(b) Dated and signed by the requester or, at the express direction and in the 22
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 2
requester's attending physician and, if the requester is an inpatient of a health care 3
facility, in the requester's patient health care record in the custody of the health care 4
(a) A witness to the making of a valid request for medication shall be an 6
individual who has attained age 18. No witness to the making of a valid request for 7
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 10
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 13
the time of the witnessing; an employee, other than a chaplain or a social worker, of 14
the health care provider; or an employee, other than a chaplain or a social worker, 15
of 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 17
residential facility, at least one of the witnesses to the request shall be a patients' 18
advocate designated under s. 156.19.
19156.07 Attending physician; responsibilities and limitations.
attending physician shall do all of the following:
Determine whether or not the requester has a terminal disease, has 22
incapacity, and is making a request under s. 156.03 voluntarily.
If the requester has a terminal disease, does not have incapacity, and is 24
making a request under s. 156.03 voluntarily, inform the requester of all of the 25
(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, 6
including comfort care, hospice care, and pain control.
Refer the requester to a consulting physician to meet the requirements of 8
Refer the requester for review and counseling if the referral is determined 10
to be 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; 13
explain the methods of revocation that are specified under s. 156.17 (1); and offer the 14
requester an opportunity to revoke the request at the time, if any, that the requester 15
makes a 2nd oral request under s. 156.13 (3) (c).
Before writing a prescription in response to a request for medication, verify 17
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 20
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 23
(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 2
determination as to whether the requester is incapacitated, is acting voluntarily, and 3
has made an informed decision.
(c) The consulting physician's diagnosis of and prognosis for the requester and 5
determination as to whether the requester is incapacitated, is acting voluntarily, and 6
has made an informed decision.
(d) A certification of the outcome and determinations made during any review 8
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 10
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 13
indicating the steps taken to fulfill the request for medication, including a notation 14
of any medication that is prescribed. The attending physician shall report the 15
information under this paragraph to the department on a form prescribed by the 16
department. Any information reported to the department under this paragraph that 17
could identify the requester, the attending physician, the consulting physician, or the 18
psychiatrist or psychologist to whom referral was made under s. 156.11, if any, is 19
confidential and may not be disclosed by the department except under an 20
investigation of an alleged violation of this chapter. The report of information under 21
this paragraph is not a violation of any person's responsibility for maintaining the 22
confidentiality of patient health care records under s. 146.82.
If the attending physician refuses to act as the attending physician in 24
complying with the requester's request for medication under this chapter, the 25
attending physician shall make a good faith attempt to transfer the requester's care
and treatment to another physician who will act as the attending physician under 2
this chapter and will comply with the requester's request for medication. If a 3
transfer is made, the attending physician to whom the requester's care and 4
treatment is transferred shall comply with the requirements of this section.
5156.09 Consulting physician.
Before an attending physician may fulfill a 6
request for medication under this chapter, a consulting physician shall examine the 7
requester and his or her relevant patient health care records and shall medically 8
confirm the attending physician's determinations that the requester suffers from a 9
terminal disease, does not have incapacity, is making a request for medication 10
voluntarily, and has made an informed decision.
11156.11 Referral for review and counseling.
If in the opinion of the 12
attending physician or the consulting physician a requester may be suffering from 13
a psychiatric or psychological disorder, including depression, that causes impaired 14
judgment, the attending physician or consulting physician shall refer the requester 15
for review and counseling to a physician specializing in psychiatry or a licensed 16
psychologist, as defined in s. 455.01 (4). No request for medication may be fulfilled 17
under this chapter unless the physician specializing in psychiatry or the 18
psychologist, to one of whom referral was made, determines and certifies in writing 19
that the requester is not suffering from a psychiatric or psychological disorder, 20
including depression, that causes impaired judgment. The certification, if any, shall 21
be filed in the requester's patient health care record under s. 156.07 (8).
22156.13 Requester rights, responsibilities, and limitations. (1)
requester may receive a prescription for medication that fulfills a request for 24
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 2
or her request for medication, and no request for medication may be denied because 3
the requester has failed to notify his or her next of kin.
To receive a prescription under a request for medication, a requester shall 5
do all of the following:
(a) Orally request his or her attending physician for medication for the purpose 7
of ending his or her life.
(b) No fewer than 15 days after making the oral request under par. (a), make 9
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 11
request of his or her attending physician for medication for the purpose of ending his 12
or her life.
13156.15 Request for medication; form.
The department shall prepare and 14
provide copies of a request for medication and accompanying information for 15
distribution in quantities to health care providers, hospitals, nursing homes, 16
multipurpose senior centers, county clerks, local bar associations, and, individually, 17
private persons. The department shall include, in information accompanying the 18
copy of the request for medication, at least the statutory definitions of terms used in 19
the request for medication, statutory restrictions on who may be witnesses to a valid 20
request for medication, and a statement explaining that valid witnesses acting in 21
good faith are statutorily immune from civil or criminal liability. The request for 22
medication distributed by the department shall be in the following form:
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 3
terminal disease and the terminality of which has been medically confirmed by a 4
I have been fully informed of my diagnosis, prognosis, the nature of medication 6
to be prescribed, and potential associated risks, the expected result, and the feasible 7
alternatives, including comfort care, hospice care, and pain control.
I request that my attending physician prescribe medication that will end my life 9
in a humane and dignified manner.
INITIAL ONE OF THE FOLLOWING 3 STATEMENTS:
.... I have informed my family members of my decision and have taken their 12
opinions into consideration.
.... 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 17
medication to be prescribed.
I make this request voluntarily and without reservation, and I accept full moral 19
responsibility for my actions.
22Statement and signatures
I know the requester personally or I have received proof of his or her identity 25
and I believe him or her to be of sound mind and at least 18 years of age. I believe
that the requester makes this request voluntarily. I am at least 18 years of age, am 2
not related to the requester by blood, marriage, or adoption, and am not directly 3
financially responsible for the requester's health care. I am not a health care 4
provider who is an individual and is serving the requester at this time, an employee 5
of a health care provider who is serving the requester at this time, other than a 6
chaplain or a social worker, or an employee, other than a chaplain or a social worker, 7
of a health care facility in which the requester is a patient. To the best of my 8
knowledge, I am not entitled to and do not have a claim 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 22
witnesses must be a patients' advocate designated by the board on aging and 23
long-term care. A patients' advocate who is a witness should print "patients' 24
advocate" after the printing of his or her name above.
1156.17 Revocation of request for medication.
A requester may revoke 2
his or her request for medication at any time by doing any of the following:
(a) Canceling, defacing, obliterating, burning, tearing, or otherwise destroying 4
the request for medication or directing another in the presence of the requester to 5
destroy, in the same manner, the request for medication.
(b) Executing a statement, in writing, that is signed and dated by the requester, 7
expressing the requester's intent to revoke the request for medication.
(c) Orally expressing the requester's intent to revoke the request for 9
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 12
of the requester's request for medication, record in the requester's medical record the 13
time, date, and place of the revocation and the time, date, and place, if different, of 14
the notification to the health care provider of the revocation.
15156.19 Designation of patients' advocates.
The board on aging and 16
long-term care shall designate staff of the long-term care ombudsman program as 17
patients' advocates. A person so designated shall serve as a witness to a request for 18
medication of a requester who is a patient or resident of a nursing home or 19
community-based residential facility, as required under s. 156.05 (2) (b), and shall 20
speak on behalf of the requester to ensure that his or her needs or wants are 21
communicated to and addressed by his or her attending physician.
22156.21 Duties and immunities. (1)
No health care provider that is not an 23
individual and no health care facility may be held civilly liable and no health care 24
provider who is an individual may be charged with a crime, held civilly liable, or 25
charged with unprofessional conduct for any of the following:
(a) Failing to fulfill a request for medication, except that failure of an attending 2
physician to fulfill a request for medication constitutes unprofessional conduct if the 3
attending physician refuses or fails to make a good faith attempt to transfer the 4
requester's care and treatment to another physician who will act as attending 5
physician under this chapter and fulfill the request for medication.
(b) In the absence of actual knowledge of a revocation, fulfilling a request for 7
medication that is in compliance with this chapter.
(c) Acting contrary to or failing to act on a revocation of a request for medication, 9
unless the health care facility or health care provider has actual knowledge of the 10
In the absence of actual notice to the contrary, a health care facility or health 12
care provider may presume that a requester was authorized to make his or her 13
request for medication under the requirements of this chapter and that the request 14
for medication is valid.