.... 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 this document, see section 154.01 of the Wisconsin Statutes or the information accompanying this document.
ATTENTION: You and the 2 witnesses must sign the document at the same time.
Signed .... Date ....
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, PHYSICIAN ASSISTANT, OR ADVANCED PRACTICE REGISTERED NURSE
1. This document authorizes the withholding or withdrawal of life-sustaining procedures or of feeding tubes when 2 physicians a physician and another physician, physician assistant, or advanced practice registered nurse, one of whom is the attending physician
health care professional, 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, physician assistant, or advanced practice registered nurse 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:
.................................................................
.................................................................
.................................................................
90,13
Section
13. 154.05 (1) (c) of the statutes is amended to read:
154.05 (1) (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 health care professional of the revocation.
90,14
Section
14. 154.05 (2) of the statutes is amended to read:
154.05 (2) Recording the revocation. The attending physician health care professional 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.
90,15
Section
15. 154.07 (1) (a) (intro.) of the statutes is amended to read:
154.07 (1) (a) (intro.) No physician health care professional, inpatient health care facility or health care professional person licensed, certified, or registered under ch. 441, 448, or 455 acting under the direction of a physician health care professional may be held criminally or civilly liable, or charged with unprofessional conduct, for any of the following:
90,16
Section
16. 154.07 (1) (a) 3. of the statutes is amended to read:
154.07 (1) (a) 3. Failing to comply with a declaration, except that failure by a physician health care professional to comply with a declaration of a qualified patient constitutes unprofessional conduct if the physician
health care professional refuses or fails to make a good faith attempt to transfer the qualified patient to another physician health care professional who will comply with the declaration.
90,17
Section
17. 154.07 (2) of the statutes is amended to read:
154.07 (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 health care professional has no effect during the course of the qualified patient's pregnancy. For the purposes of this subchapter, a physician health care professional 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.
90,18
Section
18. 154.19 (1) (intro.) of the statutes is amended to read:
154.19 (1) (intro.) No person except an attending physician health care professional may issue a do-not-resuscitate order. An attending physician health care professional may issue a do-not-resuscitate order to a patient only if all of the following apply:
90,19
Section
19. 154.19 (1) (e) of the statutes is amended to read:
154.19 (1) (e) The physician
health care professional does not know the patient to be pregnant.
90,20
Section
20. 154.19 (2) (a) of the statutes is amended to read:
154.19 (2) (a) The attending physician health care professional, or a person directed by the attending physician health care professional, shall provide the patient with written information about the resuscitation procedures that the patient has chosen to forego and the methods by which the patient may revoke the do-not-resuscitate order.
90,21
Section
21. 154.19 (2) (b) (intro.) of the statutes is amended to read:
154.19 (2) (b) (intro.) After providing the information under par. (a), the attending physician
health care professional, or the person directed by the attending physician health care professional, shall document in the patient's medical record the medical condition that qualifies the patient for the do-not-resuscitate order, shall make the order in writing and shall do one of the following, as requested by the qualified patient:
90,22
Section
22. 154.21 (2) of the statutes is amended to read:
154.21 (2) Recording the revocation. The attending physician health care professional shall be notified as soon as practicable of the patient's revocation and shall record in the patient's medical record the time, date and place of the revocation, if known, and the time, date and place, if different, that he or she was notified of the revocation. A revocation under sub. (1) is effective regardless of when the attending physician health care professional has been notified of that revocation.
90,23
Section
23. 154.23 (intro.) of the statutes is amended to read:
154.23 Liability. (intro.) No physician, emergency medical services practitioner, emergency medical responder, health care professional provider, as defined in s. 146.81 (1), or emergency health care facility may be held criminally or civilly liable, or charged with unprofessional conduct, for any of the following:
90,24
Section
24. 154.27 (1) of the statutes is amended to read:
154.27 (1) The department shall establish by rule a uniform standard for the size, color, and design of all do-not-resuscitate bracelets. Except as provided in sub. (2), the rules shall require that the do-not-resuscitate bracelets include the inscription “Do Not Resuscitate"; the name, address, date of birth and gender of the patient; and the name, business telephone number and signature of the attending physician health care professional issuing the order.
90,25
Section
25. 155.01 (1) of the statutes is renumbered 155.01 (1r).
90,26
Section
26. 155.01 (1g) of the statutes is created to read:
155.01 (1g) “Advanced practice clinician” means any of the following:
(a) A licensed psychologist, as defined in s. 455.01 (4).
(b) A registered nurse under ch. 441 who is currently certified as a nurse practitioner by a national certifying body approved by the board of nursing.
(c) A physician assistant licensed under ch. 448 who a physician responsible for overseeing the physician assistant's practice affirms is competent to conduct evaluations of the capacity of patients to manage health care decisions.
90,27
Section
27. 155.05 (2) of the statutes is amended to read:
155.05 (2) Unless otherwise specified in the power of attorney for health care instrument, an individual's power of attorney for health care takes effect upon a finding of incapacity by 2 physicians, as defined in s. 448.01 (5), or one physician and one licensed psychologist, as defined in s. 455.01 (4) advanced practice clinician, who personally examine the principal and sign a statement specifying that the principal has incapacity. Mere old age, eccentricity or physical disability, either singly or together, are insufficient to make a finding of incapacity. Neither of the individuals who make a finding of incapacity may be a relative of the principal or have knowledge that he or she is entitled to or has a claim on any portion of the principal's estate. A copy of the statement, if made, shall be appended to the power of attorney for health care instrument.
90,28
Section
28. 155.20 (4) of the statutes is amended to read:
155.20 (4) A health care agent may consent to the withholding or withdrawal of a feeding tube for the principal if the power of attorney for health care instrument so authorizes, unless the principal's attending physician health care professional, as defined in s. 154.01 (1r), advises that, in his or her professional judgment, the withholding or withdrawal will cause the principal pain or reduce the principal's comfort. A health care agent may not consent to the withholding or withdrawal of orally ingested nutrition or hydration unless provision of the nutrition or hydration is medically contraindicated.
90,29
Section
29. 155.30 (1) of the statutes is amended to read:
155.30 (1) A printed form of a power of attorney for health care instrument that is sold or otherwise distributed for use by an individual in this state who does not have the advice of legal counsel shall provide no authority other than the authority to make health care decisions on behalf of the principal and shall contain the following statement in not less than 10-point boldface type:
“NOTICE TO PERSON
MAKING THIS DOCUMENT
YOU HAVE THE RIGHT TO MAKE DECISIONS ABOUT YOUR HEALTH CARE. NO HEALTH CARE MAY BE GIVEN TO YOU OVER YOUR OBJECTION, AND NECESSARY HEALTH CARE MAY NOT BE STOPPED OR WITHHELD IF YOU OBJECT.
BECAUSE YOUR HEALTH CARE PROVIDERS IN SOME CASES MAY NOT HAVE HAD THE OPPORTUNITY TO ESTABLISH A LONG-TERM RELATIONSHIP WITH YOU, THEY ARE OFTEN UNFAMILIAR WITH YOUR BELIEFS AND VALUES AND THE DETAILS OF YOUR FAMILY RELATIONSHIPS. THIS POSES A PROBLEM IF YOU BECOME PHYSICALLY OR MENTALLY UNABLE TO MAKE DECISIONS ABOUT YOUR HEALTH CARE.
IN ORDER TO AVOID THIS PROBLEM, YOU MAY SIGN THIS LEGAL DOCUMENT TO SPECIFY THE PERSON WHOM YOU WANT TO MAKE HEALTH CARE DECISIONS FOR YOU IF YOU ARE UNABLE TO MAKE THOSE DECISIONS PERSONALLY. THAT PERSON IS KNOWN AS YOUR HEALTH CARE AGENT. YOU SHOULD TAKE SOME TIME TO DISCUSS YOUR THOUGHTS AND BELIEFS ABOUT MEDICAL TREATMENT WITH THE PERSON OR PERSONS WHOM YOU HAVE SPECIFIED. YOU MAY STATE IN THIS DOCUMENT ANY TYPES OF HEALTH CARE THAT YOU DO OR DO NOT DESIRE, AND YOU MAY LIMIT THE AUTHORITY OF YOUR HEALTH CARE AGENT. IF YOUR HEALTH CARE AGENT IS UNAWARE OF YOUR DESIRES WITH RESPECT TO A PARTICULAR HEALTH CARE DECISION, HE OR SHE IS REQUIRED TO DETERMINE WHAT WOULD BE IN YOUR BEST INTERESTS IN MAKING THE DECISION.
THIS IS AN IMPORTANT LEGAL DOCUMENT. IT GIVES YOUR AGENT BROAD POWERS TO MAKE HEALTH CARE DECISIONS FOR YOU. IT REVOKES ANY PRIOR POWER OF ATTORNEY FOR HEALTH CARE THAT YOU MAY HAVE MADE. IF YOU WISH TO CHANGE YOUR POWER OF ATTORNEY FOR HEALTH CARE, YOU MAY REVOKE THIS DOCUMENT AT ANY TIME BY DESTROYING IT, BY DIRECTING ANOTHER PERSON TO DESTROY IT IN YOUR PRESENCE, BY SIGNING A WRITTEN AND DATED STATEMENT OR BY STATING THAT IT IS REVOKED IN THE PRESENCE OF TWO WITNESSES. IF YOU REVOKE, YOU SHOULD NOTIFY YOUR AGENT, YOUR HEALTH CARE PROVIDERS AND ANY OTHER PERSON TO WHOM YOU HAVE GIVEN A COPY. IF YOUR AGENT IS YOUR SPOUSE OR DOMESTIC PARTNER AND YOUR MARRIAGE IS ANNULLED OR YOU ARE DIVORCED OR THE DOMESTIC PARTNERSHIP IS TERMINATED AFTER SIGNING THIS DOCUMENT, THE DOCUMENT IS INVALID.
YOU MAY ALSO USE THIS DOCUMENT TO MAKE OR REFUSE TO MAKE AN ANATOMICAL GIFT UPON YOUR DEATH. IF YOU USE THIS DOCUMENT TO MAKE OR REFUSE TO MAKE AN ANATOMICAL GIFT, THIS DOCUMENT REVOKES ANY PRIOR RECORD OF GIFT THAT YOU MAY HAVE MADE. YOU MAY REVOKE OR CHANGE ANY ANATOMICAL GIFT THAT YOU MAKE BY THIS DOCUMENT BY CROSSING OUT THE ANATOMICAL GIFTS PROVISION IN THIS DOCUMENT.
DO NOT SIGN THIS DOCUMENT UNLESS YOU CLEARLY UNDERSTAND IT.
IT IS SUGGESTED THAT YOU KEEP THE ORIGINAL OF THIS DOCUMENT ON FILE WITH YOUR PHYSICIAN OR OTHER PRIMARY CARE PROVIDER."
90,30
Section
30. 155.30 (3) of the statutes is amended to read:
155.30 (3) The department shall prepare and provide copies of a power of attorney for health care instrument and accompanying information for distribution in quantities to health care professionals, hospitals, nursing homes, multipurpose senior centers, county clerks, and local bar associations and individually to private persons. The department shall include, in information accompanying the copy of the instrument, at least the statutory definitions of terms used in the instrument, statutory restrictions on who may be witnesses to a valid instrument, a statement explaining that valid witnesses acting in good faith are statutorily immune from civil or criminal liability and a statement explaining that an instrument may, but need not, be filed with the register in probate of the principal's county of residence. The department may charge a reasonable fee for the cost of preparation and distribution. The power of attorney for health care instrument distributed by the department shall include the notice specified in sub. (1) and shall be in the following form:
POWER OF ATTORNEY FOR HEALTH CARE
Document made this.... day of.... (month),.... (year).
CREATION OF POWER OF ATTORNEY
FOR HEALTH CARE
I,.... (print name, address and date of birth), being of sound mind, intend by this document to create a power of attorney for health care. My executing this power of attorney for health care is voluntary. Despite the creation of this power of attorney for health care, I expect to be fully informed about and allowed to participate in any health care decision for me, to the extent that I am able. For the purposes of this document, “health care decision" means an informed decision to accept, maintain, discontinue or refuse any care, treatment, service or procedure to maintain, diagnose or treat my physical or mental condition.
In addition, I may, by this document, specify my wishes with respect to making an anatomical gift upon my death.
DESIGNATION OF HEALTH CARE AGENT
If I am no longer able to make health care decisions for myself, due to my incapacity, I hereby designate.... (print name, address and telephone number) to be my health care agent for the purpose of making health care decisions on my behalf. If he or she is ever unable or unwilling to do so, I hereby designate.... (print name, address and telephone number) to be my alternate health care agent for the purpose of making health care decisions on my behalf. Neither my health care agent nor my alternate health care agent whom I have designated is my health care provider, an employee of my health care provider, an employee of a health care facility in which I am a patient or a spouse of any of those persons, unless he or she is also my relative. For purposes of this document, “incapacity" exists if 2 physicians or a physician and a psychologist, nurse practitioner, or physician assistant who have personally examined me sign a statement that specifically expresses their opinion that I have a condition that means that I am unable to receive and evaluate information effectively or to communicate decisions to such an extent that I lack the capacity to manage my health care decisions. A copy of that statement must be attached to this document.
GENERAL STATEMENT OF AUTHORITY GRANTED
Unless I have specified otherwise in this document, if I ever have incapacity I instruct my health care provider to obtain the health care decision of my health care agent, if I need treatment, for all of my health care and treatment. I have discussed my desires thoroughly with my health care agent and believe that he or she 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 health care agent under this document.
If I am unable, due to my incapacity, to make a health care decision, my health care agent is instructed to make the health care decision for me, but my health care agent should try to discuss with me any specific proposed health care if I am able to communicate in any manner, including by blinking my eyes. If this communication cannot be made, my health care agent shall base his or her decision on any health care choices that I have expressed prior to the time of the decision. If I have not expressed a health care choice about the health care in question and communication cannot be made, my health care agent shall base his or her health care decision on what he or she believes to be in my best interest.
LIMITATIONS ON MENTAL HEALTH TREATMENT
My health care agent may not admit or commit me on an inpatient basis to an institution for mental diseases, an intermediate care facility for persons with an intellectual disability, a state treatment facility or a treatment facility. My health care agent may not consent to experimental mental health research or psychosurgery, electroconvulsive treatment or drastic mental health treatment procedures for me.
ADMISSION TO NURSING HOMES OR
COMMUNITY-BASED RESIDENTIAL FACILITIES
My health care agent may admit me to a nursing home or community-based 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 a purpose other than recuperative care or respite care, but if I have checked “No" to 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 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 feeding tube withheld or withdrawn from me, unless my physician, physician assistant, or nurse practitioner has advised that, in his or her professional judgment, this will cause me pain or will reduce my comfort. If I have checked “No" to the following, my health care agent may not have a feeding tube withheld or withdrawn from me.
