“Social worker" means a person certified under s. 457.08 as a social worker, 12
advanced practice social worker, independent social worker, or clinical social worker.
“Terminal disease" means an incurable and irreversible disease that has 14
been diagnosed by an individual's attending physician and medically confirmed and 15
that will, within reasonable medical judgment, cause death within 6 months.
16156.03 Authorization to make request.
An individual who is of sound mind, 17
has attained age 18, has residence in this state, does not have incapacity, and has a 18
terminal disease may voluntarily make a request for medication for the purpose of 19
ending his or her life in a humane and dignified manner. An individual for whom an 20
adjudication of incompetence and appointment of a guardian of the person is in effect 21
under ch. 54 is presumed not to be of sound mind for purposes of this section.
22156.05 Requester rights, responsibilities, and limitations. (1)
requester may receive a prescription that fulfills a request for medication unless he 24
or she has made an informed decision. An informed decision under this chapter 25
means a decision by an individual to request and obtain a prescription for medication
so as to end his or her life in a humane and dignified manner that is based on an 2
appreciation of the relevant facts and is made after having been fully informed by 3
the attending physician of all of the following:
(a) The individual's medical diagnosis.
(b) The individual's prognosis.
(c) The potential risks associated with taking the medication to be prescribed 7
under this chapter.
(d) The probable result of taking the medication to be prescribed under this 9
(e) The feasible alternatives, including comfort care, hospice care, and pain 11
In order to receive a prescription for medication to end his or her life, a 13
requester shall do all of the following:
(a) Make an oral request for medication for the purpose of ending his or her life 15
to his or her attending physician.
(b) No fewer than 15 days after making the oral request for medication under 17
par. (a), complete a valid written request for medication under s. 156.07. The written 18
request under this paragraph may not be completed until a consulting physician 19
completes the examination and report required under s. 156.11.
(c) After completing a written request for medication under par. (b), make a 2nd 21
oral request for medication for the purpose of ending his or her life to his or her 22
No requester may be required to notify his or her next of kin regarding his 24
or her request for medication, and no request for medication may be denied because 25
the requester has failed to notify his or her next of kin.
1156.07 Valid written request for medication; requirements. (1)
written request for medication under s. 156.05 (2) (b) is valid only if it is all of the 3
(a) In writing.
(b) Dated and signed by the requester or, at the express direction and in the 6
presence of the requester, by an individual who has attained age 18.
(c) Signed in the presence of 3 witnesses who meet the requirements of sub. (2).
(d) Made voluntarily.
(e) Substantially in the form specified in s. 156.15.
(f) Filed in the requester's patient health care record in the custody of the 11
requester's attending physician and, if the requester is an inpatient of a health care 12
facility, in the requester's patient health care record in the custody of the health care 13
(a) A witness to the making of a valid written request for medication under 15
this section shall be an individual who has attained age 18. No witness to the making 16
of a valid written request for medication may, at the time of the witnessing, be any 17
of the following:
1. Related to the requester by blood, marriage, or adoption.
2. An individual who has knowledge that he or she is entitled to or has a claim 20
on any portion of the requester's estate.
3. Directly financially responsible for the requester's health care.
4. An individual who is a health care provider who is serving the requester at 23
the time of the witnessing; an employee, other than a chaplain or a social worker, of 24
the health care provider; or an employee, other than a chaplain or a social worker, 25
of a health care facility in which the requester is a patient.
(b) If a requester is a resident of a nursing home or community-based 2
residential facility, at least one of the witnesses to the request shall be a residents' 3
advocate designated under s. 156.19.
4156.09 Attending physician; responsibilities, and limitations.
attending physician shall do all of the following:
Determine whether the requester has a terminal disease, does not have 7
incapacity, and is making a request under this chapter voluntarily.
Inform the requester of all of the following:
(a) The requester's medical diagnosis.
(b) The requester's prognosis.
(c) The potential risks associated with taking the medication to be prescribed 12
under this chapter.
(d) The probable result of taking the medication to be prescribed under this 14
(e) The feasible alternatives to taking the medication to be prescribed under 16
this chapter, including comfort care, hospice care, and pain control.
Refer the requester to a consulting physician under the requirements of s. 18
Refer the requester for review and counseling if the referral is determined 20
to be appropriate under s. 156.13.
Ask the requester to notify his or her next of kin with respect to the request 22
Inform the requester that he or she may revoke the request for medication 24
at any time; explain the methods of revocation that are specified under s. 156.17 (1);
and offer the requester an opportunity to revoke the request at the time, if any, that 2
the requester orally asks for medication under s. 156.05 (2) (c).
Before writing a prescription that fulfills a request for medication, verify 4
that all of the following have occurred:
(a) The requester has fulfilled the requirements of s. 156.05 (2).
(b) No fewer than 48 hours have elapsed since the requester made a 2nd oral 7
request for medication under s. 156.05 (2) (c).
(c) The requester has made an informed decision under s. 156.05 (1).
Document or file all of the following in the requester's patient health care 10
(a) All occasions that the requester orally asks for medication under s. 156.05 12
(2) (a) or (c) as well as all written requests for medication under s. 156.05 (2) (b) that 13
are made by the requester.
(b) The attending physician's diagnosis of and prognosis for the requester and 15
determination as to whether the requester is incapacitated, is acting voluntarily, and 16
has made an informed decision under s. 156.05 (1).
(c) The consulting physician's diagnosis of and prognosis for the requester and 18
determination as to whether the requester is incapacitated, is acting voluntarily, and 19
has made an informed decision under s. 156.05 (1).
(d) A certification of the outcome and determinations made during any review 21
and counseling for which the requester was referred under s. 156.13.
(e) A certification as to whether the attending physician offered the requester 23
an opportunity to revoke the request for medication, as required under sub. (6).
(f) Evidence of a revocation, if made, as specified in s. 156.17 (2).
(g) A certification as to whether the requirements of this chapter are met and 2
indicating the steps taken to fulfill the request for medication, including a notation 3
of any medication that is prescribed. The attending physician shall report the 4
information under this paragraph to the department on a form prescribed by the 5
Information reported to the department under this paragraph that 6
could identify the requester, the attending physician, the consulting physician, or the 7
psychiatrist or psychologist to whom referral was made under s. 156.13, if any, is 8
confidential and may not be disclosed by the department except under an 9
investigation of an alleged violation of this chapter. The report of information under 10
this paragraph is not a violation of any person's responsibility for maintaining the 11
confidentiality of patient health care records under s. 146.82.
If the attending physician refuses to fulfill the requester's request for 13
medication that meets the requirements of this chapter, the attending physician 14
shall make a good faith attempt to transfer the requester's care and treatment to 15
another physician who will act as the attending physician under this chapter and will 16
fulfill the requester's request for medication. If a transfer is made, the attending 17
physician to whom the requester's care and treatment is transferred shall comply 18
with the requirements of this section.
19156.11 Consulting physician confirmation.
Before an attending physician 20
may fulfill a request for medication under this chapter, a consulting physician shall 21
examine the requester and his or her relevant patient health care records and shall 22
medically confirm the attending physician's determinations that the requester 23
suffers from a terminal disease, does not have incapacity, is making a request for 24
medication voluntarily, and has made an informed decision. The consulting 25
physician shall complete a written report regarding his or her findings and provide
it to the attending physician for filing in the requester's patient health care record 2
in compliance with the certification requirement of s. 156.09 (8) (g).
3156.13 Referral for review and counseling.
If in the opinion of the 4
attending physician or the consulting physician a requester may be suffering from 5
a psychiatric or psychological disorder, including depression, that causes impaired 6
judgment, the attending physician or consulting physician shall refer the requester 7
for review and counseling to a physician specializing in psychiatry or a licensed 8
psychologist, as defined in s. 455.01 (4). If a referral is made by the attending or 9
consulting physician, no request for medication may be fulfilled under this chapter 10
unless the physician specializing in psychiatry, or the psychologist, to whom referral 11
was made, determines and certifies in writing that the requester is not suffering from 12
a psychiatric or psychological disorder, including depression, that causes impaired 13
judgment. The attending physician shall file the certification in the requester's 14
patient health care record under s. 156.09 (8) (d).
15156.15 Written request for medication; form.
The department shall 16
prepare and provide copies of a request for medication authorization form and 17
accompanying information for distribution in quantities to health care providers, 18
hospitals, nursing homes, multipurpose senior centers, county clerks, and local bar 19
associations and individually to private persons. The department shall include, in 20
information accompanying the copy of the request for medication authorization 21
form, at least the statutory definitions of terms used in the request for medication 22
authorization form, statutory restrictions on who may be witnesses to a valid request 23
for medication under s. 156.07, and a statement explaining that valid witnesses 24
acting in good faith are statutorily immune from civil or criminal liability. The
request for medication authorization form distributed by the department shall be in 2
the following form:
REQUEST FOR MEDICATION4
AUTHORIZATION TO END MY LIFE IN A5
HUMANE AND DIGNIFIED MANNER
I, .... (insert name), am an adult of sound mind, do not have incapacity, and am 7
a resident of Wisconsin.
I am suffering from .... (insert description of terminal disease), which my 9
attending physician has determined is a terminal disease and which has been 10
medically confirmed by a consulting physician.
I have been fully informed of my diagnosis, prognosis, the nature of medication 12
to be prescribed and potential associated risks, the expected result, and the feasible 13
alternatives, including comfort care, hospice care, and pain control.
I request that my attending physician prescribe medication that will end my life 15
in a humane and dignified manner.
INITIAL ONE OF THE FOLLOWING 3 STATEMENTS:
.... I have informed my family members of my decision and taken their opinions 18
.... I have decided not to inform my family of my decision.
.... I have no family to inform of my decision.
I understand that I have the right to revoke this request at any time.
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.