AB32,5,3
1(17) "Terminal disease" means an incurable and irreversible disease that has
2been diagnosed by an individual's attending physician and medically confirmed and
3that will, within reasonable medical judgment, cause death within 6 months.
AB32,5,9 4156.03 Authorization to make request. An individual who is of sound mind,
5has attained age 18, has residence in this state, does not have incapacity and has a
6terminal disease may voluntarily make a request for medication for the purpose of
7ending his or her life in a humane and dignified manner. An individual for whom an
8adjudication of incompetence and appointment of a guardian of the person is in effect
9under ch. 880 is presumed not to be of sound mind for purposes of this section.
AB32,5,11 10156.05 Valid request for medication; requirements. (1) A valid request
11for medication shall be, for the purposes of s. 156.03, all of the following:
AB32,5,1212 (a) In writing.
AB32,5,1413 (b) Dated and signed by the requester or, at the express direction and in the
14presence of the requester, by an individual who has attained age 18.
AB32,5,1515 (c) Signed in the presence of 3 witnesses who meet the requirements of sub. (2).
AB32,5,1616 (d) Made voluntarily.
AB32,5,1717 (e) Substantially in the form specified in s. 156.15.
AB32,5,2118 (f) Filed in the requester's patient health care record in the custody of the
19requester's attending physician and, if the requester is an inpatient of a health care
20facility, in the requester's patient health care record in the custody of the health care
21facility.
AB32,5,24 22(2) (a) A witness to the making of a valid request for medication shall be an
23individual who has attained age 18. No witness to the making of a valid request for
24medication may, at the time of the witnessing, be any of the following:
AB32,5,2525 1. Related to the requester by blood, marriage or adoption.
AB32,6,2
12. An individual who has knowledge that he or she is entitled to or has a claim
2on any portion of the requester's estate.
AB32,6,33 3. Directly financially responsible for the requester's health care.
AB32,6,74 4. An individual who is a health care provider who is serving the requester at
5the time of the witnessing; an employe, other than a chaplain or a social worker, of
6the health care provider; or an employe, other than a chaplain or a social worker, of
7a health care facility in which the requester is a patient.
AB32,6,108 (b) If a requester is a patient or resident of a nursing home or community-based
9residential facility, at least one of the witnesses to the request shall be a patients'
10advocate designated under s. 156.19.
AB32,6,12 11156.07 Attending physician; responsibilities and limitations. The
12attending physician shall do all of the following:
AB32,6,14 13(1) Determine whether the requester has a terminal disease, does not have
14incapacity and is making a request under s. 156.03 voluntarily.
AB32,6,15 15(2) Inform the requester of all of the following:
AB32,6,1616 (a) The requester's medical diagnosis.
AB32,6,1717 (b) The requester's prognosis.
AB32,6,1818 (c) The potential risks associated with taking the medication to be prescribed.
AB32,6,1919 (d) The probable result of taking the medication to be prescribed.
AB32,6,2120 (e) The feasible alternatives to taking the medication to be prescribed,
21including comfort care and care of a hospice.
AB32,6,23 22(3) Refer the requester to a consulting physician to meet the requirements of
23s. 156.09.
AB32,6,25 24(4) Refer the requester for review and counseling if this is determined to be
25appropriate under s. 156.11.
AB32,7,1
1(5) Ask the requester to notify his or her next of kin with respect to the request.
AB32,7,5 2(6) Inform the requester that he or she may revoke the request at any time;
3explain the methods of revocation that are specified under s. 156.17 (1); and offer the
4requester an opportunity to revoke the request at the time, if any, that the requester
5makes a 2nd oral request under s. 156.13 (3) (c).
AB32,7,7 6(7) Before writing a prescription in response to a request for medication, verify
7that all of the following have occurred:
AB32,7,88 (a) The requester has fulfilled the requirements of s. 156.13 (3).
AB32,7,109 (b) No fewer than 48 hours have elapsed since the requester made a written
10request for medication.
AB32,7,1111 (c) The requester has made an informed decision.
AB32,7,13 12(8) Document or file all of the following in the requester's patient health care
13record:
AB32,7,1414 (a) All oral and written requests for medication that are made by the requester.
AB32,7,1715 (b) The attending physician's diagnosis of and prognosis for the requester and
16determination as to whether the requester is incapacitated, is acting voluntarily and
17has made an informed decision.
AB32,7,2018 (c) The consulting physician's diagnosis of and prognosis for the requester and
19determination as to whether the requester is incapacitated, is acting voluntarily and
20has made an informed decision.
AB32,7,2221 (d) A certification of the outcome and determinations made during any review
22and counseling for which the requester was referred under s. 156.11.
AB32,7,2423 (e) The attending physician's offer of an opportunity to revoke the request for
24medication, as required under sub. (6).
AB32,7,2525 (f) Evidence of a revocation, if made, as specified in s. 156.17 (2).
AB32,8,11
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. Any 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. 156.11, 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.
AB32,8,18 12(9) If the attending physician refuses to act as the attending physician in
13complying with the requester's request for medication under this chapter, the
14attending physician shall make a good-faith attempt to transfer the requester's care
15and treatment to another physician who will act as the attending physician under
16this chapter and will comply with the requester's request for medication. If a
17transfer is made, the attending physician to whom the requester's care and
18treatment is transferred shall comply with the requirements of this section.
AB32,8,24 19156.09 Consulting physician. Before an attending physician may fulfill a
20request for medication under this chapter, a consulting physician shall examine the
21requester and his or her relevant patient health care records and shall medically
22confirm the attending physician's determinations that the requester suffers from a
23terminal disease, does not have incapacity, is making a request for medication
24voluntarily and has made an informed decision.
AB32,9,11
1156.11 Referral for review and counseling. If in the opinion of the
2attending physician or the consulting physician a requester may be suffering from
3a psychiatric or psychological disorder, including depression, that causes impaired
4judgment, the attending physician or consulting physician shall refer the requester
5for review and counseling to a physician specializing in psychiatry or a licensed
6psychologist, as defined in s. 455.01 (4). No request for medication may be fulfilled
7under this chapter unless the physician specializing in psychiatry or psychologist to
8whom referral was made determines and certifies in writing that the requester is not
9suffering from a psychiatric or psychological disorder, including depression, that
10causes impaired judgment. The certification, if any, shall be filed in the requester's
11patient health care record under s. 156.07 (8).
AB32,9,14 12156.13 Requester rights, responsibilities and limitations. (1) No
13requester may receive a prescription for medication that fulfills a request for
14medication under this chapter unless he or she has made an informed decision.
AB32,9,17 15(2) No requester may be required to notify his or her next of kin regarding his
16or her request for medication, and no request for medication may be denied because
17the requester has failed to notify his or her next of kin.
AB32,9,19 18(3) In order to receive a prescription under a request for medication, a
19requester shall do all of the following:
AB32,9,2120 (a) Orally make a request of his or her attending physician for medication for
21the purpose of ending his or her life.
AB32,9,2322 (b) No fewer than 15 days after orally making the request under par. (a), make
23a request for medication that meets the requirements of s. 156.05.
AB32,10,3
1(c) After making a request for medication under par. (b), make a 2nd oral
2request of his or her attending physician for medication for the purpose of ending his
3or her life.
AB32,10,14 4156.15 Request for medication; form. The department shall prepare and
5provide copies of a request for medication and accompanying information for
6distribution in quantities to health care providers, hospitals, nursing homes,
7multipurpose senior centers, county clerks and local bar associations and
8individually to private persons. The department shall include, in information
9accompanying the copy of the request for medication, at least the statutory
10definitions of terms used in the request for medication, statutory restrictions on who
11may be witnesses to a valid request for medication and a statement explaining that
12valid witnesses acting in good faith are statutorily immune from civil or criminal
13liability. The request for medication distributed by the department shall be in the
14following form:
AB32,10,1515 REQUEST FOR MEDICATION
AB32,10,1616 TO END MY LIFE IN A HUMANE
AB32,10,1717 AND DIGNIFIED MANNER
AB32,10,1818 I, ...., am an adult of sound mind and am a resident of Wisconsin.
AB32,10,2019 I am suffering from ...., which my attending physician has determined is a
20terminal disease and which has been medically confirmed by a consulting physician.
AB32,10,2321 I have been fully informed of my diagnosis, prognosis, the nature of medication
22to be prescribed and potential associated risks, the expected result, and the feasible
23alternatives, including comfort care, hospice care and pain control.
AB32,10,2524 I request that my attending physician prescribe medication that will end my life
25in a humane and dignified manner.
AB32,11,1
1INITIAL ONE OF THE FOLLOWING 3 STATEMENTS:
AB32,11,32 .... I have informed my family of my decision and taken their opinions into
3consideration.
AB32,11,44 .... I have decided not to inform my family of my decision.
AB32,11,55 .... I have no family to inform of my decision.
AB32,11,66 I understand that I have the right to revoke this request at any time.
AB32,11,87 I understand the full import of this request and I expect to die when I take the
8medication to be prescribed.
AB32,11,109 I make this request voluntarily and without reservation, and I accept full moral
10responsibility for my actions.
AB32,11,1111 Signed: ....
AB32,11,1212 Dated: ....
AB32,11,13 13Statement and signatures
AB32,11,14 14of witnesses
AB32,11,2415 I know the requester personally or I have received proof of his or her identity
16and I believe him or her to be of sound mind and at least 18 years of age. I believe
17that the requester makes this request voluntarily. I am at least 18 years of age, am
18not related to the requester by blood, marriage or adoption and am not directly
19financially responsible for the requester's health care. I am not a health care
20provider who is serving the requester at this time, an employe of the health care
21provider, other than a chaplain or a social worker, or an employe, other than a
22chaplain or a social worker, of a health care facility in which the requester is a
23patient. To the best of my knowledge, I am not entitled to and do not have a claim
24on the requester's estate.
AB32,11,2525 Witness No. 1:
AB32,12,1
1(print) Name: ....
AB32,12,22 Address: ....
AB32,12,33 Signature: ....
AB32,12,44 Witness No. 2:
AB32,12,55 (print) Name: ....
AB32,12,66 Address: ....
AB32,12,77 Signature: ....
AB32,12,88 Witness No. 3:
AB32,12,99 (print) Name: ....
AB32,12,1010 Address: ....
AB32,12,1111 Signature: ....
AB32,12,1512 If the requester is a patient in a health care facility, at least one of the above
13witnesses must be a patients' advocate designated by the board on aging and
14long-term care. A patients' advocate who is a witness should print "patients'
15advocate" after the printing of his or her name above.
AB32,12,17 16156.17 Revocation of request for medication. (1) A requester may revoke
17his or her request for medication at any time by doing any of the following:
AB32,12,2018 (a) Canceling, defacing, obliterating, burning, tearing or otherwise destroying
19the request for medication or directing another in the presence of the requester to so
20destroy the request for medication.
AB32,12,2221 (b) Executing a statement, in writing, that is signed and dated by the requester,
22expressing the requester's intent to revoke the request for medication.
AB32,12,2423 (c) Orally expressing the requester's intent to revoke the request for
24medication, in the presence of 2 witnesses.
AB32,12,2525 (d) Making a subsequent request for medication.
AB32,13,4
1(2) The requester's health care provider shall, upon notification of revocation
2of the requester's request for medication, record in the requester's medical record the
3time, date and place of the revocation and the time, date and place, if different, of the
4notification to the health care provider of the revocation.
AB32,13,11 5156.19 Designation or patients' advocates. The board on aging and
6long-term care shall designate staff of the long-term care ombudsman program as
7patients' advocates. A person so designated shall serve as a witness to a request for
8medication of a requester who is a patient or resident of a nursing home or
9community-based residential facility, as required under s. 156.05 (2) (b), and shall
10speak on behalf of the requester to ensure that his or her needs or wants are
11communicated to and addressed by his or her attending physician.
AB32,13,14 12156.21 Duties and immunities. (1) No health care facility or health care
13provider may be charged with a crime, held civilly liable or charged with
14unprofessional conduct for any of the following:
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