AB915: Bill Text

AB915,7,4 AUTHORITY GRANTED

AB915,7,11 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.

AB915,7,20 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.

AB915,7,21 LIMITATIONS ON

AB915,7,22 MENTAL HEALTH TREATMENT

AB915,8,2 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 the mentally retarded, 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.

AB915,8,4 ADMISSION TO NURSING HOMES OR COMMUNITY-BASED RESIDENTIAL FACILITIES

AB915,8,6 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.

AB915,8,9 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:

AB915,8,10 1. A nursing home — Yes.... No....

AB915,8,11 2. A community-based residential facility — Yes.... No....

AB915,8,13 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.

AB915,8,14 PROVISION OF A FEEDING TUBE

AB915,8,19 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 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.

AB915,8,22 My health care agent may not have orally ingested nutrition or hydration withheld or withdrawn from me unless provision of the nutrition or hydration is medically contraindicated.

AB915,8,23 Withhold or withdraw a feeding tube — Yes.... No....

AB915,8,25 If I have not checked either "Yes" or "No" immediately above, my health care agent may not have a feeding tube withdrawn from me.

AB915,9,1 HEALTH CARE DECISIONS

AB915,9,2 FOR PREGNANT WOMEN

AB915,9,6 If I have checked "Yes" to the following, my health care agent may make health care decisions for me even if my agent knows I am pregnant. If I have checked "No" to the following, my health care agent may not make health care decisions for me if my health care agent knows I am pregnant.

AB915,9,7 Health care decision if I am pregnant — Yes.... No....

AB915,9,10 If I have not checked either "Yes" or "No" immediately above, my health care agent may not make health care decisions for me if my health care agent knows I am pregnant.

AB915,9,11 STATEMENT OF DESIRES, SPECIAL

AB915,9,12 PROVISIONS OR LIMITATIONS

AB915,9,16 In exercising authority under this document, my health care agent shall act consistently with my following stated desires, if any, and is subject to any special provisions or limitations that I specify. The following are specific desires, provisions or limitations that I wish to state (add more items if needed):

AB915,9,17 1) -

AB915,9,18 2) -

AB915,9,19 3) -

AB915,9,20 INSPECTION AND DISCLOSURE OF INFORMATION

AB915,9,21 RELATING TO MY PHYSICAL OR MENTAL HEALTH

AB915,9,23 Subject to any limitations in this document, my health care agent has the authority to do all of the following:

AB915,9,25 (a) Request, review and receive any information, oral or written, regarding my physical or mental health, including medical and hospital records.

AB915,10,2 (b) Execute on my behalf any documents that may be required in order to obtain this information.

AB915,10,3 (c) Consent to the disclosure of this information.

AB915,10,4 (The principal and the witnesses all must sign the document at the same time.)

AB915,10,5 SIGNATURE OF PRINCIPAL

AB915,10,6 (person creating the power

AB915,10,7 of attorney for health care)

AB915,10,8 Signature.... Date....

AB915,10,10 (The signing of this document by the principal revokes all previous powers of attorney for health care documents.)

AB915,10,11 STATEMENT OF WITNESSES

AB915,10,21 I know the principal personally and I believe him or her to be of sound mind and at least 18 years of age. I believe that his or her execution of this power of attorney for health care is voluntary. I am at least 18 years of age, am not related to the principal by blood, marriage or adoption and am not directly financially responsible for the principal's health care. I am not a health care provider who is serving the principal at this time, an employe of the health care provider, other than a chaplain or a social worker, or an employe, other than a chaplain or a social worker, of an inpatient health care facility in which the declarant is a patient. I am not the principal's health care agent. To the best of my knowledge, I am not entitled to and do not have a claim on the principal's estate.

AB915,10,22 Witness No. 1:

AB915,10,23 (print) Name.... Date....

AB915,10,24 Address....

AB915,10,25 Signature....

AB915,11,1 Witness No. 2:

AB915,11,2 (print) Name.... Date....

AB915,11,3 Address....

AB915,11,4 Signature....

AB915,11,5 STATEMENT OF HEALTH CARE AGENT

AB915,11,6 AND ALTERNATE HEALTH CARE AGENT

AB915,11,10 I understand that.... (name of principal) has designated me to be his or her health care agent or alternate health care agent if he or she is ever found to have incapacity and unable to make health care decisions himself or herself. .... (name of principal) has discussed his or her desires regarding health care decisions with me.

AB915,11,11 Agent's signature....

AB915,11,12 Address....

AB915,11,13 Alternate's signature....

AB915,11,14 Address....

AB915,11,17 Failure to execute a power of attorney for health care document under chapter 155 of the Wisconsin Statutes creates no presumption about the intent of any individual with regard to his or her health care decisions.

AB915,11,19 This power of attorney for health care is executed as provided in chapter 155 of the Wisconsin Statutes.

AB915,11,20 ANATOMICAL GIFTS (optional)

AB915,11,21 Upon my death:

AB915,11,23 .... I wish to donate only the following organs or parts: .... (specify the organs or parts).

AB915,11,24 .... I wish to donate any needed organ or part.

AB915,12,4 .... I wish to donate my body for anatomical study if needed. (Since many institutions have certain conditions that must be met before receiving donation of a body, I will attempt to contact the institution to which the donation is intended to be made.)

AB915,12,7 .... I refuse to make an anatomical gift. (If this revokes a prior commitment that I have made to make an anatomical gift to a designated donee, I will attempt to notify the donee to which or to whom I agreed to donate.)

AB915,12,9 Failing to check any of the lines immediately above creates no presumption about my desire to make or refuse to make an anatomical gift.

AB915,12,10 Signature.... Date....

AB915, s. 7 Section 7. 155.30 (3m) of the statutes is created to read:

AB915,12,14 155.30 (3m) The department may modify the form specified in sub. (3) to include, for the purposes of making an anatomical gift, the toll-free telephone number of the Wisconsin donor registry under s. 157.06 (10r).

AB915, s. 8 Section 8. 157.06 (1) (c) 2. of the statutes is renumbered 157.06 (1) (c) and amended to read:

AB915,12,20 157.06 (1) (c) "Document of gift" means a card, a statement attached to or imprinted on a license under s. 343.175 (2) or on an identification card under s. 343.50 (3), a will, an enrollment form signed as specified in sub. (10r) (b) or another writing used to make an anatomical gift.

AB915, s. 9 Section 9. 157.06 (1) (em) of the statutes is created to read:

AB915,12,23 157.06 (1) (em) "Eye bank" means a repository for donated human eyes or portions of eyes destined for ocular transplant surgery and research.

AB915, s. 10 Section 10. 157.06 (1) (km) of the statutes is created to read:

AB915,12,25 157.06 (1) (km) "Tissue bank" means a repository for donated tissue and bone.

AB915, s. 11 Section 11. 157.06 (2) (b) of the statutes is amended to read:

AB915,13,7 157.06 (2) (b) An anatomical gift under par. (a) may be made only by a document of gift signed and dated by the donor. If the donor cannot so sign and date, the document of gift shall be signed and dated by another individual and by 2 witnesses, all of whom have signed and dated at the direction and in the presence of the donor and of each other, and the document of gift shall state that it has been so signed and dated.

AB915, s. 12 Section 12. 157.06 (2) (f) 1. of the statutes is amended to read:

AB915,13,9 157.06 (2) (f) 1. Signing and dating a statement of amendment or revocation.

AB915, s. 13 Section 13. 157.06 (2) (f) 1m. of the statutes is amended to read:

AB915,13,13 157.06 (2) (f) 1m. Signing and dating a new document of gift. Signing and dating a new document of gift revokes any previously signed and dated document of gift.

AB915, s. 14 Section 14. 157.06 (2) (f) 4. of the statutes is amended to read:

AB915,13,16 157.06 (2) (f) 4. Delivering a signed and dated statement of amendment or revocation to a specified donee to whom a document of gift had been delivered.

AB915, s. 15 Section 15. 157.06 (2) (f) 5. b. of the statutes is renumbered 157.06 (2) (f) 5. and amended to read:

AB915,13,21 157.06 (2) (f) 5. Crossing out or amending and dating the donor authorization or refusal in the space provided on his or her license as prescribed in s. 343.175 (2) or identification card as prescribed in s. 343.50 (3).

AB915, s. 16 Section 16. 157.06 (2) (i) 1. of the statutes is amended to read:

AB915,13,24 157.06 (2) (i) 1. Making a writing of refusal that is signed and dated in the same manner as is required for a document of gift.

AB915, s. 17 Section 17. 157.06 (2) (i) 2. b. of the statutes is amended to read:

AB915,14,3 157.06 (2) (i) 2. b. Attaching Dating and attaching a statement of refusal to or imprinting a statement of refusal on his or her license under s. 343.175 (2) or identification card under s. 343.50 (3).