4. By law, this document cannot be used to authorize: a) withholding or withdrawal of any medication, procedure or feeding tube if to do so would cause me pain or reduce my comfort; and b) withholding or withdrawal of nutrition or hydration that is administered to me through means other than a feeding tube unless, in my physician's opinion, this administration is medically contraindicated.
5. If I have been diagnosed as pregnant and my physician knows of this diagnosis, this document has no effect during the course of my pregnancy.
Signed ....
Date ....
Address ....
If you are interested in more information about the significant terms used in this document, see section 154.01 of the Wisconsin Statutes or the information accompanying this document.
ATTENTION: You and the 2 witnesses must sign the document at the same time.
Signed .... Date ....
Address .... Date of birth ....
I know believe that the person signing this document personally and I believe him or her to be is of sound mind. I am an adult and am not related to the person signing this document by blood, marriage or adoption, and. I am not entitled to and do not have a claim on any portion of the persons's estate and am not otherwise restricted by law from being a witness.
Witness ....
Witness ....
Witness signature .... Date signed ....
Print name ....
Witness signature .... Date signed ....
Print name ....
This document is executed as provided in chapter 154, Wisconsin Statutes.
DIRECTIVES TO ATTENDING
PHYSICIAN
1. This document authorizes the withholding or withdrawal of life-sustaining procedures or of feeding tubes when 2 physicians, one of whom is the attending physician, have personally examined and certified in writing that the patient has a terminal condition or is in a persistent vegetative state.
2. The choices in this document were made by a competent adult. Under the law, the patient's stated desires must be followed unless you believe that withholding or withdrawing life-sustaining procedures or feeding tubes would cause the patient pain or reduced comfort and that the pain or discomfort cannot be alleviated through pain relief measures. If the patient's stated desires are that life-sustaining procedures or feeding tubes be used, this directive must be followed.
3. If you feel that you cannot comply with this document, you must make a good faith attempt to transfer the patient to another physician who will comply. Refusal or failure to make a good faith attempt to do so constitutes unprofessional conduct.
4. If you know that the patient is pregnant, this document has no effect during her pregnancy.
* * * * *
The person making this living will may use the following space to record the names of those individuals and health care providers to whom he or she has given copies of this document:
.................................................................
.................................................................
.................................................................
168,5
Section 5
. 154.05 (1) (d) of the statutes is created to read:
154.05 (1) (d) By executing a subsequent declaration.
168,7
Section 7
. 154.11 (7) (d) of the statutes is created to read:
154.11 (7) (d) Nothing in this chapter, except par. (b), may be construed to render invalid a declaration that was validly executed under this chapter before the effective date of this paragraph .... [revisor inserts date].
168,8
Section 8
. 154.11 (8) and (9) of the statutes are created to read:
154.11 (8) Inclusion in medical record. Upon receipt of a declaration, a health care facility, as defined in s. 155.01 (6), or a health care provider, as defined in s. 155.01 (7), shall, if the declarant is a patient of the health care facility or health care provider, include the declaration in the medical record of the declarant.
(9) Declaration from other jurisdiction. A valid document that authorizes the withholding or withdrawal of life-sustaining procedures or of feeding tubes and that is executed in another state or jurisdiction in compliance with the law of that state or jurisdiction is valid and enforceable in this state to the extent that the document is consistent with the laws of this state.
168,9
Section 9
. 154.15 (1) of the statutes is amended to read:
154.15 (1) Any person who wilfully intentionally conceals, cancels, defaces, obliterates or damages the declaration of another without the declarant's consent may be fined not more than $500 or imprisoned not more than 30 days or both.
168,10
Section 10
. 154.15 (2) of the statutes is amended to read:
154.15 (2) Any person who, with the intent to cause a withholding or withdrawal of life-sustaining procedures or feeding tubes contrary to the wishes of the declarant, illegally falsifies or forges the declaration of another or conceals a declaration revoked under s. 154.05 (1) (a) or (b) or any responsible person who intentionally withholds personal actual knowledge of a revocation under s. 154.05 shall be fined not more than $10,000 or imprisoned not more than 10 years or both.
168,11
Section 11
. 1991 Wisconsin Act 84, section 19 (title) is amended to read:
[1991 Wisconsin Act 84] Section 19 (title) Initial applicability and applicability.
168,12
Section 12
. 1991 Wisconsin Act 84, section 19 is renumbered 1991 Wisconsin Act 84, section 19 (1).
168,13
Section 13
. 1991 Wisconsin Act 84, section 19 (2) is created to read:
[1991 Wisconsin Act 84] Section 19 (2) Notwithstanding subsection (1) and section 154.11 (7) (c) of the statutes, the treatment of section 154.11 (5m) of the statutes applies to any declarations executed under chapter 154 of the statutes, regardless of the date of execution.
168,14
Section 14
.
Nonstatutory provisions; health and social services.
(1) Printing and distribution of certain forms. By the date that is 45 days after the effective date of this subsection, the department of health and social services shall prepare and provide copies for distribution of the form declaration and accompanying information under section 154.03 (2) of the statutes, as affected by this act.
