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 the
8psychologist, to one of whom referral was made, determines and certifies in writing
9that the requester is not suffering from a psychiatric or psychological disorder,
10including depression, that causes impaired judgment. The certification, if any, shall
11be filed in the requester's patient health care record under s. 156.07 (8).
SB124,9,14 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.
SB124,9,17 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.
SB124,9,19 18(3) In order to receive a prescription under a request for medication, a
19requester shall do all of the following:
SB124,9,2120 (a) Orally make a request of his or her attending physician for medication for
21the purpose of ending his or her life.
SB124,9,2322 (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.
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.
SB124,10,14 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:
SB124,10,1818 I, ...., am an adult of sound mind and am a resident of Wisconsin.
SB124,10,2019 I am suffering from ...., which my attending physician has determined is a
20terminal disease and which has been medically confirmed by a consulting physician.
SB124,10,2321 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.
SB124,10,2524 I request that my attending physician prescribe medication that will end my life
25in a humane and dignified manner.
SB124,11,32 .... I have informed my family members of my decision and taken their opinions
3into consideration.
SB124,11,44 .... I have decided not to inform my family of my decision.
SB124,11,55 .... I have no family to inform of my decision.
SB124,11,66 I understand that I have the right to revoke this request at any time.
SB124,11,87 I understand the full import of this request and I expect to die when I take the
8medication to be prescribed.
SB124,11,109 I make this request voluntarily and without reservation, and I accept full moral
10responsibility for my actions.
SB124,11,1111 Signed: ....
SB124,11,1212 Dated: ....
SB124,11,13 13Statement and signatures
SB124,11,14 14of witnesses
SB124,11,2415 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.
SB124,11,2525 Witness No. 1:
1(print) Name: ....
SB124,12,22 Address: ....
SB124,12,33 Signature: ....
SB124,12,44 Witness No. 2:
SB124,12,55 (print) Name: ....
SB124,12,66 Address: ....
SB124,12,77 Signature: ....
SB124,12,88 Witness No. 3:
SB124,12,99 (print) Name: ....
SB124,12,1010 Address: ....
SB124,12,1111 Signature: ....
SB124,12,1512 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.
SB124,12,17 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:
SB124,12,2018 (a) Canceling, defacing, obliterating, burning, tearing or otherwise destroying
19the request for medication or directing another in the presence of the requester to
20destroy, in the same manner, the request for medication.
SB124,12,2221 (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.
SB124,12,2423 (c) Orally expressing the requester's intent to revoke the request for
24medication, in the presence of 2 witnesses.
SB124,12,2525 (d) Making a subsequent request for medication.
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.
SB124,13,11 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.
SB124,13,14 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:
SB124,13,1915 (a) Failing to fulfill a request for medication, except that failure of an attending
16physician to fulfill a request for medication constitutes unprofessional conduct if the
17attending physician refuses or fails to make a good faith attempt to transfer the
18requester's care and treatment to another physician who will act as attending
19physician under this chapter and fulfill the request for medication.
SB124,13,2120 (b) In the absence of actual knowledge of a revocation, fulfilling a request for
21medication that is in compliance with this chapter.
SB124,13,2422 (c) Acting contrary to or failing to act on a revocation of a request for medication,
23unless the health care facility or health care provider has actual knowledge of the
1(2) In the absence of actual notice to the contrary, a health care facility or health
2care provider may presume that a requester was authorized to make his or her
3request for medication under the requirements of this chapter and that the request
4for medication is valid.
SB124,14,7 5(3) (a) No person who acts in good faith as a witness to a request for medication
6under this chapter may be held civilly or criminally liable for a death that results
7from taking medication under a fulfilled request for medication under this chapter.
SB124,14,98 (b) Paragraph (a) does not apply to a person who acts as a witness in violation
9of s. 156.05 (2) (a).
SB124,14,13 10156.23 General provisions. (1) (a) The making of a request for medication
11under this chapter does not, for any purpose, constitute attempted suicide. Taking
12medication under a fulfilled request for medication under this chapter does not, for
13any purpose, constitute suicide.
SB124,14,1614 (b) Paragraph (a) does not prohibit an insurer from making a determination
15that a requester has attempted suicide or committed suicide if the requester has so
16acted, apart from the request for medication.
SB124,14,19 17(2) The making of a request for medication under this chapter does not revoke
18or otherwise modify a power of attorney for health care or living will that the
19requester may have executed.
SB124,14,23 20(3) No individual may be required to make a request for medication as a
21condition for receipt of health care or admission to a health care facility. The making
22of a request for medication is not a bar to the receipt of health care or the admission
23to a health care facility.
SB124,14,25 24(4) A request for medication that is in its original form or is a legible photocopy
25or electronic facsimile copy is presumed to be valid.
1(5) Nothing in this chapter may be construed to condone, authorize, approve
2or permit any affirmative or deliberate act to end life other than through taking
3medication that is prescribed under a request for medication as provided in this
SB124,15,8 5156.25 Record review. The department shall annually examine a sampling
6of patient health care records of requesters for whom medication was prescribed as
7requested under a request for medication and about whom the department has
8received information under s. 156.07 (8) (g).
SB124,15,12 9156.27 Penalties. (1) Any person who wilfully conceals, cancels, defaces,
10obliterates or damages the request for medication of another without the requester's
11consent may be fined not more than $500 or imprisoned for not more than 30 days
12or both.
SB124,15,17 13(2) Any person who, with the intent to cause a requester to take medication that
14is prescribed under a request for medication contrary to the wishes of the requester,
15illegally falsifies or forges the request for medication of another or conceals a
16revocation under s. 156.17 (1) (a) or (b) shall be fined not more than $10,000 or
17imprisoned for not more than 10 years or both.
SB124,15,21 18(3) Any responsible person who, with the intent to cause a requester to take
19medication that is prescribed under a request for medication contrary to the wishes
20of the requester, conceals personal knowledge of a revocation under s. 156.17 shall
21be fined not more than $10,000 or imprisoned for not more than 10 years or both.
SB124, s. 4 22Section 4. 979.01 (1) (intro.) of the statutes is amended to read:
SB124,16,723 979.01 (1) (intro.) All Except as provided in sub. (1g), all physicians, authorities
24of hospitals, sanatoriums, institutions (public and private), convalescent homes,
25authorities of any institution of a like nature, and other persons having knowledge

1of the death of any person who has died under any of the following circumstances,
2shall immediately report such death to the sheriff, police chief, medical examiner or
3coroner of the county wherein such death took place, and the sheriff or police chief
4shall, immediately upon notification, notify the coroner or the medical examiner and
5the coroner or medical examiner of the county where death took place, if the crime,
6injury or event occurred in another county, shall report such death immediately to
7the coroner or medical examiner of that county:
SB124, s. 5 8Section 5. 979.01 (1g) of the statutes is created to read:
SB124,16,119 979.01 (1g) Subsection (1) does not apply to a death that results from taking
10medication under a fulfilled request for medication that is in accordance with the
11requirements of ch. 156.
SB124,16,1212 (End)