SB151,6,44 1. Related to the requester by blood, marriage, or adoption.
SB151,6,65 2. An individual who has knowledge that he or she is entitled to or has a claim
6on any portion of the requester's estate.
SB151,6,77 3. Directly financially responsible for the requester's health care.
SB151,6,118 4. An individual who is a health care provider who is serving the requester at
9the time of the witnessing; an employee, other than a chaplain or a social worker, of
10the health care provider; or an employee, other than a chaplain or a social worker,
11of a health care facility in which the requester is a patient.
SB151,6,1412 (b) If a requester is a resident of a nursing home or community-based
13residential facility, at least one of the witnesses to the request shall be a patients'
14advocate designated under s. 156.19.
SB151,6,16 15156.07 Attending physician; responsibilities and limitations. The
16attending physician shall do all of the following:
SB151,6,18 17(1) Determine whether the requester has a terminal disease, does not have
18incapacity, and is making a request under s. 156.03 voluntarily.
SB151,6,19 19(2) Inform the requester of all of the following:
SB151,6,2020 (a) The requester's medical diagnosis.
SB151,6,2121 (b) The requester's prognosis.
SB151,6,2222 (c) The potential risks associated with taking the medication to be prescribed.
SB151,6,2323 (d) The probable result of taking the medication to be prescribed.
SB151,6,2524 (e) The feasible alternatives to taking the medication to be prescribed,
25including comfort care, care of a hospice, and pain control.
SB151,7,2
1(3) Refer the requester to a consulting physician under the requirements of s.
2156.09.
SB151,7,4 3(4) Refer the requester for review and counseling if the referral is determined
4to be appropriate under s. 156.11.
SB151,7,6 5(5) Ask the requester to notify his or her next of kin with respect to the request
6for medication.
SB151,7,10 7(6) Inform the requester that he or she may revoke the request for medication
8at any time; explain the methods of revocation that are specified under s. 156.17 (1);
9and offer the requester an opportunity to revoke the request at the time, if any, that
10the requester orally asks for medication under s. 156.13 (3) (c).
SB151,7,12 11(7) Before writing a prescription that fulfills a request for medication, verify
12that all of the following have occurred:
SB151,7,1313 (a) The requester has fulfilled the requirements of s. 156.13 (3).
SB151,7,1514 (b) No fewer than 48 hours have elapsed since the requester made a request
15for medication.
SB151,7,1616 (c) The requester has made an informed decision.
SB151,7,18 17(8) Document or file all of the following in the requester's patient health care
18record:
SB151,7,2019 (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.
SB151,7,2321 (b) The attending physician's diagnosis of and prognosis for the requester and
22determination as to whether the requester is incapacitated, is acting voluntarily, and
23has made an informed decision.
SB151,8,3
1(c) The consulting physician's diagnosis of and prognosis for the requester and
2determination as to whether the requester is incapacitated, is acting voluntarily, and
3has made an informed decision.
SB151,8,54 (d) A certification of the outcome and determinations made during any review
5and counseling for which the requester was referred under s. 156.11.
SB151,8,76 (e) A certification as to whether the attending physician offered the requester
7an opportunity to revoke the request for medication, as required under sub. (6).
SB151,8,88 (f) Evidence of a revocation, if made, as specified in s. 156.17 (2).
SB151,8,199 (g) A certification as to whether the requirements of this chapter are met and
10indicating the steps taken to fulfill the request for medication, including a notation
11of any medication that is prescribed. The attending physician shall report the
12information under this paragraph to the department on a form prescribed by the
13department. Information reported to the department under this paragraph that
14could identify the requester, the attending physician, the consulting physician, or the
15psychiatrist or psychologist to whom referral was made under s. 156.11, if any, is
16confidential and may not be disclosed by the department except under an
17investigation of an alleged violation of this chapter. The report of information under
18this paragraph is not a violation of any person's responsibility for maintaining the
19confidentiality of patient health care records under s. 146.82.
SB151,9,2 20(9) If the attending physician refuses to fulfill the requester's request for
21medication under this chapter, the attending physician shall make a good faith
22attempt to transfer the requester's care and treatment to another physician who will
23act as the attending physician under this chapter and will fulfill the requester's
24request for medication. If a transfer is made, the attending physician to whom the

1requester's care and treatment is transferred shall comply with the requirements of
2this section.
SB151,9,8 3156.09 Consulting physician. Before an attending physician may fulfill a
4request for medication under this chapter, a consulting physician shall examine the
5requester and his or her relevant patient health care records and shall medically
6confirm the attending physician's determinations that the requester suffers from a
7terminal disease, does not have incapacity, is making a request for medication
8voluntarily, and has made an informed decision.
SB151,9,19 9156.11 Referral for review and counseling. If in the opinion of the
10attending physician or the consulting physician a requester may be suffering from
11a psychiatric or psychological disorder, including depression, that causes impaired
12judgment, the attending physician or consulting physician shall refer the requester
13for review and counseling to a physician specializing in psychiatry or a licensed
14psychologist, as defined in s. 455.01 (4). No request for medication may be fulfilled
15under this chapter unless the physician specializing in psychiatry, or the
16psychologist, to whom referral was made, determines and certifies in writing that the
17requester is not suffering from a psychiatric or psychological disorder, including
18depression, that causes impaired judgment. The certification, if any, shall be filed
19in the requester's patient health care record under s. 156.07 (8).
SB151,9,22 20156.13 Requester rights, responsibilities, and limitations. (1) No
21requester may receive a prescription that fulfills a request for medication unless he
22or she has made an informed decision.
SB151,9,25 23(2) No requester may be required to notify his or her next of kin regarding his
24or her request for medication, and no request for medication may be denied because
25the requester has failed to notify his or her next of kin.
SB151,10,2
1(3) In order to receive a prescription that fulfills a request for medication, a
2requester shall do all of the following:
SB151,10,43 (a) Orally ask his or her attending physician for medication for the purpose of
4ending his or her life.
SB151,10,65 (b) No fewer than 15 days after asking for medication under par. (a), make a
6request for medication.
SB151,10,97 (c) After making a request for medication under par. (b), orally ask his or her
8attending physician a 2nd time for medication for the purpose of ending his or her
9life.
SB151,10,20 10156.15 Request for medication; form. The department shall prepare and
11provide copies of a request for medication form and accompanying information for
12distribution in quantities to health care providers, hospitals, nursing homes,
13multipurpose senior centers, county clerks, and local bar associations and
14individually to private persons. The department shall include, in information
15accompanying the copy of the request for medication form, at least the statutory
16definitions of terms used in the request for medication form, statutory restrictions
17on who may be witnesses to a valid request for medication, and a statement
18explaining that valid witnesses acting in good faith are statutorily immune from civil
19or criminal liability. The request for medication form distributed by the department
20shall be in the following form:
SB151,10,2121 REQUEST FOR MEDICATION
SB151,10,2222 TO END MY LIFE IN A HUMANE
SB151,10,2323 AND DIGNIFIED MANNER
SB151,10,2524 I, ...., am an adult of sound mind, do not have incapacity, and am a resident of
25Wisconsin.
SB151,11,2
1I am suffering from ...., which my attending physician has determined is a
2terminal disease and which has been medically confirmed by a consulting physician.
SB151,11,53 I have been fully informed of my diagnosis, prognosis, the nature of medication
4to be prescribed and potential associated risks, the expected result, and the feasible
5alternatives, including comfort care, hospice care, and pain control.
SB151,11,76 I request that my attending physician prescribe medication that will end my life
7in a humane and dignified manner.
SB151,11,88 INITIAL ONE OF THE FOLLOWING 3 STATEMENTS:
SB151,11,109 .... I have informed my family members of my decision and taken their opinions
10into consideration.
SB151,11,1111 .... I have decided not to inform my family of my decision.
SB151,11,1212 .... I have no family to inform of my decision.
SB151,11,1313 I understand that I have the right to revoke this request at any time.
SB151,11,1514 I understand the full import of this request and I expect to die when I take the
15medication to be prescribed.
SB151,11,1716 I make this request voluntarily and without reservation, and I accept full moral
17responsibility for my actions.
SB151,11,1818 Signed: ....
SB151,11,1919 Dated: ....
SB151,11,20 20Statement and signatures
SB151,11,21 21of witnesses
SB151,12,622 I know the requester personally or I have received proof of his or her identity
23and I believe him or her to be of sound mind and at least 18 years of age. I believe
24that the requester makes this request voluntarily. I am at least 18 years of age, am
25not related to the requester by blood, marriage, or adoption, and am not directly

1financially responsible for the requester's health care. I am not a health care
2provider who is serving the requester at this time; an employee of the health care
3provider, other than a chaplain or a social worker; or an employee, other than a
4chaplain or a social worker, of a health care facility in which the requester is a
5patient. To the best of my knowledge, I am not entitled to and do not have a claim
6on the requester's estate.
SB151,12,77 Witness No. 1:
SB151,12,88 (print) Name: ....
SB151,12,99 Address: ....
SB151,12,1010 Signature: ....
SB151,12,1111 Witness No. 2:
SB151,12,1212 (print) Name: ....
SB151,12,1313 Address: ....
SB151,12,1414 Signature: ....
SB151,12,1515 Witness No. 3:
SB151,12,1616 (print) Name: ....
SB151,12,1717 Address: ....
SB151,12,1818 Signature: ....
SB151,12,2219 If the requester is a patient in a health care facility, at least one of the above
20witnesses must be a patients' advocate designated by the board on aging and
21long-term care. A patients' advocate who is a witness should print "patients'
22advocate" after the printing of his or her name above.
SB151,12,24 23156.17 Revocation of request for medication. (1) A requester may revoke
24his or her request for medication at any time by doing any of the following:
SB151,13,3
1(a) Canceling, defacing, obliterating, burning, tearing, or otherwise destroying
2the request for medication or directing another in the presence of the requester to
3destroy, in the same manner, the request for medication.
SB151,13,54 (b) Executing a statement, in writing, that is signed and dated by the requester,
5expressing the requester's intent to revoke the request for medication.
SB151,13,76 (c) Orally expressing the requester's intent to revoke the request for
7medication, in the presence of 2 witnesses.
SB151,13,88 (d) Making a subsequent request for medication.
SB151,13,12 9(2) The requester's health care provider shall, upon notification of revocation
10of the requester's request for medication, record in the requester's medical record the
11time, date, and place of the revocation and the time, date, and place, if different, of
12the notification to the health care provider of the revocation.
SB151,13,19 13156.19 Designation of patients' advocates. The board on aging and
14long-term care shall designate staff of the long-term care ombudsman program as
15patients' advocates. A person so designated shall serve as a witness to a request for
16medication of a requester who is a patient or resident of a nursing home or
17community-based residential facility, as required under s. 156.05 (2) (b), and shall
18speak on behalf of the requester to ensure that his or her needs or wants are
19communicated to and addressed by his or her attending physician.
SB151,13,22 20156.21 Duties and immunities. (1) No health care facility or health care
21provider may be charged with a crime, held civilly liable, or charged with
22unprofessional conduct for any of the following:
SB151,14,223 (a) Failing to fulfill a request for medication, except that failure of an attending
24physician to fulfill a request for medication constitutes unprofessional conduct if the
25attending physician refuses or fails to make a good faith attempt to transfer the

1requester's care and treatment to another physician who will act as attending
2physician under this chapter and fulfill the request for medication.
SB151,14,43 (b) In the absence of actual knowledge of a revocation, fulfilling a request for
4medication that is in compliance with this chapter.
SB151,14,75 (c) Acting contrary to or failing to act on a revocation of a request for medication,
6unless the health care facility or health care provider has actual knowledge of the
7revocation.
SB151,14,12 8(2) In the absence of actual notice to the contrary, a health care facility or a
9health care provider, other than a physician acting as the requester's attending
10physician under this chapter, may presume that a requester was authorized to make
11his or her request for medication under the requirements of this chapter and that the
12request for medication is valid.
SB151,14,15 13(3) (a) No person who acts in good faith as a witness to a request for medication
14under this chapter may be held civilly or criminally liable for a death that results
15from taking medication under a fulfilled request for medication under this chapter.
SB151,14,1716 (b) Paragraph (a) does not apply to a person who acts as a witness in violation
17of s. 156.05 (2) (a).
SB151,14,21 18156.23 General provisions. (1) (a) The making of a request for medication
19under this chapter does not, for any purpose, constitute attempted suicide. Taking
20medication under a fulfilled request for medication under this chapter does not, for
21any purpose, constitute suicide.
SB151,14,2422 (b) Paragraph (a) does not prohibit an insurer from making a determination
23that a requester has attempted suicide or committed suicide if the requester has so
24acted, apart from the request for medication.
SB151,15,3
1(2) The making of a request for medication under this chapter does not revoke
2or otherwise modify a power of attorney for health care or living will that the
3requester may have executed.
SB151,15,7 4(3) No individual may be required to make a request for medication as a
5condition for receipt of health care or admission to a health care facility. The making
6of a request for medication is not a bar to the receipt of health care or the admission
7to a health care facility.
Loading...
Loading...