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 9
the time of the witnessing; an employee, other than a chaplain or a social worker, of 10
the health care provider; or an employee, other than a chaplain or a social worker, 11
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 13
residential facility, at least one of the witnesses to the request shall be a patients' 14
advocate designated under s. 156.19.
15156.07 Attending physician; responsibilities and limitations.
attending physician shall do all of the following:
Determine whether the requester has a terminal disease, does not have 18
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, 25
including comfort care, care of a hospice, and pain control.
Refer the requester to a consulting physician under the requirements of s. 2
Refer the requester for review and counseling if the referral is determined 4
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; 7
explain the methods of revocation that are specified under s. 156.17 (1); and offer the 8
requester an opportunity to revoke the request at the time, if any, that the requester 9
makes a 2nd oral request under s. 156.13 (3) (c).
Before writing a prescription in response to a request for medication, verify 11
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 14
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 17
(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 20
determination as to whether the requester is incapacitated, is acting voluntarily, and 21
has made an informed decision.
(c) The consulting physician's diagnosis of and prognosis for the requester and 23
determination as to whether the requester is incapacitated, is acting voluntarily, and 24
has made an informed decision.
(d) A certification of the outcome and determinations made during any review 2
and counseling for which the requester was referred under s. 156.11.
(e) A certification as to whether the attending physician offered the requester 4
an opportunity to revoke the request for 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 7
indicating the steps taken to fulfill the request for medication, including a notation 8
of any medication that is prescribed. The attending physician shall report the 9
information under this paragraph to the department on a form prescribed by the 10
department. Information reported to the department under this paragraph that 11
could identify the requester, the attending physician, the consulting physician, or the 12
psychiatrist or psychologist to whom referral was made under s. 156.11, if any, is 13
confidential and may not be disclosed by the department except under an 14
investigation of an alleged violation of this chapter. The report of information under 15
this paragraph is not a violation of any person's responsibility for maintaining the 16
confidentiality of patient health care records under s. 146.82.
If the attending physician refuses to act as the attending physician in 18
complying with the requester's request for medication under this chapter, the 19
attending physician shall make a good faith attempt to transfer the requester's care 20
and treatment to another physician who will act as the attending physician under 21
this chapter and will comply with the requester's request for medication. If a 22
transfer is made, the attending physician to whom the requester's care and 23
treatment is transferred shall comply with the requirements of this section.
24156.09 Consulting physician.
Before an attending physician may fulfill a 25
request for medication under this chapter, a consulting physician shall examine the
requester and his or her relevant patient health care records and shall medically 2
confirm the attending physician's determinations that the requester suffers from a 3
terminal disease, does not have incapacity, is making a request for medication 4
voluntarily, and has made an informed decision.
5156.11 Referral for review and counseling.
If in the opinion of the 6
attending physician or the consulting physician a requester may be suffering from 7
a psychiatric or psychological disorder, including depression, that causes impaired 8
judgment, the attending physician or consulting physician shall refer the requester 9
for review and counseling to a physician specializing in psychiatry or a licensed 10
psychologist, as defined in s. 455.01 (4). No request for medication may be fulfilled 11
under this chapter unless the physician specializing in psychiatry, or the 12
psychologist, to whom referral was made, determines and certifies in writing that the 13
requester is not suffering from a psychiatric or psychological disorder, including 14
depression, that causes impaired judgment. The certification, if any, shall be filed 15
in the requester's patient health care record under s. 156.07 (8).
16156.13 Requester rights, responsibilities, and limitations. (1)
requester may receive a prescription for medication that fulfills a request for 18
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 20
or her request for medication, and no request for medication may be denied because 21
the requester has failed to notify his or her next of kin.
In order to receive a prescription under a request for medication, a 23
requester shall do all of the following:
(a) Orally make a request of his or her attending physician for medication for 25
the purpose of ending his or her life.
(b) No fewer than 15 days after orally making the request under par. (a), make 2
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 4
request of his or her attending physician for medication for the purpose of ending his 5
or her life.
6156.15 Request for medication; form.
The department shall prepare and 7
provide copies of a request for medication and accompanying information for 8
distribution in quantities to health care providers, hospitals, nursing homes, 9
multipurpose senior centers, county clerks, and local bar associations and 10
individually to private persons. The department shall include, in information 11
accompanying the copy of the request for medication, at least the statutory 12
definitions of terms used in the request for medication, statutory restrictions on who 13
may be witnesses to a valid request for medication, and a statement explaining that 14
valid witnesses acting in good faith are statutorily immune from civil or criminal 15
liability. The request for medication distributed by the department shall be in the 16
REQUEST FOR MEDICATION
TO END MY LIFE IN A HUMANE
AND DIGNIFIED MANNER
I, ...., am an adult of sound mind, do not have incapacity, and am a resident of 21
I am suffering from ...., which my attending physician has determined is a 23
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 2
to be prescribed and potential associated risks, the expected result, and the feasible 3
alternatives, including comfort care, hospice care, and pain control.
I request that my attending physician prescribe medication that will end my life 5
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 8
.... 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 13
medication to be prescribed.
I make this request voluntarily and without reservation, and I accept full moral 15
responsibility for my actions.
18Statement and signatures
I know the requester personally or I have received proof of his or her identity 21
and I believe him or her to be of sound mind and at least 18 years of age. I believe 22
that the requester makes this request voluntarily. I am at least 18 years of age, am 23
not related to the requester by blood, marriage, or adoption, and am not directly 24
financially responsible for the requester's health care. I am not a health care 25
provider who is serving the requester at this time; an employee of the health care
provider, other than a chaplain or a social worker; or an employee, other than a 2
chaplain or a social worker, of a health care facility in which the requester is a 3
patient. To the best of my knowledge, I am not entitled to and do not have a claim 4
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 18
witnesses must be a patients' advocate designated by the board on aging and 19
long-term care. A patients' advocate who is a witness should print "patients' 20
advocate" after the printing of his or her name above.
21156.17 Revocation of request for medication. (1)
A requester may revoke 22
his or her request for medication at any time by doing any of the following:
(a) Canceling, defacing, obliterating, burning, tearing, or otherwise destroying 24
the request for medication or directing another in the presence of the requester to 25
destroy, in the same manner, the request for medication.
(b) Executing a statement, in writing, that is signed and dated by the requester, 2
expressing the requester's intent to revoke the request for medication.
(c) Orally expressing the requester's intent to revoke the request for 4
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 7
of the requester's request for medication, record in the requester's medical record the 8
time, date, and place of the revocation and the time, date, and place, if different, of 9
the notification to the health care provider of the revocation.
10156.19 Designation of patients' advocates.
The board on aging and 11
long-term care shall designate staff of the long-term care ombudsman program as 12
patients' advocates. A person so designated shall serve as a witness to a request for 13
medication of a requester who is a patient or resident of a nursing home or 14
community-based residential facility, as required under s. 156.05 (2) (b), and shall 15
speak on behalf of the requester to ensure that his or her needs or wants are 16
communicated to and addressed by his or her attending physician.
17156.21 Duties and immunities. (1)
No health care facility or health care 18
provider may be charged with a crime, held civilly liable, or charged with 19
unprofessional conduct for any of the following:
(a) Failing to fulfill a request for medication, except that failure of an attending 21
physician to fulfill a request for medication constitutes unprofessional conduct if the 22
attending physician refuses or fails to make a good faith attempt to transfer the 23
requester's care and treatment to another physician who will act as attending 24
physician under this chapter and fulfill the request for medication.
(b) In the absence of actual knowledge of a revocation, fulfilling a request for 2
medication that is in compliance with this chapter.
(c) Acting contrary to or failing to act on a revocation of a request for medication, 4
unless the health care facility or health care provider has actual knowledge of the 5
In the absence of actual notice to the contrary, a health care facility or health 7
care provider may presume that a requester was authorized to make his or her 8
request for medication under the requirements of this chapter and that the request 9
for medication is valid.
(a) No person who acts in good faith as a witness to a request for medication 11
under this chapter may be held civilly or criminally liable for a death that results 12
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 14
of s. 156.05 (2) (a).
15156.23 General provisions. (1)
(a) The making of a request for medication 16
under this chapter does not, for any purpose, constitute attempted suicide. Taking 17
medication under a fulfilled request for medication under this chapter does not, for 18
any purpose, constitute suicide.
(b) Paragraph (a) does not prohibit an insurer from making a determination 20
that a requester has attempted suicide or committed suicide if the requester has so 21
acted, apart from the request for medication.
The making of a request for medication under this chapter does not revoke 23
or otherwise modify a power of attorney for health care or living will that the 24
requester may have executed.
No individual may be required to make a request for medication as a 2
condition for receipt of health care or admission to a health care facility. The making 3
of a request for medication is not a bar to the receipt of health care or the admission 4
to a health care facility.
A request for medication that is in its original form or is a legible photocopy 6
or electronic facsimile copy is presumed to be valid.
Nothing in this chapter may be construed to condone, authorize, approve, 8
or permit any affirmative or deliberate act to end life other than through taking 9
medication that is prescribed under a request for medication as provided in this 10