Address .... Date of birth ....
I believe that the person signing this document is of sound mind. I am an adult and am not related to the person signing this document by blood, marriage or adoption. I am not entitled to and do not have a claim on any portion of the person's estate and am not otherwise restricted by law from being a witness.
Witness signature .... Date signed ....
Print name ....
Witness signature .... Date signed ....
Print name ....
DIRECTIVES TO ATTENDING PHYSICIAN
1. This document authorizes the withholding or withdrawal of life-sustaining procedures or of feeding tubes when 2 physicians, one of whom is the attending physician, have personally examined and certified in writing that the patient has a terminal condition or is in a persistent vegetative state.
2. The choices in this document were made by a competent adult. Under the law, the patient's stated desires must be followed unless you believe that withholding or withdrawing life-sustaining procedures or feeding tubes would cause the patient pain or reduced comfort and that the pain or discomfort cannot be alleviated through pain relief measures. If the patient's stated desires are that life-sustaining procedures or feeding tubes be used, this directive must be followed.
3. If you feel that you cannot comply with this document, you must make a good faith attempt to transfer the patient to another physician who will comply. Refusal or failure to make a good faith attempt to do so constitutes unprofessional conduct.
4. If you know that the patient is pregnant, this document has no effect during her pregnancy.
* * * * *
The person making this living will may use the following space to record the names of those individuals and health care providers to whom he or she has given copies of this document:
.................................................................
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154.03 Annotation
Living will statutes: The first decade. Gelfand. 1987 WLR 737.
154.03 Annotation
Planning Ahead for Incapacity. Shapiro. Wis. Law. Aug. 1991.
154.03 Annotation
Wisconsin's New Living Will Act. Gilbert. Wis. Law. March 1992.
154.05
154.05
Revocation of declaration. 154.05(1)
(1)
Method of revocation. A declaration may be revoked at any time by the declarant by any of the following methods:
154.05(1)(a)
(a) By being canceled, defaced, obliterated, burned, torn or otherwise destroyed by the declarant or by some person who is directed by the declarant and who acts in the presence of the declarant.
154.05(1)(b)
(b) By a written revocation of the declarant expressing the intent to revoke, signed and dated by the declarant.
154.05(1)(c)
(c) By a verbal expression by the declarant of his or her intent to revoke the declaration. This revocation becomes effective only if the declarant or a person who is acting on behalf of the declarant notifies the attending physician of the revocation.
154.05(2)
(2) Recording the revocation. The attending physician shall record in the patient's medical record the time, date and place of the revocation and the time, date and place, if different, that he or she was notified of the revocation.
154.05 History
History: 1983 a. 202;
1995 a. 168.
154.07
154.07
Duties and immunities. 154.07(1)(a)(a) No physician, inpatient health care facility or health care professional acting under the direction of a physician may be held criminally or civilly liable, or charged with unprofessional conduct, for any of the following:
154.07(1)(a)1.
1. Participating in the withholding or withdrawal of life-sustaining procedures or feeding tubes under this subchapter.
154.07(1)(a)2.
2. Failing to act upon a revocation unless the person or facility has actual knowledge of the revocation.
154.07(1)(a)3.
3. Failing to comply with a declaration, except that failure by a physician to comply with a declaration of a qualified patient constitutes unprofessional conduct if the physician refuses or fails to make a good faith attempt to transfer the qualified patient to another physician who will comply with the declaration.
154.07(1)(b)1.1. No person who acts in good faith as a witness to a declaration under this subchapter may be held civilly or criminally liable for participating in the withholding or withdrawal of life-sustaining procedures or feeding tubes under this subchapter.
154.07(1)(c)
(c) Pars.
(a) and
(b) apply to acts or omissions in connection with a provision of a document that is executed in another jurisdiction if the provision is valid and enforceable under
s. 154.11 (9).
154.07(2)
(2) Effect of declaration. The desires of a qualified patient who is competent supersede the effect of the declaration at all times. If a qualified patient is adjudicated incompetent at the time of the decision to withhold or withdraw life-sustaining procedures or feeding tubes, a declaration executed under this subchapter is presumed to be valid. The declaration of a qualified patient who is diagnosed as pregnant by the attending physician has no effect during the course of the qualified patient's pregnancy. For the purposes of this subchapter, a physician or inpatient health care facility may presume in the absence of actual notice to the contrary that a person who executed a declaration was of sound mind at the time.
154.11
154.11
General provisions. 154.11(1)(1)
Suicide. The withholding or withdrawal of life-sustaining procedures or feeding tubes from a qualified patient under this subchapter does not, for any purpose, constitute suicide. Execution of a declaration under this subchapter does not, for any purpose, constitute attempted suicide.
154.11(2)
(2) Life insurance. Making a declaration under
s. 154.03 may not be used to impair in any manner the procurement of any policy of life insurance, and may not be used to modify the terms of an existing policy of life insurance. No policy of life insurance may be impaired in any manner by the withholding or withdrawal of life-sustaining procedures or feeding tubes from an insured qualified patient.
154.11(3)
(3) Health insurance. No person may be required to execute a declaration as a condition prior to being insured for, or receiving, health care services.
154.11(4)
(4) Other rights. This subchapter does not impair or supersede any of the following:
154.11(4)(a)
(a) A person's right to withhold or withdraw life-sustaining procedures or feeding tubes.
154.11(4)(b)
(b) The right of any person who does not have a declaration in effect to receive life-sustaining procedures or feeding tubes.
154.11(5)
(5) Intent. Failure to execute a declaration under this subchapter creates no presumption that the person consents to the use or withholding of life-sustaining procedures or feeding tubes in the event that the person suffers from a terminal condition or is in a persistent vegetative state.
154.11(5m)
(5m) Valid declaration. A declaration that is in its original form or is a legible photocopy or electronic facsimile copy is presumed to be valid.
154.11(6)
(6) Construction. Nothing in this subchapter condones, authorizes or permits any affirmative or deliberate act to end life other than to permit the natural process of dying.
154.11(7)(a)(a) A declaration under s.
154.03 (2), 1983 stats., that is executed before April 22, 1986, and that is not subsequently revoked or has not subsequently expired is governed by the provisions of ch.
154, 1983 stats.
154.11(7)(b)
(b) A declaration under s.
154.03 (2), 1983 stats., that is executed after April 22, 1986, is void.
154.11(7)(c)
(c) A declaration under s.
154.03 (2), 1989 stats., that is executed before, on or after December 11, 1991, and that is not subsequently revoked or has not subsequently expired is governed by the provisions of ch.
154, 1989 stats.
154.11(7)(d)
(d) Nothing in this chapter, except
par. (b), may be construed to render invalid a declaration that was validly executed under this chapter before April 6, 1996.
154.11(8)
(8) Inclusion in medical record. Upon receipt of a declaration, a health care facility, as defined in
s. 155.01 (6), or a health care provider, as defined in
s. 155.01 (7), shall, if the declarant is a patient of the health care facility or health care provider, include the declaration in the medical record of the declarant.
154.11(9)
(9) Declaration from other jurisdiction. A valid document that authorizes the withholding or withdrawal of life-sustaining procedures or of feeding tubes and that is executed in another state or jurisdiction in compliance with the law of that state or jurisdiction is valid and enforceable in this state to the extent that the document is consistent with the laws of this state.
154.13
154.13
Filing declaration. 154.13(1)(1) A declarant or an individual authorized by the declarant may, for a fee, file the declarant's declaration, for safekeeping, with the register in probate of the county in which the declarant resides.
154.13(2)
(2) If a declarant or authorized individual has filed the declarant's declaration as specified in
sub. (1), the following persons may have access to the declaration without first obtaining consent from the declarant:
154.13(2)(a)
(a) The individual authorized by the declarant.
154.13(2)(b)
(b) A health care provider who is providing care to the declarant.
154.13(2)(c)
(c) The court and all parties involved in proceedings in this state for adjudication of incompetency and appointment of a guardian for the declarant, for emergency detention under
s. 51.15, for involuntary commitment under
s. 51.20, or for protective placement or protective services under
ch. 55.
154.13(2)(d)
(d) Any person under the order of a court for good cause shown.
154.13(3)
(3) Failure to file a declaration under
sub. (1) creates no presumption about the intent of an individual with regard to his or her health care decisions.
154.13 History
History: 1991 a. 281;
2005 a. 387.
154.15(1)(1) Any person who intentionally conceals, cancels, defaces, obliterates or damages the declaration of another without the declarant's consent may be fined not more than $500 or imprisoned not more than 30 days or both.
154.15(2)
(2) Any person who, with the intent to cause a withholding or withdrawal of life-sustaining procedures or feeding tubes contrary to the wishes of the declarant, illegally falsifies or forges the declaration of another or conceals a declaration revoked under
s. 154.05 (1) (a) or
(b) or any person who intentionally withholds actual knowledge of a revocation under
s. 154.05 is guilty of a Class F felony.
DO-NOT-RESUSCITATE ORDERS
154.17
154.17
Definitions. In this subchapter:
154.17(1)
(1) "Do-not-resuscitate bracelet" means a standardized identification bracelet that meets the specifications established under
s. 154.27 (1), or that is approved by the department under
s. 154.27 (2), that bears the inscription "Do Not Resuscitate" and signifies that the wearer is a qualified patient who has obtained a do-not-resuscitate order and that the order has not been revoked.
154.17(2)
(2) "Do-not-resuscitate order" means a written order issued under the requirements of this subchapter that directs emergency medical technicians, first responders and emergency health care facilities personnel not to attempt cardiopulmonary resuscitation on a person for whom the order is issued if that person suffers cardiac or respiratory arrest.
154.17(4)
(4) "Qualified patient" means a person who has attained the age of 18 and to whom any of the following conditions applies:
154.17(4)(b)
(b) The person has a medical condition such that, were the person to suffer cardiac or pulmonary failure, resuscitation would be unsuccessful in restoring cardiac or respiratory function or the person would experience repeated cardiac or pulmonary failure within a short period before death occurs.
154.17(4)(c)
(c) The person has a medical condition such that, were the person to suffer cardiac or pulmonary failure, resuscitation of that person would cause significant physical pain or harm that would outweigh the possibility that resuscitation would successfully restore cardiac or respiratory function for an indefinite period of time.
154.17(5)
(5) "Resuscitation" means cardiopulmonary resuscitation or any component of cardiopulmonary resuscitation, including cardiac compression, endotracheal intubation and other advanced airway management, artificial ventilation, defibrillation, administration of cardiac resuscitation medications and related procedures. "Resuscitation" does not include the Heimlich maneuver or similar procedure used to expel an obstruction from the throat.
154.19
154.19
Do-not-resuscitate order. 154.19(1)
(1) No person except an attending physician may issue a do-not-resuscitate order. An attending physician may issue a do-not-resuscitate order to a patient only if all of the following apply:
