakota estate planning attorney in our directory.

How Long Does the Process Take?

An estate planning attorney can prepare and finalize your South Dakota Living Will and Durable Power of Attorney for Health Care within 2 to 5 business days, and both become legally valid the moment they are signed and witnessed or notarized. A Comfort One paper directive or MOST form becomes clinically active immediately upon signature by you and your physician, PA, or nurse practitioner. If you mail an application and $45.50 payment to Pierre for the engraved Comfort One bracelet, processing and mail delivery from the South Dakota Department of Health typically take 2 to 3 weeks.

Frequently Asked Questions (FAQ)