AB417,5,14 13156.05 Valid request for medication; requirements. (1) A valid request
14for medication shall be, for the purposes of s. 156.03, all of the following:
AB417,5,1515 (a) In writing.
AB417,5,1716 (b) Dated and signed by the requester or, at the express direction and in the
17presence of the requester, by an individual who has attained age 18.
AB417,5,1818 (c) Signed in the presence of 3 witnesses who meet the requirements of sub. (2).
AB417,5,1919 (d) Made voluntarily.
AB417,5,2020 (e) Substantially in the form specified in s. 156.15.
AB417,5,2421 (f) Filed in the requester's patient health care record in the custody of the
22requester's attending physician and, if the requester is an inpatient of a health care
23facility, in the requester's patient health care record in the custody of the health care
24facility.
AB417,6,3
1(2) (a) A witness to the making of a valid request for medication shall be an
2individual who has attained age 18. No witness to the making of a valid request for
3medication may, at the time of the witnessing, be any of the following:
AB417,6,44 1. Related to the requester by blood, marriage, or adoption.
AB417,6,65 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.
AB417,6,77 3. Directly financially responsible for the requester's health care.
AB417,6,118 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.
AB417,6,1412 (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.
AB417,6,16 15156.07 Attending physician; responsibilities and limitations. The
16attending physician shall do all of the following:
AB417,6,18 17(1) Determine whether the requester has a terminal disease, does not have
18incapacity, and is making a request under s. 156.03 voluntarily.
AB417,6,19 19(2) Inform the requester of all of the following:
AB417,6,2020 (a) The requester's medical diagnosis.
AB417,6,2121 (b) The requester's prognosis.
AB417,6,2222 (c) The potential risks associated with taking the medication to be prescribed.
AB417,6,2323 (d) The probable result of taking the medication to be prescribed.
AB417,6,2524 (e) The feasible alternatives to taking the medication to be prescribed,
25including comfort care, care of a hospice, and pain control.
AB417,7,2
1(3) Refer the requester to a consulting physician under the requirements of s.
2156.09.
AB417,7,4 3(4) Refer the requester for review and counseling if the referral is determined
4to be appropriate under s. 156.11.
AB417,7,5 5(5) Ask the requester to notify his or her next of kin with respect to the request.
AB417,7,9 6(6) Inform the requester that he or she may revoke the request at any time;
7explain the methods of revocation that are specified under s. 156.17 (1); and offer the
8requester an opportunity to revoke the request at the time, if any, that the requester
9makes a 2nd oral request under s. 156.13 (3) (c).
AB417,7,11 10(7) Before writing a prescription in response to a request for medication, verify
11that all of the following have occurred:
AB417,7,1212 (a) The requester has fulfilled the requirements of s. 156.13 (3).
AB417,7,1413 (b) No fewer than 48 hours have elapsed since the requester made a written
14request for medication.
AB417,7,1515 (c) The requester has made an informed decision.
AB417,7,17 16(8) Document or file all of the following in the requester's patient health care
17record:
AB417,7,1818 (a) All oral and written requests for medication that are made by the requester.
AB417,7,2119 (b) The attending physician's diagnosis of and prognosis for the requester and
20determination as to whether the requester is incapacitated, is acting voluntarily, and
21has made an informed decision.
AB417,7,2422 (c) The consulting physician's diagnosis of and prognosis for the requester and
23determination as to whether the requester is incapacitated, is acting voluntarily, and
24has made an informed decision.
AB417,8,2
1(d) A certification of the outcome and determinations made during any review
2and counseling for which the requester was referred under s. 156.11.
AB417,8,43 (e) A certification as to whether the attending physician offered the requester
4an opportunity to revoke the request for medication, as required under sub. (6).
AB417,8,55 (f) Evidence of a revocation, if made, as specified in s. 156.17 (2).
AB417,8,166 (g) A certification as to whether the requirements of this chapter are met and
7indicating the steps taken to fulfill the request for medication, including a notation
8of any medication that is prescribed. The attending physician shall report the
9information under this paragraph to the department on a form prescribed by the
10department. Information reported to the department under this paragraph that
11could identify the requester, the attending physician, the consulting physician, or the
12psychiatrist or psychologist to whom referral was made under s. 156.11, if any, is
13confidential and may not be disclosed by the department except under an
14investigation of an alleged violation of this chapter. The report of information under
15this paragraph is not a violation of any person's responsibility for maintaining the
16confidentiality of patient health care records under s. 146.82.
AB417,8,23 17(9) If the attending physician refuses to act as the attending physician in
18complying with the requester's request for medication under this chapter, the
19attending physician shall make a good faith attempt to transfer the requester's care
20and treatment to another physician who will act as the attending physician under
21this chapter and will comply with the requester's request for medication. If a
22transfer is made, the attending physician to whom the requester's care and
23treatment is transferred shall comply with the requirements of this section.
AB417,9,4 24156.09 Consulting physician. Before an attending physician may fulfill a
25request for medication under this chapter, a consulting physician shall examine the

1requester and his or her relevant patient health care records and shall medically
2confirm the attending physician's determinations that the requester suffers from a
3terminal disease, does not have incapacity, is making a request for medication
4voluntarily, and has made an informed decision.
AB417,9,15 5156.11 Referral for review and counseling. If in the opinion of the
6attending physician or the consulting physician a requester may be suffering from
7a psychiatric or psychological disorder, including depression, that causes impaired
8judgment, the attending physician or consulting physician shall refer the requester
9for review and counseling to a physician specializing in psychiatry or a licensed
10psychologist, as defined in s. 455.01 (4). No request for medication may be fulfilled
11under this chapter unless the physician specializing in psychiatry, or the
12psychologist, to whom referral was made, determines and certifies in writing that the
13requester is not suffering from a psychiatric or psychological disorder, including
14depression, that causes impaired judgment. The certification, if any, shall be filed
15in the requester's patient health care record under s. 156.07 (8).
AB417,9,18 16156.13 Requester rights, responsibilities, and limitations. (1) No
17requester may receive a prescription for medication that fulfills a request for
18medication under this chapter unless he or she has made an informed decision.
AB417,9,21 19(2) No requester may be required to notify his or her next of kin regarding his
20or her request for medication, and no request for medication may be denied because
21the requester has failed to notify his or her next of kin.
AB417,9,23 22(3) In order to receive a prescription under a request for medication, a
23requester shall do all of the following:
AB417,9,2524 (a) Orally make a request of his or her attending physician for medication for
25the purpose of ending his or her life.
AB417,10,2
1(b) No fewer than 15 days after orally making the request under par. (a), make
2a request for medication that meets the requirements of s. 156.05.
AB417,10,53 (c) After making a request for medication under par. (b), make a 2nd oral
4request of his or her attending physician for medication for the purpose of ending his
5or her life.
AB417,10,16 6156.15 Request for medication; form. The department shall prepare and
7provide copies of a request for medication and accompanying information for
8distribution in quantities to health care providers, hospitals, nursing homes,
9multipurpose senior centers, county clerks, and local bar associations and
10individually to private persons. The department shall include, in information
11accompanying the copy of the request for medication, at least the statutory
12definitions of terms used in the request for medication, statutory restrictions on who
13may be witnesses to a valid request for medication, and a statement explaining that
14valid witnesses acting in good faith are statutorily immune from civil or criminal
15liability. The request for medication distributed by the department shall be in the
16following form:
AB417,10,1717 REQUEST FOR MEDICATION
AB417,10,1818 TO END MY LIFE IN A HUMANE
AB417,10,1919 AND DIGNIFIED MANNER
AB417,10,2020 I, ...., am an adult of sound mind and am a resident of Wisconsin.
AB417,10,2221 I am suffering from ...., which my attending physician has determined is a
22terminal disease and which has been medically confirmed by a consulting physician.
AB417,10,2523 I have been fully informed of my diagnosis, prognosis, the nature of medication
24to be prescribed and potential associated risks, the expected result, and the feasible
25alternatives, including comfort care, hospice care, and pain control.
AB417,11,2
1I request that my attending physician prescribe medication that will end my life
2in a humane and dignified manner.
AB417,11,33 INITIAL ONE OF THE FOLLOWING 3 STATEMENTS:
AB417,11,54 .... I have informed my family members of my decision and taken their opinions
5into consideration.
AB417,11,66 .... I have decided not to inform my family of my decision.
AB417,11,77 .... I have no family to inform of my decision.
AB417,11,88 I understand that I have the right to revoke this request at any time.
AB417,11,109 I understand the full import of this request and I expect to die when I take the
10medication to be prescribed.
AB417,11,1211 I make this request voluntarily and without reservation, and I accept full moral
12responsibility for my actions.
AB417,11,1313 Signed: ....
AB417,11,1414 Dated: ....
AB417,11,15 15Statement and signatures
AB417,11,16 16of witnesses
AB417,12,217 I know the requester personally or I have received proof of his or her identity
18and I believe him or her to be of sound mind and at least 18 years of age. I believe
19that the requester makes this request voluntarily. I am at least 18 years of age, am
20not related to the requester by blood, marriage, or adoption, and am not directly
21financially responsible for the requester's health care. I am not a health care
22provider who is serving the requester at this time, an employee of the health care
23provider, other than a chaplain or a social worker, or an employee, other than a
24chaplain or a social worker, of a health care facility in which the requester is a

1patient. To the best of my knowledge, I am not entitled to and do not have a claim
2on the requester's estate.
AB417,12,33 Witness No. 1:
AB417,12,44 (print) Name: ....
AB417,12,55 Address: ....
AB417,12,66 Signature: ....
AB417,12,77 Witness No. 2:
AB417,12,88 (print) Name: ....
AB417,12,99 Address: ....
AB417,12,1010 Signature: ....
AB417,12,1111 Witness No. 3:
AB417,12,1212 (print) Name: ....
AB417,12,1313 Address: ....
AB417,12,1414 Signature: ....
AB417,12,1815 If the requester is a patient in a health care facility, at least one of the above
16witnesses must be a patients' advocate designated by the board on aging and
17long-term care. A patients' advocate who is a witness should print "patients'
18advocate" after the printing of his or her name above.
AB417,12,20 19156.17 Revocation of request for medication. (1) A requester may revoke
20his or her request for medication at any time by doing any of the following:
AB417,12,2321 (a) Canceling, defacing, obliterating, burning, tearing, or otherwise destroying
22the request for medication or directing another in the presence of the requester to
23destroy, in the same manner, the request for medication.
AB417,12,2524 (b) Executing a statement, in writing, that is signed and dated by the requester,
25expressing the requester's intent to revoke the request for medication.
AB417,13,2
1(c) Orally expressing the requester's intent to revoke the request for
2medication, in the presence of 2 witnesses.
AB417,13,33 (d) Making a subsequent request for medication.
AB417,13,7 4(2) The requester's health care provider shall, upon notification of revocation
5of the requester's request for medication, record in the requester's medical record the
6time, date, and place of the revocation and the time, date, and place, if different, of
7the notification to the health care provider of the revocation.
AB417,13,14 8156.19 Designation of patients' advocates. The board on aging and
9long-term care shall designate staff of the long-term care ombudsman program as
10patients' advocates. A person so designated shall serve as a witness to a request for
11medication of a requester who is a patient or resident of a nursing home or
12community-based residential facility, as required under s. 156.05 (2) (b), and shall
13speak on behalf of the requester to ensure that his or her needs or wants are
14communicated to and addressed by his or her attending physician.
AB417,13,17 15156.21 Duties and immunities. (1) No health care facility or health care
16provider may be charged with a crime, held civilly liable, or charged with
17unprofessional conduct for any of the following:
AB417,13,2218 (a) Failing to fulfill a request for medication, except that failure of an attending
19physician to fulfill a request for medication constitutes unprofessional conduct if the
20attending physician refuses or fails to make a good faith attempt to transfer the
21requester's care and treatment to another physician who will act as attending
22physician under this chapter and fulfill the request for medication.
AB417,13,2423 (b) In the absence of actual knowledge of a revocation, fulfilling a request for
24medication that is in compliance with this chapter.
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