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 10
medication to be prescribed.
I make this request voluntarily and without reservation, and I accept full moral 12
responsibility for my actions.
15Statement and signatures
I know the requester personally or I have received proof of his or her identity 18
and I believe him or her to be of sound mind and at least 18 years of age. I believe 19
that the requester makes this request voluntarily. I am at least 18 years of age, am 20
not related to the requester by blood, marriage, or adoption, and am not directly 21
financially responsible for the requester's health care. I am not a health care 22
provider who is serving the requester at this time, an employee of the health care 23
provider, other than a chaplain or a social worker, or an employee, other than a 24
chaplain or a social worker, of a health care facility in which the requester is a
patient. To the best of my knowledge, I am not entitled to and do not have a claim 2
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 16
witnesses must be a patients' advocate designated by the board on aging and 17
long-term care. A patients' advocate who is a witness should print "patients' 18
advocate" after the printing of his or her name above.
19156.17 Revocation of request for medication. (1)
A requester may revoke 20
his or her request for medication at any time by doing any of the following:
(a) Canceling, defacing, obliterating, burning, tearing, or otherwise destroying 22
the request for medication or directing another in the presence of the requester to 23
destroy, in the same manner, the request for medication.
(b) Executing a statement, in writing, that is signed and dated by the requester, 25
expressing the requester's intent to revoke the request for medication.
(c) Orally expressing the requester's intent to revoke the request for 2
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 5
of the requester's request for medication, record in the requester's medical record the 6
time, date, and place of the revocation and the time, date, and place, if different, of 7
the notification to the health care provider of the revocation.
8156.19 Designation of patients' advocates.
The board on aging and 9
long-term care shall designate staff of the long-term care ombudsman program as 10
patients' advocates. A person so designated shall serve as a witness to a request for 11
medication of a requester who is a patient or resident of a nursing home or 12
community-based residential facility, as required under s. 156.05 (2) (b), and shall 13
speak on behalf of the requester to ensure that his or her needs or wants are 14
communicated to and addressed by his or her attending physician.
15156.21 Duties and immunities. (1)
No health care facility or health care 16
provider may be charged with a crime, held civilly liable, or charged with 17
unprofessional conduct for any of the following:
(a) Failing to fulfill a request for medication, except that failure of an attending 19
physician to fulfill a request for medication constitutes unprofessional conduct if the 20
attending physician refuses or fails to make a good faith attempt to transfer the 21
requester's care and treatment to another physician who will act as attending 22
physician under this chapter and fulfill the request for medication.
(b) In the absence of actual knowledge of a revocation, fulfilling a request for 24
medication that is in compliance with this chapter.
(c) Acting contrary to or failing to act on a revocation of a request for medication, 2
unless the health care facility or health care provider has actual knowledge of the 3
In the absence of actual notice to the contrary, a health care facility or health 5
care provider may presume that a requester was authorized to make his or her 6
request for medication under the requirements of this chapter and that the request 7
for medication is valid.
(a) No person who acts in good faith as a witness to a request for medication 9
under this chapter may be held civilly or criminally liable for a death that results 10
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 12
of s. 156.05 (2) (a).
13156.23 General provisions. (1)
(a) The making of a request for medication 14
under this chapter does not, for any purpose, constitute attempted suicide. Taking 15
medication under a fulfilled request for medication under this chapter does not, for 16
any purpose, constitute suicide.
(b) Paragraph (a) does not prohibit an insurer from making a determination 18
that a requester has attempted suicide or committed suicide if the requester has so 19
acted, apart from the request for medication.
The making of a request for medication under this chapter does not revoke 21
or otherwise modify a power of attorney for health care or living will that the 22
requester may have executed.
No individual may be required to make a request for medication as a 24
condition for receipt of health care or admission to a health care facility. The making
of a request for medication is not a bar to the receipt of health care or the admission 2
to a health care facility.
A request for medication that is in its original form or is a legible photocopy 4
or electronic facsimile copy is presumed to be valid.
Nothing in this chapter may be construed to condone, authorize, approve, 6
or permit any affirmative or deliberate act to end life other than through taking 7
medication that is prescribed under a request for medication as provided in this 8
9156.25 Record review.
The department shall annually examine a sampling 10
of patient health care records of requesters for whom medication was prescribed as 11
requested under a request for medication and about whom the department has 12
received information under s. 156.07 (8) (g).
13156.27 Penalties. (1)
Any person who willfully conceals, cancels, defaces, 14
obliterates, or damages the request for medication of another without the requester's 15
consent may be fined not more than $500 or imprisoned for not more than 30 days 16
Any person who, with the intent to cause a requester to take medication that 18
is prescribed under a request for medication contrary to the wishes of the requester, 19
illegally falsifies or forges the request for medication of another or conceals a 20
revocation under s. 156.17 (1) (a) or (b) shall be fined not more than $10,000 or 21
imprisoned for not more than 10 years or both.
Any responsible person who, with the intent to cause a requester to take 23
medication that is prescribed under a request for medication contrary to the wishes 24
of the requester, conceals personal knowledge of a revocation under s. 156.17 shall
be fined not more than $10,000 or, except for a health care facility, imprisoned for not 2
more than 10 years or both.
AB348, s. 4
979.01 (1) (intro.) of the statutes is amended to read:
(intro.) All Except as provided in sub. (1j), all
physicians, authorities 5
of hospitals, sanatoriums, public and private institutions, convalescent homes, 6
authorities of any institution of a like nature, and other persons having knowledge 7
of the death of any person who has died under any of the following circumstances, 8
shall immediately report the death to the sheriff, police chief, or and
examiner or coroner of the county and to the police chief of any community
where the 10
death took place:
AB348, s. 5
979.01 (1g) of the statutes is amended to read:
A sheriff or police chief shall, immediately upon notification of a 13
death under sub. (1), notify the coroner or the medical examiner, and the coroner or
14medical examiner of the county where death took place
, if the crime, injury, or event 15
occurred in another county, shall immediately
report the death to the coroner or 16
medical examiner of that county.
AB348, s. 6
979.01 (1j) of the statutes is created to read:
Subsection (1) does not apply to a death that results from taking 19
medication under a fulfilled request for medication that is in accordance with the 20
requirements of ch. 156.
AB348, s. 7
979.01 (1r) of the statutes is repealed.