10156.05 Valid request for medication; requirements. (1)
A valid request 11
for medication shall be, for the purposes of s. 156.03, all of the following:
(a) In writing.
(b) Dated and signed by the requester or, at the express direction and in the 14
presence of the requester, by an individual who has attained age 18.
(c) Signed in the presence of 3 witnesses who meet the requirements of sub. (2).
(d) Made voluntarily.
(e) Substantially in the form specified in s. 156.15.
(f) Filed in the requester's patient health care record in the custody of the 19
requester's attending physician and, if the requester is an inpatient of a health care 20
facility, in the requester's patient health care record in the custody of the health care 21
(a) A witness to the making of a valid request for medication shall be an 23
individual who has attained age 18. No witness to the making of a valid request for 24
medication may, at the time of the witnessing, be any of the following:
1. Related to the requester by blood, marriage or adoption.
2. An individual who has knowledge that he or she is entitled to or has a claim 2
on any portion of the requester's estate.
3. Directly financially responsible for the requester's health care.
4. An individual who is a health care provider who is serving the requester at 5
the time of the witnessing; an employe, other than a chaplain or a social worker, of 6
the health care provider; or an employe, other than a chaplain or a social worker, of 7
a health care facility in which the requester is a patient.
(b) If a requester is a resident of a nursing home or community-based 9
residential facility, at least one of the witnesses to the request shall be a patients' 10
advocate designated under s. 156.19.
11156.07 Attending physician; responsibilities and limitations.
attending physician shall do all of the following:
Determine whether the requester has a terminal disease, does not have 14
incapacity and is making a request under s. 156.03 voluntarily.
Inform the requester of all of the following:
(a) The requester's medical diagnosis.
(b) The requester's prognosis.
(c) The potential risks associated with taking the medication to be prescribed.
(d) The probable result of taking the medication to be prescribed.
(e) The feasible alternatives to taking the medication to be prescribed, 21
including comfort care, care of a hospice and pain control.
Refer the requester to a consulting physician to meet the requirements of 23
Refer the requester for review and counseling if this is determined to be 25
appropriate under s. 156.11.
Ask the requester to notify his or her next of kin with respect to the request.
Inform the requester that he or she may revoke the request at any time; 3
explain the methods of revocation that are specified under s. 156.17 (1); and offer the 4
requester an opportunity to revoke the request at the time, if any, that the requester 5
makes a 2nd oral request under s. 156.13 (3) (c).
Before writing a prescription in response to a request for medication, verify 7
that all of the following have occurred:
(a) The requester has fulfilled the requirements of s. 156.13 (3).
(b) No fewer than 48 hours have elapsed since the requester made a written 10
request for medication.
(c) The requester has made an informed decision.
Document or file all of the following in the requester's patient health care 13
(a) All oral and written requests for medication that are made by the requester.
(b) The attending physician's diagnosis of and prognosis for the requester and 16
determination as to whether the requester is incapacitated, is acting voluntarily and 17
has made an informed decision.
(c) The consulting physician's diagnosis of and prognosis for the requester and 19
determination as to whether the requester is incapacitated, is acting voluntarily and 20
has made an informed decision.
(d) A certification of the outcome and determinations made during any review 22
and counseling for which the requester was referred under s. 156.11.
(e) The attending physician's offer of an opportunity to revoke the request for 24
medication, as required under sub. (6).
(f) Evidence of a revocation, if made, as specified in s. 156.17 (2).
(g) A certification as to whether the requirements of this chapter are met and 2
indicating the steps taken to fulfill the request for medication, including a notation 3
of any medication that is prescribed. The attending physician shall report the 4
information under this paragraph to the department on a form prescribed by the 5
department. Any information reported to the department under this paragraph that 6
could identify the requester, the attending physician, the consulting physician or the 7
psychiatrist or psychologist to whom referral was made under s. 156.11, if any, is 8
confidential and may not be disclosed by the department except under an 9
investigation of an alleged violation of this chapter. The report of information under 10
this paragraph is not a violation of any person's responsibility for maintaining the 11
confidentiality of patient health care records under s. 146.82.
If the attending physician refuses to act as the attending physician in 13
complying with the requester's request for medication under this chapter, the 14
attending physician shall make a good faith attempt to transfer the requester's care 15
and treatment to another physician who will act as the attending physician under 16
this chapter and will comply with the requester's request for medication. If a 17
transfer is made, the attending physician to whom the requester's care and 18
treatment is transferred shall comply with the requirements of this section.
19156.09 Consulting physician.
Before an attending physician may fulfill a 20
request for medication under this chapter, a consulting physician shall examine the 21
requester and his or her relevant patient health care records and shall medically 22
confirm the attending physician's determinations that the requester suffers from a 23
terminal disease, does not have incapacity, is making a request for medication 24
voluntarily and has made an informed decision.
1156.11 Referral for review and counseling.
If in the opinion of the 2
attending physician or the consulting physician a requester may be suffering from 3
a psychiatric or psychological disorder, including depression, that causes impaired 4
judgment, the attending physician or consulting physician shall refer the requester 5
for review and counseling to a physician specializing in psychiatry or a licensed 6
psychologist, as defined in s. 455.01 (4). No request for medication may be fulfilled 7
under this chapter unless the physician specializing in psychiatry or the 8
psychologist, to one of whom referral was made, determines and certifies in writing 9
that the requester is not suffering from a psychiatric or psychological disorder, 10
including depression, that causes impaired judgment. The certification, if any, shall 11
be filed in the requester's patient health care record under s. 156.07 (8).
12156.13 Requester rights, responsibilities and limitations. (1)
requester may receive a prescription for medication that fulfills a request for 14
medication under this chapter unless he or she has made an informed decision.
No requester may be required to notify his or her next of kin regarding his 16
or her request for medication, and no request for medication may be denied because 17
the requester has failed to notify his or her next of kin.
In order to receive a prescription under a request for medication, a 19
requester shall do all of the following:
(a) Orally make a request of his or her attending physician for medication for 21
the purpose of ending his or her life.
(b) No fewer than 15 days after orally making the request under par. (a), make 23
a request for medication that meets the requirements of s. 156.05.
(c) After making a request for medication under par. (b), make a 2nd oral 2
request of his or her attending physician for medication for the purpose of ending his 3
or her life.
4156.15 Request for medication; form.
The department shall prepare and 5
provide copies of a request for medication and accompanying information for 6
distribution in quantities to health care providers, hospitals, nursing homes, 7
multipurpose senior centers, county clerks and local bar associations and 8
individually to private persons. The department shall include, in information 9
accompanying the copy of the request for medication, at least the statutory 10
definitions of terms used in the request for medication, statutory restrictions on who 11
may be witnesses to a valid request for medication and a statement explaining that 12
valid witnesses acting in good faith are statutorily immune from civil or criminal 13
liability. The request for medication distributed by the department shall be in the 14
REQUEST FOR MEDICATION
TO END MY LIFE IN A HUMANE
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 members of my decision and taken their opinions 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 20
destroy, in the same manner, 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.