9Declaration to physicians
(WISCONSIN LIVING WILL)
I,...., being of sound mind, voluntarily state my desire that my dying not be 12
prolonged under the circumstances specified in this document. Under those 13
circumstances, I direct that I be permitted to die naturally. If I am unable to give 14
directions regarding the use of life-sustaining procedures or feeding tubes, I intend 15
that my family and physician honor this document as the final expression of my legal 16
right to refuse medical or surgical treatment.
1. If I have a TERMINAL CONDITION, as determined by 2 physicians who 18
have personally examined me, I do not want my dying to be artificially prolonged and 19
I do not want life-sustaining procedures to be used. In addition, the following are 20
my directions regarding the use of feeding tubes:
.... YES, I want feeding tubes used if I have a terminal condition.
.... NO, I do not want feeding tubes used if I have a terminal condition.
If you have not checked either box, feeding tubes will be used.
2. If I am in a PERSISTENT VEGETATIVE STATE, as determined by 2 2
physicians who have personally examined me, the following are my directions 3
regarding the use of life-sustaining procedures:
.... YES, I want life-sustaining procedures used if I am in a persistent 5
.... NO, I do not want life-sustaining procedures used if I am in a persistent 7
If you have not checked either box, life-sustaining procedures will be used.
3. If I am in a PERSISTENT VEGETATIVE STATE, as determined by 2 10
physicians who have personally examined me, the following are my directions 11
regarding the use of feeding tubes:
.... YES, I want feeding tubes used if I am in a persistent vegetative state.
.... NO, I do not want feeding tubes used if I am in a persistent vegetative state.
If you have not checked either box, feeding tubes will be used.
If you are interested in more information about the significant terms used in 16
this document, see section 154.01 of the Wisconsin Statutes or the information 17
accompanying this document.
ATTENTION: You and the 2 witnesses must sign the document at the same 19
Date of birth ....
I believe that the person signing this document is of sound mind. I am an adult 23
and am not related to the person signing this document by blood, marriage or 24
adoption. I am not entitled to and do not have a claim on any portion of the person's 25
estate and am not otherwise restricted by law from being a witness.
Witness signature ....
Date signed ....
Print name ....
Witness signature ....
Date signed ....
Print name ....
1. This document authorizes the withholding or withdrawal of life-sustaining 8
procedures or of feeding tubes when 2 physicians, one of whom is the attending 9
physician, have personally examined and certified in writing that the patient has a 10
terminal condition or is in a persistent vegetative state.
2. The choices in this document were made by a competent adult. Under the 12
law, the patient's stated desires must be followed unless you believe that withholding 13
or withdrawing life-sustaining procedures or feeding tubes would cause the patient 14
pain or reduced comfort and that the pain or discomfort cannot be alleviated through 15
pain relief measures. If the patient's stated desires are that life-sustaining 16
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 18
faith attempt to transfer the patient to another physician who will comply. Refusal 19
or failure to make a good faith attempt to do so constitutes unprofessional conduct.
20 4. If you know that the patient is pregnant, this document has no effect during
The person making this living will may use the following space to record the 24
names of those individuals and health care providers to whom he or she has given 25
copies of this document:
154.07 (2) of the statutes is amended to read:
154.07 (2) Effect of declaration.
The desires of a qualified patient who is 6
competent supersede the effect of the declaration at all times. If a qualified patient 7
is adjudicated incompetent at the time of the decision to withhold or withdraw 8
life-sustaining procedures or feeding tubes, a declaration executed under this 9
subchapter is presumed to be valid. The declaration of a qualified patient who is
10diagnosed as pregnant by the attending physician has no effect during the course of
11the qualified patient's pregnancy.
For the purposes of this subchapter, a physician 12
or inpatient health care facility may presume in the absence of actual notice to the 13
contrary that a person who executed a declaration was of sound mind at the time.
154.19 (1) (e) of the statutes is repealed.
154.19 (3) (b) 3. of the statutes is repealed.
155.20 (6) of the statutes is amended to read:
If the principal is known to be pregnant, the health care agent may 18
make a health care decision on behalf of the principal that the power of attorney for 19
health care instrument authorizes, unless the power of attorney for health care
20instrument specifies otherwise
155.30 (3) of the statutes is amended to read:
The department shall prepare and provide copies of a power of 23
attorney for health care instrument and accompanying information for distribution 24
in quantities to health care professionals, hospitals, nursing homes, multipurpose 25
senior centers, county clerks, and local bar associations and individually to private
persons. The department shall include, in information accompanying the copy of the 2
instrument, at least the statutory definitions of terms used in the instrument, 3
statutory restrictions on who may be witnesses to a valid instrument, a statement 4
explaining that valid witnesses acting in good faith are statutorily immune from civil 5
or criminal liability and a statement explaining that an instrument may, but need 6
not, be filed with the register in probate of the principal's county of residence. The 7
department may charge a reasonable fee for the cost of preparation and distribution. 8
The power of attorney for health care instrument distributed by the department 9
shall include the notice specified in sub. (1) and shall be in the following form:
POWER OF ATTORNEY11
FOR HEALTH CARE
Document made this.... day of.... (month),.... (year).
CREATION OF POWER OF ATTORNEY14
FOR HEALTH CARE
I,.... (print name, address and date of birth), being of sound mind, intend by this 16
document to create a power of attorney for health care. My executing this power of 17
attorney for health care is voluntary. Despite the creation of this power of attorney 18
for health care, I expect to be fully informed about and allowed to participate in any 19
health care decision for me, to the extent that I am able. For the purposes of this 20
document, "health care decision" means an informed decision to accept, maintain, 21
discontinue or refuse any care, treatment, service or procedure to maintain, diagnose 22
or treat my physical or mental condition.
In addition, I may, by this document, specify my wishes with respect to making 24
an anatomical gift upon my death.
HEALTH CARE AGENT
If I am no longer able to make health care decisions for myself, due to my 4
incapacity, I hereby designate.... (print name, address and telephone number) to be 5
my health care agent for the purpose of making health care decisions on my behalf. 6
If he or she is ever unable or unwilling to do so, I hereby designate.... (print name, 7
address and telephone number) to be my alternate health care agent for the purpose 8
of making health care decisions on my behalf. Neither my health care agent nor my 9
alternate health care agent whom I have designated is my health care provider, an 10
employee of my health care provider, an employee of a health care facility in which 11
I am a patient or a spouse of any of those persons, unless he or she is also my relative. 12
For purposes of this document, "incapacity" exists if 2 physicians or a physician and 13
a psychologist who have personally examined me sign a statement that specifically 14
expresses their opinion that I have a condition that means that I am unable to receive 15
and evaluate information effectively or to communicate decisions to such an extent 16
that I lack the capacity to manage my health care decisions. A copy of that statement 17
must be attached to this document.
OF AUTHORITY GRANTED
Unless I have specified otherwise in this document, if I ever have incapacity I 21
instruct my health care provider to obtain the health care decision of my health care 22
agent, if I need treatment, for all of my health care and treatment. I have discussed 23
my desires thoroughly with my health care agent and believe that he or she 24
understands my philosophy regarding the health care decisions I would make if I
were able. I desire that my wishes be carried out through the authority given to my 2
health care agent under this document.
If I am unable, due to my incapacity, to make a health care decision, my health 4
care agent is instructed to make the health care decision for me, but my health care 5
agent should try to discuss with me any specific proposed health care if I am able to 6
communicate in any manner, including by blinking my eyes. If this communication 7
cannot be made, my health care agent shall base his or her decision on any health 8
care choices that I have expressed prior to the time of the decision. If I have not 9
expressed a health care choice about the health care in question and communication 10
cannot be made, my health care agent shall base his or her health care decision on 11
what he or she believes to be in my best interest.
MENTAL HEALTH TREATMENT
My health care agent may not admit or commit me on an inpatient basis to an 15
institution for mental diseases, an intermediate care facility for persons with an 16
intellectual disability, a state treatment facility or a treatment facility. My health 17
care agent may not consent to experimental mental health research or 18
psychosurgery, electroconvulsive treatment or drastic mental health treatment 19
procedures for me.
ADMISSION TO NURSING HOMES OR21
My health care agent may admit me to a nursing home or community-based 24
residential facility for short-term stays for recuperative care or respite care.
If I have checked "Yes" to the following, my health care agent may admit me for 2
a purpose other than recuperative care or respite care, but if I have checked "No" to 3
the following, my health care agent may not so admit me:
1. A nursing home — Yes.... No....
2. A community-based residential facility — Yes.... No....
If I have not checked either "Yes" or "No" immediately above, my health care 7
agent may admit me only for short-term stays for recuperative care or respite care.
PROVISION OF A FEEDING TUBE
If I have checked "Yes" to the following, my health care agent may have a 10
feeding tube withheld or withdrawn from me, unless my physician has advised that, 11
in his or her professional judgment, this will cause me pain or will reduce my comfort. 12
If I have checked "No" to the following, my health care agent may not have a feeding 13
tube withheld or withdrawn from me.
My health care agent may not have orally ingested nutrition or hydration 15
withheld or withdrawn from me unless provision of the nutrition or hydration is 16
Withhold or withdraw a feeding tube — Yes.... No....
If I have not checked either "Yes" or "No" immediately above, my health care 19
agent may not have a feeding tube withdrawn from me.
HEALTH CARE DECISIONS FOR 21
If I have checked "Yes" to the following, my health care agent may make health 23
care decisions for me even if my agent knows I am pregnant. If I have checked "No" 24
to the following, my health care agent may not make health care decisions for me if 25
my health care agent knows I am pregnant.
Health care decision if I am pregnant — Yes.... No....
If I have not checked either "Yes" or "No" immediately above, my health care 3
agent may not
make health care decisions for me if my health care agent knows I am 4
STATEMENT OF DESIRES, SPECIAL6
PROVISIONS OR LIMITATIONS
In exercising authority under this document, my health care agent shall act 8
consistently with my following stated desires, if any, and is subject to any special 9
provisions or limitations that I specify. The following are specific desires, provisions 10
or limitations that I wish to state (add more items if needed):
INSPECTION AND DISCLOSURE OF 15
INFORMATION RELATING TO MY16
PHYSICAL OR MENTAL HEALTH
Subject to any limitations in this document, my health care agent has the 18
authority to do all of the following:
(a) Request, review and receive any information, oral or written, regarding my 20
physical or mental health, including medical and hospital records.
(b) Execute on my behalf any documents that may be required in order to obtain 22
(c) Consent to the disclosure of this information.
(The principal and the witnesses all must sign the document at the same time.)
SIGNATURE OF PRINCIPAL
(person creating the power of attorney for health care)
(The signing of this document by the principal revokes all previous powers of 4
attorney for health care documents.)
STATEMENT OF WITNESSES
I know the principal personally and I believe him or her to be of sound mind and 7
at least 18 years of age. I believe that his or her execution of this power of attorney 8
for health care is voluntary. I am at least 18 years of age, am not related to the 9
principal by blood, marriage, or adoption, am not the domestic partner under ch. 770 10
of the principal, and am not directly financially responsible for the principal's health 11
care. I am not a health care provider who is serving the principal at this time, an 12
employee of the health care provider, other than a chaplain or a social worker, or an 13
employee, other than a chaplain or a social worker, of an inpatient health care facility 14
in which the declarant is a patient. I am not the principal's health care agent. To 15
the best of my knowledge, I am not entitled to and do not have a claim on the 16
Witness No. 1:
(print) Name.... Date....