AB216,4,1
1(9) “Patient health care records" has the meaning given in s. 146.81 (4).
AB216,4,4 2(10) “Request for medication" means a request for medication under the
3requirements of this chapter for the purpose of ending the requester's life in a
4humane and dignified manner.
AB216,4,5 5(11) “Requester" means an individual who makes a request for medication.
AB216,4,6 6(12) “Residence" has the meaning given in s. 46.27 (1) (d).
AB216,4,10 7(13) “Responsible person" means the attending physician, a health care
8provider serving the requester, an inpatient health care facility in which the
9requester is located, or the requester's spouse, child, parent, brother, sister,
10grandparent, or grandchild.
AB216,4,12 11(14) “Social worker" means a person certified under s. 457.08 as a social worker,
12advanced practice social worker, independent social worker, or clinical social worker.
AB216,4,15 13(15) “Terminal disease" means an incurable and irreversible disease that has
14been diagnosed by an individual's attending physician and medically confirmed and
15that will, within reasonable medical judgment, cause death within 6 months.
AB216,4,21 16156.03 Authorization to make request. An individual who is of sound mind,
17has attained age 18, has residence in this state, does not have incapacity, and has a
18terminal disease may voluntarily make a request for medication for the purpose of
19ending his or her life in a humane and dignified manner. An individual for whom an
20adjudication of incompetence and appointment of a guardian of the person is in effect
21under ch. 54 is presumed not to be of sound mind for purposes of this section.
AB216,5,3 22156.05 Requester rights, responsibilities, and limitations. (1) No
23requester may receive a prescription that fulfills a request for medication unless he
24or she has made an informed decision. An informed decision under this chapter
25means a decision by an individual to request and obtain a prescription for medication

1so as to end his or her life in a humane and dignified manner that is based on an
2appreciation of the relevant facts and is made after having been fully informed by
3the attending physician of all of the following:
AB216,5,44 (a) The individual's medical diagnosis.
AB216,5,55 (b) The individual's prognosis.
AB216,5,76 (c) The potential risks associated with taking the medication to be prescribed
7under this chapter.
AB216,5,98 (d) The probable result of taking the medication to be prescribed under this
9chapter.
AB216,5,1110 (e) The feasible alternatives, including comfort care, hospice care, and pain
11control.
AB216,5,13 12(2) In order to receive a prescription for medication to end his or her life, a
13requester shall do all of the following:
AB216,5,1514 (a) Make an oral request for medication for the purpose of ending his or her life
15to his or her attending physician.
AB216,5,1916 (b) No fewer than 15 days after making the oral request for medication under
17par. (a), complete a valid written request for medication under s. 156.07. The written
18request under this paragraph may not be completed until a consulting physician
19completes the examination and report required under s. 156.11.
AB216,5,2220 (c) After completing a written request for medication under par. (b), make a 2nd
21oral request for medication for the purpose of ending his or her life to his or her
22attending physician.
AB216,5,25 23(3) No requester may be required to notify his or her next of kin regarding his
24or her request for medication, and no request for medication may be denied because
25the requester has failed to notify his or her next of kin.
AB216,6,3
1156.07 Valid written request for medication; requirements. (1) A
2written request for medication under s. 156.05 (2) (b) is valid only if it is all of the
3following:
AB216,6,44 (a) In writing.
AB216,6,65 (b) Dated and signed by the requester or, at the express direction and in the
6presence of the requester, by an individual who has attained age 18.
AB216,6,77 (c) Signed in the presence of 3 witnesses who meet the requirements of sub. (2).
AB216,6,88 (d) Made voluntarily.
AB216,6,99 (e) Substantially in the form specified in s. 156.15.
AB216,6,1310 (f) Filed in the requester's patient health care record in the custody of the
11requester's attending physician and, if the requester is an inpatient of a health care
12facility, in the requester's patient health care record in the custody of the health care
13facility.
AB216,6,17 14(2) (a) A witness to the making of a valid written request for medication under
15this section shall be an individual who has attained age 18. No witness to the making
16of a valid written request for medication may, at the time of the witnessing, be any
17of the following:
AB216,6,1818 1. Related to the requester by blood, marriage, or adoption.
AB216,6,2019 2. An individual who has knowledge that he or she is entitled to or has a claim
20on any portion of the requester's estate.
AB216,6,2121 3. Directly financially responsible for the requester's health care.
AB216,6,2522 4. An individual who is a health care provider who is serving the requester at
23the time of the witnessing; an employee, other than a chaplain or a social worker, of
24the health care provider; or an employee, other than a chaplain or a social worker,
25of a health care facility in which the requester is a patient.
AB216,7,3
1(b) If a requester is a resident of a nursing home or community-based
2residential facility, at least one of the witnesses to the request shall be a residents'
3advocate designated under s. 156.19.
AB216,7,5 4156.09 Attending physician; responsibilities, and limitations. The
5attending physician shall do all of the following:
AB216,7,7 6(1) Determine whether the requester has a terminal disease, does not have
7incapacity, and is making a request under this chapter voluntarily.
AB216,7,8 8(2) Inform the requester of all of the following:
AB216,7,99 (a) The requester's medical diagnosis.
AB216,7,1010 (b) The requester's prognosis.
AB216,7,1211 (c) The potential risks associated with taking the medication to be prescribed
12under this chapter.
AB216,7,1413 (d) The probable result of taking the medication to be prescribed under this
14chapter.
AB216,7,1615 (e) The feasible alternatives to taking the medication to be prescribed under
16this chapter, including comfort care, hospice care, and pain control.
AB216,7,18 17(3) Refer the requester to a consulting physician under the requirements of s.
18156.11.
AB216,7,20 19(4) Refer the requester for review and counseling if the referral is determined
20to be appropriate under s. 156.13.
AB216,7,22 21(5) Ask the requester to notify his or her next of kin with respect to the request
22for medication.
AB216,8,2 23(6) Inform the requester that he or she may revoke the request for medication
24at any time; explain the methods of revocation that are specified under s. 156.17 (1);

1and offer the requester an opportunity to revoke the request at the time, if any, that
2the requester orally asks for medication under s. 156.05 (2) (c).
AB216,8,4 3(7) Before writing a prescription that fulfills a request for medication, verify
4that all of the following have occurred:
AB216,8,55 (a) The requester has fulfilled the requirements of s. 156.05 (2).
AB216,8,76 (b) No fewer than 48 hours have elapsed since the requester made a 2nd oral
7request for medication under s. 156.05 (2) (c).
AB216,8,88 (c) The requester has made an informed decision under s. 156.05 (1).
AB216,8,10 9(8) Document or file all of the following in the requester's patient health care
10record:
AB216,8,1311 (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
13are made by the requester.
AB216,8,1614 (b) The attending physician's diagnosis of and prognosis for the requester and
15determination as to whether the requester is incapacitated, is acting voluntarily, and
16has made an informed decision under s. 156.05 (1).
AB216,8,1917 (c) The consulting physician's diagnosis of and prognosis for the requester and
18determination as to whether the requester is incapacitated, is acting voluntarily, and
19has made an informed decision under s. 156.05 (1).
AB216,8,2120 (d) A certification of the outcome and determinations made during any review
21and counseling for which the requester was referred under s. 156.13.
AB216,8,2322 (e) A certification as to whether the attending physician offered the requester
23an opportunity to revoke the request for medication, as required under sub. (6).
AB216,8,2424 (f) Evidence of a revocation, if made, as specified in s. 156.17 (2).
AB216,9,11
1(g) A certification as to whether the requirements of this chapter are met and
2indicating the steps taken to fulfill the request for medication, including a notation
3of any medication that is prescribed. The attending physician shall report the
4information under this paragraph to the department on a form prescribed by the
5department.   Information reported to the department under this paragraph that
6could identify the requester, the attending physician, the consulting physician, or the
7psychiatrist or psychologist to whom referral was made under s. 156.13, if any, is
8confidential and may not be disclosed by the department except under an
9investigation of an alleged violation of this chapter. The report of information under
10this paragraph is not a violation of any person's responsibility for maintaining the
11confidentiality of patient health care records under s. 146.82.
AB216,9,18 12(9) If the attending physician refuses to fulfill the requester's request for
13medication that meets the requirements of this chapter, the attending physician
14shall make a good faith attempt to transfer the requester's care and treatment to
15another physician who will act as the attending physician under this chapter and will
16fulfill the requester's request for medication. If a transfer is made, the attending
17physician to whom the requester's care and treatment is transferred shall comply
18with the requirements of this section.
AB216,9,25 19156.11 Consulting physician confirmation. Before an attending physician
20may fulfill a request for medication under this chapter, a consulting physician shall
21examine the requester and his or her relevant patient health care records and shall
22medically confirm the attending physician's determinations that the requester
23suffers from a terminal disease, does not have incapacity, is making a request for
24medication voluntarily, and has made an informed decision. The consulting
25physician shall complete a written report regarding his or her findings and provide

1it to the attending physician for filing in the requester's patient health care record
2in compliance with the certification requirement of s. 156.09 (8) (g).
AB216,10,14 3156.13 Referral for review and counseling. If in the opinion of the
4attending physician or the consulting physician a requester may be suffering from
5a psychiatric or psychological disorder, including depression, that causes impaired
6judgment, the attending physician or consulting physician shall refer the requester
7for review and counseling to a physician specializing in psychiatry or a licensed
8psychologist, as defined in s. 455.01 (4). If a referral is made by the attending or
9consulting physician, no request for medication may be fulfilled under this chapter
10unless the physician specializing in psychiatry, or the psychologist, to whom referral
11was made, determines and certifies in writing that the requester is not suffering from
12a psychiatric or psychological disorder, including depression, that causes impaired
13judgment. The attending physician shall file the certification in the requester's
14patient health care record under s. 156.09 (8) (d).
AB216,11,2 15156.15 Written request for medication; form. The department shall
16prepare and provide copies of a request for medication authorization form and
17accompanying information for distribution in quantities to health care providers,
18hospitals, nursing homes, multipurpose senior centers, county clerks, and local bar
19associations and individually to private persons. The department shall include, in
20information accompanying the copy of the request for medication authorization
21form, at least the statutory definitions of terms used in the request for medication
22authorization form, statutory restrictions on who may be witnesses to a valid request
23for medication under s. 156.07, and a statement explaining that valid witnesses
24acting in good faith are statutorily immune from civil or criminal liability. The

1request for medication authorization form distributed by the department shall be in
2the following form:
AB216,11,53 REQUEST FOR MEDICATION
4 AUTHORIZATION TO END MY LIFE IN A
5 HUMANE AND DIGNIFIED MANNER
AB216,11,76 I, .... (insert name), am an adult of sound mind, do not have incapacity, and am
7a resident of Wisconsin.
AB216,11,108 I am suffering from .... (insert description of terminal disease), which my
9attending physician has determined is a terminal disease and which has been
10medically confirmed by a consulting physician.
AB216,11,1311 I have been fully informed of my diagnosis, prognosis, the nature of medication
12to be prescribed and potential associated risks, the expected result, and the feasible
13alternatives, including comfort care, hospice care, and pain control.
AB216,11,1514 I request that my attending physician prescribe medication that will end my life
15in a humane and dignified manner.
AB216,11,1616 INITIAL ONE OF THE FOLLOWING 3 STATEMENTS:
AB216,11,1817 .... I have informed my family members of my decision and taken their opinions
18into consideration.
AB216,11,1919 .... I have decided not to inform my family of my decision.
AB216,11,2020 .... I have no family to inform of my decision.
AB216,11,2121 I understand that I have the right to revoke this request at any time.
AB216,11,2322 I understand the full import of this request and I expect to die when I take the
23medication to be prescribed.
AB216,11,2524 I make this request voluntarily and without reservation, and I accept full moral
25responsibility for my actions.
AB216,12,1
1Signed: ....
AB216,12,22 Dated: ....
AB216,12,3 3Statement and signatures
AB216,12,4 4of witnesses
AB216,12,145 I know the requester personally or I have received proof of his or her identity
6and I believe him or her to be of sound mind and at least 18 years of age. I believe
7that the requester makes this request voluntarily. I am at least 18 years of age, am
8not related to the requester by blood, marriage, or adoption, and am not directly
9financially responsible for the requester's health care. I am not a health care
10provider who is serving the requester at this time; an employee of the health care
11provider, other than a chaplain or a social worker; or an employee, other than a
12chaplain or a social worker, of a health care facility in which the requester is a
13patient. To the best of my knowledge, I am not entitled to and do not have a claim
14on the requester's estate.
AB216,12,1515 Witness No. 1:
AB216,12,1616 (print) Name: ....
AB216,12,1717 Address: ....
AB216,12,1818 Signature: ....
AB216,12,1919 Witness No. 2:
AB216,12,2020 (print) Name: ....
AB216,12,2121 Address: ....
AB216,12,2222 Signature: ....
AB216,12,2323 Witness No. 3:
AB216,12,2424 (print) Name: ....
AB216,12,2525 Address: ....
AB216,13,1
1Signature: ....
Loading...
Loading...