SB184,10,13 4156.15 Request for medication; form. The department shall prepare and
5provide copies of a request for medication and accompanying information for
6distribution in quantities to health care providers, hospitals, nursing homes,
7multipurpose senior centers, county clerks, local bar associations, and, individually,
8private persons. The department shall include, in information accompanying the
9copy of the request for medication, at least the statutory definitions of terms used in
10the request for medication, statutory restrictions on who may be witnesses to a valid
11request for medication, and a statement explaining that valid witnesses acting in
12good faith are statutorily immune from civil or criminal liability. The request for
13medication distributed by the department shall be in the following form:
SB184,10,1414 REQUEST FOR MEDICATION
SB184,10,1515 TO END MY LIFE IN A HUMANE
SB184,10,1616 AND DIGNIFIED MANNER
SB184,10,1717 I, ...., am an adult of sound mind and am a resident of Wisconsin.
SB184,10,2018 I am suffering from ...., which my attending physician has determined is a
19terminal disease and the terminality of which has been medically confirmed by a
20consulting physician.
SB184,10,2321 I have been fully informed of my diagnosis, prognosis, the nature of medication
22to be prescribed, and potential associated risks, the expected result, and the feasible
23alternatives, including comfort care, hospice care, and pain control.
SB184,10,2524 I request that my attending physician prescribe medication that will end my life
25in a humane and dignified manner.
SB184,11,1
1INITIAL ONE OF THE FOLLOWING 3 STATEMENTS:
SB184,11,32 .... I have informed my family members of my decision and have taken their
3opinions into consideration.
SB184,11,44 .... I have decided not to inform my family of my decision.
SB184,11,55 .... I have no family to inform of my decision.
SB184,11,66 I understand that I have the right to revoke this request at any time.
SB184,11,87 I understand the full import of this request and I expect to die when I take the
8medication to be prescribed.
SB184,11,109 I make this request voluntarily and without reservation, and I accept full moral
10responsibility for my actions.
SB184,11,1111 Signed: ....
SB184,11,1212 Dated: ....
SB184,11,13 13Statement and signatures
SB184,11,14 14of witnesses
SB184,11,2415 I know the requester personally or I have received proof of his or her identity
16and I believe him or her to be of sound mind and at least 18 years of age. I believe
17that the requester makes this request voluntarily. I am at least 18 years of age, am
18not related to the requester by blood, marriage, or adoption and am not directly
19financially responsible for the requester's health care. I am not a health care
20provider who is an individual and is serving the requester at this time, an employee
21of a health care provider who is serving the requester at this time, other than a
22chaplain or a social worker, or an employee, other than a chaplain or a social worker,
23of a health care facility in which the requester is a patient. To the best of my
24knowledge, I am not entitled to and do not have a claim on the requester's estate.
SB184,11,2525 Witness No. 1:
SB184,12,1
1(print) Name: ....
SB184,12,22 Address: ....
SB184,12,33 Signature: ....
SB184,12,44 Witness No. 2:
SB184,12,55 (print) Name: ....
SB184,12,66 Address: ....
SB184,12,77 Signature: ....
SB184,12,88 Witness No. 3:
SB184,12,99 (print) Name: ....
SB184,12,1010 Address: ....
SB184,12,1111 Signature: ....
SB184,12,1512 If the requester is a patient in a health care facility, at least one of the above
13witnesses must be a patients' advocate designated by the board on aging and
14long-term care. A patients' advocate who is a witness should print "patients'
15advocate" after the printing of his or her name above.
SB184,12,17 16156.17 Revocation of request for medication. (1) A requester may revoke
17his or her request for medication at any time by doing any of the following:
SB184,12,2018 (a) Canceling, defacing, obliterating, burning, tearing, or otherwise destroying
19the request for medication or directing another in the presence of the requester to
20destroy, in the same manner, the request for medication.
SB184,12,2221 (b) Executing a statement, in writing, that is signed and dated by the requester,
22expressing the requester's intent to revoke the request for medication.
SB184,12,2423 (c) Orally expressing the requester's intent to revoke the request for
24medication, in the presence of 2 witnesses.
SB184,12,2525 (d) Making a subsequent request for medication.
SB184,13,4
1(2) The requester's health care provider shall, upon notification of revocation
2of the requester's request for medication, record in the requester's medical record the
3time, date, and place of the revocation and the time, date, and place, if different, of
4the notification to the health care provider of the revocation.
SB184,13,11 5156.19 Designation of patients' advocates. The board on aging and
6long-term care shall designate staff of the long-term care ombudsman program as
7patients' advocates. A person so designated shall serve as a witness to a request for
8medication of a requester who is a patient or resident of a nursing home or
9community-based residential facility, as required under s. 156.05 (2) (b), and shall
10speak on behalf of the requester to ensure that his or her needs or wants are
11communicated to and addressed by his or her attending physician.
SB184,13,15 12156.21 Duties and immunities. (1) No health care provider that is not an
13individual and no health care facility may be held civilly liable and no health care
14provider who is an individual may be charged with a crime, held civilly liable or
15charged with unprofessional conduct for any of the following:
SB184,13,2016 (a) Failing to fulfill a request for medication, except that failure of an attending
17physician to fulfill a request for medication constitutes unprofessional conduct if the
18attending physician refuses or fails to make a good faith attempt to transfer the
19requester's care and treatment to another physician who will act as attending
20physician under this chapter and fulfill the request for medication.
SB184,13,2221 (b) In the absence of actual knowledge of a revocation, fulfilling a request for
22medication that is in compliance with this chapter.
SB184,13,2523 (c) Acting contrary to or failing to act on a revocation of a request for medication,
24unless the health care facility or health care provider has actual knowledge of the
25revocation.
SB184,14,4
1(2) In the absence of actual notice to the contrary, a health care facility or health
2care provider may presume that a requester was authorized to make his or her
3request for medication under the requirements of this chapter and that the request
4for medication is valid.
SB184,14,7 5(3) (a) No person who acts in good faith as a witness to a request for medication
6under this chapter may be held civilly or criminally liable for a death that results
7from taking medication under a fulfilled request for medication under this chapter.
SB184,14,98 (b) Paragraph (a) does not apply to a person who acts as a witness in violation
9of s. 156.05 (2) (a).
SB184,14,13 10156.23 General provisions. (1) (a) The making of a request for medication
11under this chapter does not, for any purpose, constitute attempted suicide. Taking
12medication under a fulfilled request for medication under this chapter does not, for
13any purpose, constitute suicide.
SB184,14,1614 (b) Paragraph (a) does not prohibit an insurer from making a determination
15that a requester has attempted suicide or committed suicide if the requester has so
16acted, apart from the request for medication.
SB184,14,19 17(2) The making of a request for medication under this chapter does not revoke
18or otherwise modify a power of attorney for health care or living will that the
19requester may have executed.
SB184,14,23 20(3) No individual may be required to make a request for medication as a
21condition for receipt of health care or admission to a health care facility. The making
22of a request for medication is not a bar to the receipt of health care or the admission
23to a health care facility.
SB184,14,25 24(4) A request for medication that is in its original form or is a legible photocopy
25or electronic facsimile copy is presumed to be valid.
SB184,15,4
1(5) Nothing in this chapter may be construed to condone, authorize, approve,
2or permit any affirmative or deliberate act to end life other than through taking
3medication that is prescribed under a request for medication as provided in this
4chapter.
SB184,15,8 5156.25 Record review. The department shall annually examine a sampling
6of patient health care records of requesters for whom medication was prescribed as
7requested under a request for medication and about whom the department has
8received information under s. 156.07 (8) (g).
SB184,15,12 9156.27 Penalties. (1) Any person who wilfully conceals, cancels, defaces,
10obliterates, or damages the request for medication of another without the requester's
11consent may be fined not more than $500 or imprisoned for not more than 30 days
12or both.
SB184,15,17 13(2) Any person who, with the intent to cause a requester to take medication that
14is prescribed under a request for medication contrary to the wishes of the requester,
15illegally falsifies or forges the request for medication of another, or conceals a
16revocation under s. 156.17 (1) (a) or (b) shall be fined not more than $10,000 or
17imprisoned for not more than 10 years or both.
SB184,15,21 18(3) Any responsible person who, with the intent to cause a requester to take
19medication that is prescribed under a request for medication contrary to the wishes
20of the requester, conceals personal knowledge of a revocation under s. 156.17 shall
21be fined not more than $10,000 or imprisoned for not more than 10 years or both.
SB184, s. 4 22Section 4. 979.01 (1) of the statutes is amended to read:
SB184,16,723 979.01 (1) All Except as provided in sub. (1t), all physicians, authorities of
24hospitals, sanatoriums, public and private institutions, convalescent homes,
25authorities of any institution of a like nature, and other persons having knowledge

1of the death of any person who has died under any of the following circumstances,
2shall immediately report the death to the sheriff, police chief, medical examiner, or
3coroner of the county where the death took place, and the sheriff or police chief shall,
4immediately upon notification, notify the coroner or the medical examiner and the
5coroner or medical examiner of the county where the death took place, if the crime,
6injury or event occurred in another county, shall report the death immediately to the
7coroner or medical examiner of that county
.
SB184, s. 5 8Section 5. 979.01 (1t) of the statutes is created to read:
SB184,16,119 979.01 (1t) Subsection (1) does not apply to a death that results from taking
10medication under a fulfilled request for medication that is in accordance with the
11requirements of ch. 156.
SB184, s. 6 12Section 6. Initial applicability.
SB184,16,1513 (1) Requests for medication; penalties. The treatment of section 156.27 of the
14statutes first applies to requests for medication made under the requirements of
15chapter 156 of the statutes on the effective date of this subsection.
SB184,16,1616 (End)
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