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 6
Inform the requester that he or she may revoke the request for medication 8
at any time; explain the methods of revocation that are specified under s. 156.17 (1); 9
and offer the requester an opportunity to revoke the request at the time, if any, that 10
the requester orally asks for medication under s. 156.13 (3) (c).
Before writing a prescription that fulfills a request for medication, verify 12
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 request 15
(c) The requester has made an informed decision.
Document or file all of the following in the requester's patient health care 18
(a) All occasions which the requester orally asks for medication under s. 156.13 20
(3) and all requests for medication that are made by the requester.
(b) The attending physician's diagnosis of and prognosis for the requester and 22
determination as to whether the requester is incapacitated, is acting voluntarily, and 23
has made an informed decision.
(c) The consulting 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.
(d) A certification of the outcome and determinations made during any review 5
and counseling for which the requester was referred under s. 156.11.
(e) A certification as to whether the attending physician offered the requester 7
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 10
indicating the steps taken to fulfill the request for medication, including a notation 11
of any medication that is prescribed. The attending physician shall report the 12
information under this paragraph to the department on a form prescribed by the 13
department. Information reported to the department under this paragraph that 14
could identify the requester, the attending physician, the consulting physician, or the 15
psychiatrist or psychologist to whom referral was made under s. 156.11, if any, is 16
confidential and may not be disclosed by the department except under an 17
investigation of an alleged violation of this chapter. The report of information under 18
this paragraph is not a violation of any person's responsibility for maintaining the 19
confidentiality of patient health care records under s. 146.82.
If the attending physician refuses to fulfill the requester's request for 21
medication under this chapter, the attending physician shall make a good faith 22
attempt to transfer the requester's care and treatment to another physician who will 23
act as the attending physician under this chapter and will fulfill the requester's 24
request for medication. If a transfer is made, the attending physician to whom the
requester's care and treatment is transferred shall comply with the requirements of 2
3156.09 Consulting physician.
Before an attending physician may fulfill a 4
request for medication under this chapter, a consulting physician shall examine the 5
requester and his or her relevant patient health care records and shall medically 6
confirm the attending physician's determinations that the requester suffers from a 7
terminal disease, does not have incapacity, is making a request for medication 8
voluntarily, and has made an informed decision.
9156.11 Referral for review and counseling.
If in the opinion of the 10
attending physician or the consulting physician a requester may be suffering from 11
a psychiatric or psychological disorder, including depression, that causes impaired 12
judgment, the attending physician or consulting physician shall refer the requester 13
for review and counseling to a physician specializing in psychiatry or a licensed 14
psychologist, as defined in s. 455.01 (4). No request for medication may be fulfilled 15
under this chapter unless the physician specializing in psychiatry, or the 16
psychologist, to whom referral was made, determines and certifies in writing that the 17
requester is not suffering from a psychiatric or psychological disorder, including 18
depression, that causes impaired judgment. The certification, if any, shall be filed 19
in the requester's patient health care record under s. 156.07 (8).
20156.13 Requester rights, responsibilities, and limitations. (1)
requester may receive a prescription that fulfills a request for medication unless he 22
or she has made an informed decision.
No requester may be required to notify his or her next of kin regarding his 24
or her request for medication, and no request for medication may be denied because 25
the requester has failed to notify his or her next of kin.
In order to receive a prescription that fulfills a request for medication, a 2
requester shall do all of the following:
(a) Orally ask his or her attending physician for medication for the purpose of 4
ending his or her life.
(b) No fewer than 15 days after asking for medication under par. (a), make a 6
request for medication.
(c) After making a request for medication under par. (b), orally ask his or her 8
attending physician a 2nd time for medication for the purpose of ending his or her 9
10156.15 Request for medication; form.
The department shall prepare and 11
provide copies of a request for medication form and accompanying information for 12
distribution in quantities to health care providers, hospitals, nursing homes, 13
multipurpose senior centers, county clerks, and local bar associations and 14
individually to private persons. The department shall include, in information 15
accompanying the copy of the request for medication form, at least the statutory 16
definitions of terms used in the request for medication form, statutory restrictions 17
on who may be witnesses to a valid request for medication, and a statement 18
explaining that valid witnesses acting in good faith are statutorily immune from civil 19
or criminal liability. The request for medication form distributed by the department 20
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, do not have incapacity, and am a resident of 25
I am suffering from ...., which my attending physician has determined is a 2
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 4
to be prescribed and potential associated risks, the expected result, and the feasible 5
alternatives, including comfort care, hospice care, and pain control.
I request that my attending physician prescribe medication that will end my life 7
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 10
.... 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 15
medication to be prescribed.
I make this request voluntarily and without reservation, and I accept full moral 17
responsibility for my actions.
20Statement and signatures
I know the requester personally or I have received proof of his or her identity 23
and I believe him or her to be of sound mind and at least 18 years of age. I believe 24
that the requester makes this request voluntarily. I am at least 18 years of age, am 25
not related to the requester by blood, marriage, or adoption, and am not directly
financially responsible for the requester's health care. I am not a health care 2
provider who is serving the requester at this time; an employee of the health care 3
provider, other than a chaplain or a social worker; or an employee, other than a 4
chaplain or a social worker, of a health care facility in which the requester is a 5
patient. To the best of my knowledge, I am not entitled to and do not have a claim 6
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 20
witnesses must be a patients' advocate designated by the board on aging and 21
long-term care. A patients' advocate who is a witness should print "patients' 22
advocate" after the printing of his or her name above.
23156.17 Revocation of request for medication. (1)
A requester may revoke 24
his or her request for medication at any time by doing any of the following:
(a) Canceling, defacing, obliterating, burning, tearing, or otherwise destroying 2
the request for medication or directing another in the presence of the requester to 3
destroy, in the same manner, the request for medication.
(b) Executing a statement, in writing, that is signed and dated by the requester, 5
expressing the requester's intent to revoke the request for medication.
(c) Orally expressing the requester's intent to revoke the request for 7
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 10
of the requester's request for medication, record in the requester's medical record the 11
time, date, and place of the revocation and the time, date, and place, if different, of 12
the notification to the health care provider of the revocation.
13156.19 Designation of patients' advocates.
The board on aging and 14
long-term care shall designate staff of the long-term care ombudsman program as 15
patients' advocates. A person so designated shall serve as a witness to a request for 16
medication of a requester who is a patient or resident of a nursing home or 17
community-based residential facility, as required under s. 156.05 (2) (b), and shall 18
speak on behalf of the requester to ensure that his or her needs or wants are 19
communicated to and addressed by his or her attending physician.
20156.21 Duties and immunities. (1)
No health care facility or health care 21
provider may be charged with a crime, held civilly liable, or charged with 22
unprofessional conduct for any of the following:
(a) Failing to fulfill a request for medication, except that failure of an attending 24
physician to fulfill a request for medication constitutes unprofessional conduct if the 25
attending physician refuses or fails to make a good faith attempt to transfer the
requester's care and treatment to another physician who will act as attending 2
physician under this chapter and fulfill the request for medication.
(b) In the absence of actual knowledge of a revocation, fulfilling a request for 4
medication that is in compliance with this chapter.
(c) Acting contrary to or failing to act on a revocation of a request for medication, 6
unless the health care facility or health care provider has actual knowledge of the 7
In the absence of actual notice to the contrary, a health care facility or a 9
health care provider, other than a physician acting as the requester's attending 10
physician under this chapter, may presume that a requester was authorized to make 11
his or her request for medication under the requirements of this chapter and that the 12
request for medication is valid.
(a) No person who acts in good faith as a witness to a request for medication 14
under this chapter may be held civilly or criminally liable for a death that results 15
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 17
of s. 156.05 (2) (a).
18156.23 General provisions. (1)
(a) The making of a request for medication 19
under this chapter does not, for any purpose, constitute attempted suicide. Taking 20
medication under a fulfilled request for medication under this chapter does not, for 21
any purpose, constitute suicide.
(b) Paragraph (a) does not prohibit an insurer from making a determination 23
that a requester has attempted suicide or committed suicide if the requester has so 24
acted, apart from the request for medication.
The making of a request for medication under this chapter does not revoke 2
or otherwise modify a power of attorney for health care or living will that the 3
requester may have executed.
No individual may be required to make a request for medication as a 5
condition for receipt of health care or admission to a health care facility. The making 6
of a request for medication is not a bar to the receipt of health care or the admission 7
to a health care facility.
A request for medication that has not been revoked and that is in its original 9
form or is a legible photocopy or electronic facsimile copy is presumed to be valid.
Nothing in this chapter may be construed to condone, authorize, approve, 11
or permit any affirmative or deliberate act to end life other than through taking 12
medication that is prescribed under a request for medication as provided in this 13
14156.25 Record review.
The department shall annually examine a sampling 15
of patient health care records of requesters for whom medication was prescribed in 16
fulfillment of a request for medication and about whom the department has received 17
information under s. 156.07 (8) (g).