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21Witness signature .... Date signed ....
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23This document is executed as provided in chapter 154, Wisconsin Statutes.
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24DIRECTIVES TO ATTENDING
25PHYSICIAN
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11. This document authorizes the withholding or withdrawal of life-sustaining
2procedures or of feeding tubes when 2 physicians, one of whom is the attending
3physician, have personally examined and certified in writing that the patient has a
4terminal condition or is in a persistent vegetative state.
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52. The choices in this document were made by a competent adult. Under the
6law, the patient's stated desires must be followed unless you believe that withholding
7or withdrawing life-sustaining procedures or feeding tubes would cause the patient
8pain or reduced comfort and that the pain or discomfort cannot be alleviated through
9pain relief measures. If the patient's stated desires are that life-sustaining
10procedures or feeding tubes be used, this directive must be followed.
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113. If you feel that you cannot comply with this document, you must make a good
12faith attempt to transfer the patient to another physician who will comply. Refusal
13or failure to make a good faith attempt to do so constitutes unprofessional conduct.
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144. If you know that the patient is pregnant, this document has no effect during
15her pregnancy.
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17The person making this living will may use the following space to record the
18names of those individuals and health care providers to whom he or she has given
19copies of this document:
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20.................................................................
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21.................................................................
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22.................................................................
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154.05
(1) (d) By executing a subsequent declaration.
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154.11
(7) (d) Nothing in this chapter, except par. (b), may be construed to
3render invalid a declaration that was validly executed under this chapter before the
4effective date of this paragraph .... [revisor inserts date].
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154.11
(8) Inclusion in medical record. Upon receipt of a declaration, a health
7care facility, as defined in s. 155.01 (6), or a health care provider, as defined in s.
8155.01 (7), shall, if the declarant is a patient of the health care facility or health care
9provider, include the declaration in the medical record of the declarant.
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10(9) Declaration from other jurisdiction. A valid document that authorizes
11the withholding or withdrawal of life-sustaining procedures or of feeding tubes and
12that is executed in another state or jurisdiction in compliance with the law of that
13state or jurisdiction is valid and enforceable in this state to the extent that the
14document is consistent with the laws of this state.
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154.15
(1) Any person who
wilfully
intentionally conceals, cancels, defaces,
17obliterates or damages the declaration of another without the declarant's consent
18may be fined not more than $500 or imprisoned not more than 30 days or both.
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154.15
(2) Any person who, with the intent to cause a withholding or
21withdrawal of life-sustaining procedures or feeding tubes contrary to the wishes of
22the declarant, illegally falsifies or forges the declaration of another or conceals a
23declaration revoked under s. 154.05 (1) (a) or (b) or any
responsible person who
24intentionally withholds
personal
actual knowledge of a revocation under s. 154.05
25shall be fined not more than $10,000 or imprisoned not more than 10 years or both.
AB399-engrossed,9,32[
1991 Wisconsin Act 84] Section 19 (title)
Initial applicability and
3applicability.
AB399-engrossed,9,107[
1991 Wisconsin Act 84] Section 19 (2) Notwithstanding subsection (1) and
8section 154.11 (7) (c) of the statutes, the treatment of section 154.11 (5m) of the
9statutes applies to any declarations executed under chapter 154 of the statutes,
10regardless of the date of execution.
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12(1)
Printing and distribution of certain forms. By the date that is 45 days
13after the effective date of this subsection, the department of health and social
14services shall prepare and provide copies for distribution of the form declaration and
15accompanying information under section 154.03 (2) of the statutes, as affected by
16this act.