SB169,4,99 (a) The individual's medical diagnosis.
SB169,4,1010 (b) The individual's prognosis.
SB169,4,1111 (c) The potential risks associated with taking the medication to be prescribed.
SB169,4,1212 (d) The probable result of taking the medication to be prescribed.
SB169,4,1413 (e) The feasible alternatives to the decision, including comfort care, hospice
14care, and pain control.
SB169,4,15 15(10) "Multipurpose senior center" has the meaning given in s. 155.01 (9).
SB169,4,16 16(11) "Patient health care records" has the meaning given in s. 146.81 (4).
SB169,4,17 17(12) "Physician" has the meaning given in s. 448.01 (5).
SB169,4,1818 (13) "Prescription" has the meaning given in s. 450.01 (19).
SB169,4,21 19(14) "Requester" means an individual who requests medication under the
20requirements of this chapter for the purpose of ending his or her life in a humane and
21dignified manner.
SB169,4,23 22(15) "Request for medication" means a document made under the requirements
23of s. 156.05.
SB169,4,24 24(16) "Residence" has the meaning given in s. 46.27 (1) (d).
SB169,5,4
1(17) "Responsible person" means the attending physician, a health care
2professional working with the requester, an inpatient health care facility in which
3the requester is located, or the requester's spouse, child, parent, brother, sister,
4grandparent, or grandchild.
SB169,5,7 5(18) "Social worker" means a person certified as a social worker, advanced
6practice social worker, independent social worker, or independent clinical social
7worker under s. 457.08.
SB169,5,11 8(19) "Terminal disease" means an incurable and irreversible disease that has
9been diagnosed by an individual's attending physician, has been medically
10confirmed, and will, within reasonable medical judgment, cause death within 6
11months.
SB169,5,17 12156.03 Authorization to make request. An individual who is of sound mind,
13has attained age 18, has residence in this state, does not have incapacity, and has a
14terminal disease may voluntarily make a request for medication for the purpose of
15ending his or her life in a humane and dignified manner. An individual for whom an
16adjudication of incompetence and appointment of a guardian of the person is in effect
17under ch. 880 is presumed not to be of sound mind for purposes of this section.
SB169,5,19 18156.05 Valid request for medication; requirements. (1) A valid request
19for medication shall be, for the purposes of s. 156.03, all of the following:
SB169,5,2020 (a) In writing.
SB169,5,2221 (b) Dated and signed by the requester or, at the express direction and in the
22presence of the requester, by an individual who has attained age 18.
SB169,5,2323 (c) Signed in the presence of 3 witnesses who meet the requirements of sub. (2).
SB169,5,2424 (d) Made voluntarily.
SB169,5,2525 (e) Substantially in the form specified in s. 156.15.
SB169,6,4
1(f) Filed in the requester's patient health care record in the custody of the
2requester's attending physician and, if the requester is an inpatient of a health care
3facility, in the requester's patient health care record in the custody of the health care
4facility.
SB169,6,7 5(2) (a) A witness to the making of a valid request for medication shall be an
6individual who has attained age 18. No witness to the making of a valid request for
7medication may, at the time of the witnessing, be any of the following:
SB169,6,88 1. Related to the requester by blood, marriage, or adoption.
SB169,6,109 2. An individual who has knowledge that he or she is entitled to or has a claim
10on any portion of the requester's estate.
SB169,6,1111 3. Directly financially responsible for the requester's health care.
SB169,6,1512 4. An individual who is a health care provider who is serving the requester at
13the time of the witnessing; an employee, other than a chaplain or a social worker, of
14the health care provider; or an employee, other than a chaplain or a social worker,
15of a health care facility in which the requester is a patient.
SB169,6,1816 (b) If a requester is a resident of a nursing home or community-based
17residential facility, at least one of the witnesses to the request shall be a patients'
18advocate designated under s. 156.19.
SB169,6,20 19156.07 Attending physician; responsibilities and limitations. The
20attending physician shall do all of the following:
SB169,6,22 21(1) Determine whether or not the requester has a terminal disease, has
22incapacity, and is making a request under s. 156.03 voluntarily.
SB169,6,25 23(2) If the requester has a terminal disease, does not have incapacity, and is
24making a request under s. 156.03 voluntarily, inform the requester of all of the
25following:
SB169,7,1
1(a) The requester's medical diagnosis.
SB169,7,22 (b) The requester's prognosis.
SB169,7,33 (c) The potential risks associated with taking the medication to be prescribed.
SB169,7,44 (d) The probable result of taking the medication to be prescribed.
SB169,7,65 (e) The feasible alternatives to taking the medication to be prescribed,
6including comfort care, hospice care, and pain control.
SB169,7,8 7(3) Refer the requester to a consulting physician to meet the requirements of
8s. 156.09.
SB169,7,10 9(4) Refer the requester for review and counseling if the referral is determined
10to be appropriate under s. 156.11.
SB169,7,11 11(5) Ask the requester to notify his or her next of kin with respect to the request.
SB169,7,15 12(6) Inform the requester that he or she may revoke the request at any time;
13explain the methods of revocation that are specified under s. 156.17 (1); and offer the
14requester an opportunity to revoke the request at the time, if any, that the requester
15makes a 2nd oral request under s. 156.13 (3) (c).
SB169,7,17 16(7) Before writing a prescription in response to a request for medication, verify
17that all of the following have occurred:
SB169,7,1818 (a) The requester has fulfilled the requirements of s. 156.13 (3).
SB169,7,2019 (b) No fewer than 48 hours have elapsed since the requester made a written
20request for medication.
SB169,7,2121 (c) The requester has made an informed decision.
SB169,7,23 22(8) Document or file all of the following in the requester's patient health care
23record:
SB169,7,2424 (a) All oral and written requests for medication that are made by the requester.
SB169,8,3
1(b) The attending physician's diagnosis of and prognosis for the requester and
2determination as to whether the requester is incapacitated, is acting voluntarily, and
3has made an informed decision.
SB169,8,64 (c) The consulting physician's diagnosis of and prognosis for the requester and
5determination as to whether the requester is incapacitated, is acting voluntarily, and
6has made an informed decision.
SB169,8,87 (d) A certification of the outcome and determinations made during any review
8and counseling for which the requester was referred under s. 156.11.
SB169,8,109 (e) The attending physician's offer of an opportunity to revoke the request for
10medication, as required under sub. (6).
SB169,8,1111 (f) Evidence of a revocation, if made, as specified in s. 156.17 (2).
SB169,8,2212 (g) A certification as to whether the requirements of this chapter are met and
13indicating the steps taken to fulfill the request for medication, including a notation
14of any medication that is prescribed. The attending physician shall report the
15information under this paragraph to the department on a form prescribed by the
16department. Any information reported to the department under this paragraph that
17could identify the requester, the attending physician, the consulting physician, or the
18psychiatrist or psychologist to whom referral was made under s. 156.11, if any, is
19confidential and may not be disclosed by the department except under an
20investigation of an alleged violation of this chapter. The report of information under
21this paragraph is not a violation of any person's responsibility for maintaining the
22confidentiality of patient health care records under s. 146.82.
SB169,9,4 23(9) If the attending physician refuses to act as the attending physician in
24complying with the requester's request for medication under this chapter, the
25attending physician shall make a good faith attempt to transfer the requester's care

1and treatment to another physician who will act as the attending physician under
2this chapter and will comply with the requester's request for medication. If a
3transfer is made, the attending physician to whom the requester's care and
4treatment is transferred shall comply with the requirements of this section.
SB169,9,10 5156.09 Consulting physician. Before an attending physician may fulfill a
6request for medication under this chapter, a consulting physician shall examine the
7requester and his or her relevant patient health care records and shall medically
8confirm the attending physician's determinations that the requester suffers from a
9terminal disease, does not have incapacity, is making a request for medication
10voluntarily, and has made an informed decision.
SB169,9,21 11156.11 Referral for review and counseling. If in the opinion of the
12attending physician or the consulting physician a requester may be suffering from
13a psychiatric or psychological disorder, including depression, that causes impaired
14judgment, the attending physician or consulting physician shall refer the requester
15for review and counseling to a physician specializing in psychiatry or a licensed
16psychologist, as defined in s. 455.01 (4). No request for medication may be fulfilled
17under this chapter unless the physician specializing in psychiatry or the
18psychologist, to one of whom referral was made, determines and certifies in writing
19that the requester is not suffering from a psychiatric or psychological disorder,
20including depression, that causes impaired judgment. The certification, if any, shall
21be filed in the requester's patient health care record under s. 156.07 (8).
SB169,9,24 22156.13 Requester rights, responsibilities, and limitations. (1) No
23requester may receive a prescription for medication that fulfills a request for
24medication under this chapter unless he or she has made an informed decision.
SB169,10,3
1(2) No requester may be required to notify his or her next of kin regarding his
2or her request for medication, and no request for medication may be denied because
3the requester has failed to notify his or her next of kin.
SB169,10,5 4(3) To receive a prescription under a request for medication, a requester shall
5do all of the following:
SB169,10,76 (a) Orally request his or her attending physician for medication for the purpose
7of ending his or her life.
SB169,10,98 (b) No fewer than 15 days after making the oral request under par. (a), make
9a request for medication that meets the requirements of s. 156.05.
SB169,10,1210 (c) After making a request for medication under par. (b), make a 2nd oral
11request of his or her attending physician for medication for the purpose of ending his
12or her life.
SB169,10,22 13156.15 Request for medication; form. The department shall prepare and
14provide copies of a request for medication and accompanying information for
15distribution in quantities to health care providers, hospitals, nursing homes,
16multipurpose senior centers, county clerks, local bar associations, and, individually,
17private persons. The department shall include, in information accompanying the
18copy of the request for medication, at least the statutory definitions of terms used in
19the request for medication, statutory restrictions on who may be witnesses to a valid
20request for medication, and a statement explaining that valid witnesses acting in
21good faith are statutorily immune from civil or criminal liability. The request for
22medication distributed by the department shall be in the following form:
SB169,10,2323 REQUEST FOR MEDICATION
SB169,10,2424 TO END MY LIFE IN A HUMANE
SB169,10,2525 AND DIGNIFIED MANNER
SB169,11,1
1I, ...., am an adult of sound mind and am a resident of Wisconsin.
SB169,11,42 I am suffering from ...., which my attending physician has determined is a
3terminal disease and the terminality of which has been medically confirmed by a
4consulting physician.
SB169,11,75 I have been fully informed of my diagnosis, prognosis, the nature of medication
6to be prescribed, and potential associated risks, the expected result, and the feasible
7alternatives, including comfort care, hospice care, and pain control.
SB169,11,98 I request that my attending physician prescribe medication that will end my life
9in a humane and dignified manner.
SB169,11,1010 INITIAL ONE OF THE FOLLOWING 3 STATEMENTS:
SB169,11,1211 .... I have informed my family members of my decision and have taken their
12opinions into consideration.
SB169,11,1313 .... I have decided not to inform my family of my decision.
SB169,11,1414 .... I have no family to inform of my decision.
SB169,11,1515 I understand that I have the right to revoke this request at any time.
SB169,11,1716 I understand the full import of this request, and I expect to die when I take the
17medication to be prescribed.
SB169,11,1918 I make this request voluntarily and without reservation, and I accept full moral
19responsibility for my actions.
SB169,11,2020 Signed: ....
SB169,11,2121 Dated: ....
SB169,11,22 22Statement and signatures
SB169,11,23 23of witnesses
SB169,12,824 I know the requester personally or I have received proof of his or her identity
25and I believe him or her to be of sound mind and at least 18 years of age. I believe

1that the requester makes this request voluntarily. I am at least 18 years of age, am
2not related to the requester by blood, marriage, or adoption, and am not directly
3financially responsible for the requester's health care. I am not a health care
4provider who is an individual and is serving the requester at this time, an employee
5of a health care provider who is serving the requester at this time, other than a
6chaplain or a social worker, or an employee, other than a chaplain or a social worker,
7of a health care facility in which the requester is a patient. To the best of my
8knowledge, I am not entitled to and do not have a claim on the requester's estate.
SB169,12,99 Witness No. 1:
SB169,12,1010 (print) Name: ....
SB169,12,1111 Address: ....
SB169,12,1212 Signature: ....
SB169,12,1313 Witness No. 2:
SB169,12,1414 (print) Name: ....
SB169,12,1515 Address: ....
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