AB298,9,25 23(2) No requester may be required to notify his or her next of kin regarding his
24or her request for medication, and no request for medication may be denied because
25the requester has failed to notify his or her next of kin.
AB298,10,2
1(3) In order to receive a prescription that fulfills a request for medication, a
2requester shall do all of the following:
AB298,10,43 (a) Orally ask his or her attending physician for medication for the purpose of
4ending his or her life.
AB298,10,65 (b) No fewer than 15 days after asking for medication under par. (a), make a
6request for medication.
AB298,10,97 (c) After making a request for medication under par. (b), orally ask his or her
8attending physician a 2nd time for medication for the purpose of ending his or her
9life.
AB298,10,20 10156.15 Request for medication; form. The department shall prepare and
11provide copies of a request for medication form and accompanying information for
12distribution in quantities to health care providers, hospitals, nursing homes,
13multipurpose senior centers, county clerks, and local bar associations and
14individually to private persons. The department shall include, in information
15accompanying the copy of the request for medication form, at least the statutory
16definitions of terms used in the request for medication form, statutory restrictions
17on who may be witnesses to a valid request for medication, and a statement
18explaining that valid witnesses acting in good faith are statutorily immune from civil
19or criminal liability. The request for medication form distributed by the department
20shall be in the following form:
AB298,10,2121 REQUEST FOR MEDICATION
AB298,10,2222 TO END MY LIFE IN A HUMANE
AB298,10,2323 AND DIGNIFIED MANNER
AB298,10,2524 I, ...., am an adult of sound mind, do not have incapacity, and am a resident of
25Wisconsin.
AB298,11,2
1I am suffering from ...., which my attending physician has determined is a
2terminal disease and which has been medically confirmed by a consulting physician.
AB298,11,53 I have been fully informed of my diagnosis, prognosis, the nature of medication
4to be prescribed and potential associated risks, the expected result, and the feasible
5alternatives, including comfort care, hospice care, and pain control.
AB298,11,76 I request that my attending physician prescribe medication that will end my life
7in a humane and dignified manner.
AB298,11,88 INITIAL ONE OF THE FOLLOWING 3 STATEMENTS:
AB298,11,109 .... I have informed my family members of my decision and taken their opinions
10into consideration.
AB298,11,1111 .... I have decided not to inform my family of my decision.
AB298,11,1212 .... I have no family to inform of my decision.
AB298,11,1313 I understand that I have the right to revoke this request at any time.
AB298,11,1514 I understand the full import of this request and I expect to die when I take the
15medication to be prescribed.
AB298,11,1716 I make this request voluntarily and without reservation, and I accept full moral
17responsibility for my actions.
AB298,11,1818 Signed: ....
AB298,11,1919 Dated: ....
AB298,11,20 20Statement and signatures
AB298,11,21 21of witnesses
AB298,12,622 I know the requester personally or I have received proof of his or her identity
23and I believe him or her to be of sound mind and at least 18 years of age. I believe
24that the requester makes this request voluntarily. I am at least 18 years of age, am
25not related to the requester by blood, marriage, or adoption, and am not directly

1financially responsible for the requester's health care. I am not a health care
2provider who is serving the requester at this time; an employee of the health care
3provider, other than a chaplain or a social worker; or an employee, other than a
4chaplain or a social worker, of a health care facility in which the requester is a
5patient. To the best of my knowledge, I am not entitled to and do not have a claim
6on the requester's estate.
AB298,12,77 Witness No. 1:
AB298,12,88 (print) Name: ....
AB298,12,99 Address: ....
AB298,12,1010 Signature: ....
AB298,12,1111 Witness No. 2:
AB298,12,1212 (print) Name: ....
AB298,12,1313 Address: ....
AB298,12,1414 Signature: ....
AB298,12,1515 Witness No. 3:
AB298,12,1616 (print) Name: ....
AB298,12,1717 Address: ....
AB298,12,1818 Signature: ....
AB298,12,2219 If the requester is a patient in a health care facility, at least one of the above
20witnesses must be a patients' advocate designated by the board on aging and
21long-term care. A patients' advocate who is a witness should print "patients'
22advocate" after the printing of his or her name above.
AB298,12,24 23156.17 Revocation of request for medication. (1) A requester may revoke
24his or her request for medication at any time by doing any of the following:
AB298,13,3
1(a) Canceling, defacing, obliterating, burning, tearing, or otherwise destroying
2the request for medication or directing another in the presence of the requester to
3destroy, in the same manner, the request for medication.
AB298,13,54 (b) Executing a statement, in writing, that is signed and dated by the requester,
5expressing the requester's intent to revoke the request for medication.
AB298,13,76 (c) Orally expressing the requester's intent to revoke the request for
7medication, in the presence of 2 witnesses.
AB298,13,88 (d) Making a subsequent request for medication.
AB298,13,12 9(2) The requester's health care provider shall, upon notification of revocation
10of the requester's request for medication, record in the requester's medical record the
11time, date, and place of the revocation and the time, date, and place, if different, of
12the notification to the health care provider of the revocation.
AB298,13,19 13156.19 Designation of patients' advocates. The board on aging and
14long-term care shall designate staff of the long-term care ombudsman program as
15patients' advocates. A person so designated shall serve as a witness to a request for
16medication of a requester who is a patient or resident of a nursing home or
17community-based residential facility, as required under s. 156.05 (2) (b), and shall
18speak on behalf of the requester to ensure that his or her needs or wants are
19communicated to and addressed by his or her attending physician.
AB298,13,22 20156.21 Duties and immunities. (1) No health care facility or health care
21provider may be charged with a crime, held civilly liable, or charged with
22unprofessional conduct for any of the following:
AB298,14,223 (a) Failing to fulfill a request for medication, except that failure of an attending
24physician to fulfill a request for medication constitutes unprofessional conduct if the
25attending physician refuses or fails to make a good faith attempt to transfer the

1requester's care and treatment to another physician who will act as attending
2physician under this chapter and fulfill the request for medication.
AB298,14,43 (b) In the absence of actual knowledge of a revocation, fulfilling a request for
4medication that is in compliance with this chapter.
AB298,14,75 (c) Acting contrary to or failing to act on a revocation of a request for medication,
6unless the health care facility or health care provider has actual knowledge of the
7revocation.
AB298,14,12 8(2) In the absence of actual notice to the contrary, a health care facility or a
9health care provider, other than a physician acting as the requester's attending
10physician under this chapter, may presume that a requester was authorized to make
11his or her request for medication under the requirements of this chapter and that the
12request for medication is valid.
AB298,14,15 13(3) (a) No person who acts in good faith as a witness to a request for medication
14under this chapter may be held civilly or criminally liable for a death that results
15from taking medication under a fulfilled request for medication under this chapter.
AB298,14,1716 (b) Paragraph (a) does not apply to a person who acts as a witness in violation
17of s. 156.05 (2) (a).
AB298,14,21 18156.23 General provisions. (1) (a) The making of a request for medication
19under this chapter does not, for any purpose, constitute attempted suicide. Taking
20medication under a fulfilled request for medication under this chapter does not, for
21any purpose, constitute suicide.
AB298,14,2422 (b) Paragraph (a) does not prohibit an insurer from making a determination
23that a requester has attempted suicide or committed suicide if the requester has so
24acted, apart from the request for medication.
AB298,15,3
1(2) The making of a request for medication under this chapter does not revoke
2or otherwise modify a power of attorney for health care or living will that the
3requester may have executed.
AB298,15,7 4(3) No individual may be required to make a request for medication as a
5condition for receipt of health care or admission to a health care facility. The making
6of a request for medication is not a bar to the receipt of health care or the admission
7to a health care facility.
AB298,15,9 8(4) A request for medication that has not been revoked and that is in its original
9form or is a legible photocopy or electronic facsimile copy is presumed to be valid.
AB298,15,13 10(5) Nothing in this chapter may be construed to condone, authorize, approve,
11or permit any affirmative or deliberate act to end life other than through taking
12medication that is prescribed under a request for medication as provided in this
13chapter.
AB298,15,17 14156.25 Record review. The department shall annually examine a sampling
15of patient health care records of requesters for whom medication was prescribed in
16fulfillment of a request for medication and about whom the department has received
17information under s. 156.07 (8) (g).
AB298,15,21 18156.27 Penalties. (1) Any person who willfully conceals, cancels, defaces,
19obliterates, or damages the request for medication of another without the requester's
20consent may be fined not more than $500 or imprisoned for not more than 30 days
21or both.
AB298,16,2 22(2) Any person who, with the intent to cause a requester to take medication that
23is prescribed under a request for medication contrary to the wishes of the requester,
24illegally falsifies or forges the request for medication of another or conceals a

1revocation under s. 156.17 (1) (a), (b), or (c) shall be fined not more than $10,000 or
2imprisoned for not more than 10 years or both.
AB298,16,7 3(3) Any responsible person who, with the intent to cause a requester to take
4medication that is prescribed under a request for medication contrary to the wishes
5of the requester, conceals personal knowledge of a revocation under s. 156.17 shall
6be fined not more than $10,000 or, except for a health care facility, imprisoned for not
7more than 10 years or both.
AB298, s. 4 8Section 4. 979.01 (1) (intro.) of the statutes is amended to read:
AB298,16,159 979.01 (1) (intro.) All Except as provided in sub. (1j), all physicians, authorities
10of hospitals, sanatoriums, public and private institutions, convalescent homes,
11authorities of any institution of a like nature, and other persons having knowledge
12of the death of any person who has died under any of the following circumstances,
13shall immediately report the death to the sheriff, police chief, or and medical
14examiner or coroner of the county and to the police chief of any community where the
15death took place:
AB298, s. 5 16Section 5. 979.01 (1g) of the statutes is amended to read:
AB298,16,2117 979.01 (1g) A sheriff or police chief shall, immediately upon notification of a
18death under sub. (1), notify the coroner or the medical examiner, and the coroner or
19medical examiner of the county where death took place
, if the crime, injury, or event
20occurred in another county, shall immediately report the death to the coroner or
21medical examiner of that county.
AB298, s. 6 22Section 6. 979.01 (1j) of the statutes is created to read:
AB298,16,2523 979.01 (1j) Subsection (1) does not apply to a death that results from taking
24medication under a fulfilled request for medication that meets the requirements of
25ch. 156.
AB298, s. 7
1Section 7. 979.01 (1r) of the statutes is repealed.
AB298,17,22 (End)
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