I understand the full import of this request and I expect to die when I take the 23
medication to be prescribed.
I make this request voluntarily and without reservation, and I accept full moral 25
responsibility for my actions.
3Statement and signatures
I know the requester personally or I have received proof of his or her identity 6
and I believe him or her to be of sound mind and at least 18 years of age. I believe 7
that the requester makes this request voluntarily. I am at least 18 years of age, am 8
not related to the requester by blood, marriage, or adoption, and am not directly 9
financially responsible for the requester's health care. I am not a health care 10
provider who is serving the requester at this time; an employee of the health care 11
provider, other than a chaplain or a social worker; or an employee, other than a 12
chaplain or a social worker, of a health care facility in which the requester is a 13
patient. To the best of my knowledge, I am not entitled to and do not have a claim 14
on the requester's estate.
Witness No. 1:
(print) Name: ....
Witness No. 2:
(print) Name: ....
Witness No. 3:
(print) Name: ....
If the requester is a resident of a nursing home or community-based residential 3
facility, at least one of the above witnesses must be a residents' advocate designated 4
by the board on aging and long-term care. A residents' advocate who is a witness 5
should print “residents' advocate" after the printing of his or her name above.
6156.17 Revocation of request for medication. (1)
A requester may revoke 7
his or her request for medication at any time by doing any of the following:
(a) Canceling, defacing, obliterating, burning, tearing, or otherwise destroying 9
the written request for medication or directing another in the presence of the 10
requester to destroy, in the same manner, the request for medication.
(b) Executing a statement, in writing, that is signed and dated by the requester, 12
expressing the requester's intent to revoke the request for medication.
(c) Orally expressing the requester's intent to revoke the request for 14
medication, in the presence of 2 witnesses or the attending physician.
A health care provider shall, upon notification of revocation of the 16
requester's request for medication, record in the requester's medical record the time, 17
date, and place of the revocation and the time, date, and place, if different, of the 18
notification to the health care provider of the revocation.
19156.19 Designation of residents' advocates.
The board on aging and 20
long-term care shall designate staff of the long-term care ombudsman program as 21
residents' advocates. A person so designated shall serve as a witness to a request for 22
medication of a requester who is a resident of a nursing home or community-based 23
residential facility, as required under s. 156.07 (2) (b), and shall speak on behalf of 24
the requester to ensure that his or her needs or wants are communicated to and 25
addressed by his or her attending physician.
1156.21 Duties and immunities. (1)
No health care facility or health care 2
provider may be charged with a crime, held civilly liable, or charged with 3
unprofessional conduct for any of the following:
(a) Failing to fulfill a request for medication, except that failure of an attending 5
physician to fulfill a request for medication constitutes unprofessional conduct if the 6
attending physician refuses or fails to make a good faith attempt to transfer the 7
requester's care and treatment to another physician who will act as attending 8
physician under this chapter and fulfill the request for medication.
(b) In the absence of actual knowledge of a revocation, fulfilling a request for 10
medication that is in compliance with this chapter.
(c) Acting contrary to or failing to act on a revocation of a request for medication, 12
unless the health care facility or health care provider has actual knowledge of the 13
In the absence of actual notice to the contrary, a health care facility or a 15
health care provider, other than a physician acting as the requester's attending 16
physician under this chapter, may presume that a requester was authorized to make 17
his or her request for medication under the requirements of this chapter and that the 18
request for medication is valid.
(a) No person who acts in good faith as a witness to a request for medication 20
under this chapter may be held civilly or criminally liable for a death that results 21
from taking medication under a fulfilled request for medication under this chapter.
(b) Paragraph (a) does not apply to a person who acts as a witness in violation 23
of s. 156.07 (2) (a).
24156.23 General provisions.
(a) The making of a request for medication 25
under this chapter does not, for any purpose, constitute attempted suicide. Taking
medication under a fulfilled request for medication under this chapter does not, for 2
any purpose, constitute suicide.
(b) Paragraph (a) does not prohibit an insurer from making a determination 4
that a requester has attempted suicide or committed suicide if the requester has so 5
acted, apart from a request for medication.
The making of a request for medication under this chapter does not revoke 7
or otherwise modify a power of attorney for health care or declaration to physicians 8
that the requester may have executed.
No individual may be required to make a request for medication as a 10
condition for receipt of health care or admission to a health care facility. The making 11
of a request for medication is not a bar to the receipt of health care or the admission 12
to a health care facility.
A written request for medication that has not been revoked and that is in 14
its original form or is a legible photocopy or electronic facsimile copy is presumed to 15
Nothing in this chapter may be construed to condone, authorize, approve, 17
or permit any affirmative or deliberate act to end life other than through taking 18
medication that is prescribed under a request for medication as provided in this 19
20156.25 Record review.
The department shall annually examine a sampling 21
of patient health care records of requesters for whom medication was prescribed in 22
fulfillment of a request for medication and about whom the department has received 23
information under s. 156.09 (8) (g).
24156.27 Penalties. (1)
Any person who willfully conceals, cancels, defaces, 25
obliterates, or damages the request for medication of another without the requester's
consent may be fined not more than $500 or imprisoned for not more than 30 days, 2
Any person who, with the intent to cause a requester to take medication that 4
is prescribed under a request for medication contrary to the wishes of the requester, 5
illegally falsifies or forges the request for medication of another or conceals a 6
revocation under s. 156.17 shall be fined not more than $10,000 or imprisoned for not 7
more than 10 years, or both.
Any responsible person who, with the intent to cause a requester to take 9
medication that is prescribed under a request for medication contrary to the wishes 10
of the requester, conceals personal knowledge of a revocation under s. 156.17 shall 11
be fined not more than $10,000 or, except for a health care facility, imprisoned for not 12
more than 10 years, or both.
979.01 (1) (intro.) of the statutes is amended to read:
Except as provided in sub. (1j), all
physicians, authorities 15
of hospitals, sanatoriums, public and private institutions, convalescent homes, 16
authorities of any institution of a like nature, and other persons having knowledge 17
of the death of any person who has died under any of the following circumstances, 18
shall immediately report the death to the sheriff, police chief, or and
examiner or coroner of the county and to the police chief of any community
where the 20
death took place:
979.01 (1g) of the statutes is amended to read:
A sheriff or police chief shall, immediately upon notification under 23
sub. (1) or s. 948.23 (1) (b) of a death, notify the coroner or the medical examiner, and
24the coroner or medical examiner of the county where death took place
, if the crime,
injury, or event occurred in another county, shall immediately
report the death to the 2
coroner or medical examiner of that county.
979.01 (1j) of the statutes is created to read:
Subsection (1) does not apply to a death that results from taking 5
medication under a fulfilled request for medication that meets the requirements of 6
979.01 (1r) of the statutes is repealed.