AND DIGNIFIED MANNER
I, ...., am an adult of sound mind and am a resident of Wisconsin.
I am suffering from ...., which my attending physician has determined is a 20
terminal disease and which has been medically confirmed by a consulting physician.
I have been fully informed of my diagnosis, prognosis, the nature of medication 22
to be prescribed and potential associated risks, the expected result, and the feasible 23
alternatives, including comfort care, hospice care and pain control.
I request that my attending physician prescribe medication that will end my life 25
in a humane and dignified manner.
INITIAL ONE OF THE FOLLOWING 3 STATEMENTS:
.... I have informed my family of my decision and taken their opinions into 3
.... 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 8
medication to be prescribed.
I make this request voluntarily and without reservation, and I accept full moral 10
responsibility for my actions.
13Statement and signatures
I know the requester personally or I have received proof of his or her identity 16
and I believe him or her to be of sound mind and at least 18 years of age. I believe 17
that the requester makes this request voluntarily. I am at least 18 years of age, am 18
not related to the requester by blood, marriage or adoption and am not directly 19
financially responsible for the requester's health care. I am not a health care 20
provider who is serving the requester at this time, an employe of the health care 21
provider, other than a chaplain or a social worker, or an employe, other than a 22
chaplain or a social worker, of a health care facility in which the requester is a 23
patient. To the best of my knowledge, I am not entitled to and do not have a claim 24
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 patient in a health care facility, at least one of the above 13
witnesses must be a patients' advocate designated by the board on aging and 14
long-term care. A patients' advocate who is a witness should print "patients' 15
advocate" after the printing of his or her name above.
16156.17 Revocation of request for medication. (1)
A requester may revoke 17
his or her request for medication at any time by doing any of the following:
(a) Canceling, defacing, obliterating, burning, tearing or otherwise destroying 19
the request for medication or directing another in the presence of the requester to so 20
destroy the request for medication.
(b) Executing a statement, in writing, that is signed and dated by the requester, 22
expressing the requester's intent to revoke the request for medication.
(c) Orally expressing the requester's intent to revoke the request for 24
medication, in the presence of 2 witnesses.
(d) Making a subsequent request for medication.
The requester's health care provider shall, upon notification of revocation 2
of the requester's request for medication, record in the requester's medical record the 3
time, date and place of the revocation and the time, date and place, if different, of the 4
notification to the health care provider of the revocation.
5156.19 Designation or patients' advocates.
The board on aging and 6
long-term care shall designate staff of the long-term care ombudsman program as 7
patients' advocates. A person so designated shall serve as a witness to a request for 8
medication of a requester who is a patient or resident of a nursing home or 9
community-based residential facility, as required under s. 156.05 (2) (b), and shall 10
speak on behalf of the requester to ensure that his or her needs or wants are 11
communicated to and addressed by his or her attending physician.
12156.21 Duties and immunities. (1)
No health care facility or health care 13
provider may be charged with a crime, held civilly liable or charged with 14
unprofessional conduct for any of the following:
(a) Failing to fulfill a request for medication, except that failure of an attending 16
physician to fulfill a request for medication constitutes unprofessional conduct if the 17
attending physician refuses or fails to make a good-faith attempt to transfer the 18
requester's care and treatment to another physician who will act as attending 19
physician under this chapter and fulfill the request for medication.
(b) In the absence of actual knowledge of a revocation, fulfilling a request for 21
medication that is in compliance with this chapter.
(c) Acting contrary to or failing to act on a revocation of a request for medication, 23
unless the health care facility or health care provider has actual knowledge of the 24
In the absence of actual notice to the contrary, a health care facility or health 2
care provider may presume that a requester was authorized to make his or her 3
request for medication under the requirements of this chapter and that the request 4
for medication is valid.
(a) No person who acts in good faith as a witness to a request for medication 6
under this chapter may be held civilly or criminally liable for a death that results 7
from taking medication under a fulfilled request for medication under this chapter.
(b) Paragraph (a) does not apply to a person who acts as a witness in violation 9
of s. 156.05 (2) (a).
10156.23 General provisions. (1)
(a) The making of a request for medication 11
under this chapter does not, for any purpose, constitute attempted suicide. Taking 12
medication under a fulfilled request for medication under this chapter does not, for 13
any purpose, constitute suicide.
(b) Paragraph (a) does not prohibit an insurer from making a determination 15
that a requester has attempted suicide or committed suicide based on the requester's 16
action to do so, apart from the request for medication.
The making of a request for medication under this chapter does not revoke 18
or otherwise modify a power of attorney for health care or living will that the 19
requester may have executed.
No individual may be required to make a request for medication as a 21
condition for receipt of health care or admission to a health care facility. The making 22
of a request for medication is not a bar to the receipt of health care or admission to 23
a health care facility.
A request for medication that is in its original form or is a legible photocopy 25
or electronic facsimile copy is presumed to be valid.
Nothing in this chapter may be construed to condone, authorize, approve 2
or permit any affirmative or deliberate act to end life other than through taking 3
medication that is prescribed under a request for medication as provided in this 4
5156.25 Record review.
The department shall annually examine a sampling 6
of patient health care records of requesters for whom medication was prescribed as 7
requested under a request for medication and about whom the department has 8
received information under s. 156.07 (8) (g).
9156.27 Penalties. (1)
Any person who wilfully conceals, cancels, defaces, 10
obliterates or damages the request for medication of another without the requester's 11
consent may be fined not more than $500 or imprisoned for not more than 30 days 12
Any person who, with the intent to cause a requester to take medication that 14
is prescribed under a request for medication contrary to the wishes of the requester, 15
illegally falsifies or forges the request for medication of another or conceals a 16
revocation under s. 156.17 (1) (a) or (b) shall be fined not more than $10,000 or 17
imprisoned for not more than 10 years or both.
Any responsible person who, with the intent to cause a requester to take 19
medication that is prescribed under a request for medication contrary to the wishes 20
of the requester, conceals personal knowledge of a revocation under s. 156.17 shall 21
be fined not more than $10,000 or imprisoned for not more than 10 years or both.
AB32, s. 5
979.01 (1) (intro.) of the statutes is amended to read:
(intro.) All Except as provided in sub. (1g), all
physicians, authorities 24
of hospitals, sanatoriums, institutions (public and private), convalescent homes, 25
authorities of any institution of a like nature, and other persons having knowledge
of the death of any person who has died under any of the following circumstances, 2
shall immediately report such death to the sheriff, police chief, medical examiner or 3
coroner of the county wherein such death took place, and the sheriff or police chief 4
shall, immediately upon notification, notify the coroner or the medical examiner and 5
the coroner or medical examiner of the county where death took place, if the crime, 6
injury or event occurred in another county, shall report such death immediately to 7
the coroner or medical examiner of that county:
AB32, s. 6
979.01 (1g) of the statutes is created to read:
Subsection (1) does not apply to a death that results from taking 10
medication under a fulfilled request for medication that is in accordance with the 11
requirements of ch. 156.