AB861,9,113 If I am unable, due to my incapacity, to make a health care decision, my health
4care agent is instructed to make the health care decision for me, but my health care
5agent should try to discuss with me any specific proposed health care if I am able to
6communicate in any manner, including by blinking my eyes. If this communication
7cannot be made, my health care agent shall base his or her decision on any health
8care choices that I have expressed prior to the time of the decision. If I have not
9expressed a health care choice about the health care in question and communication
10cannot be made, my health care agent shall base his or her health care decision on
11what he or she believes to be in my best interest.
AB861,9,1312 LIMITATIONS ON
13 MENTAL HEALTH TREATMENT
AB861,9,1914 My health care agent may not admit or commit me on an inpatient basis to an
15institution for mental diseases, an intermediate care facility for persons with an
16intellectual disability, a state treatment facility or a treatment facility. My health
17care agent may not consent to experimental mental health research or
18psychosurgery, electroconvulsive treatment or drastic mental health treatment
19procedures for me.
AB861,9,2220 ADMISSION TO NURSING HOMES OR
21 COMMUNITY-BASED
22 RESIDENTIAL FACILITIES
AB861,9,2423 My health care agent may admit me to a nursing home or community-based
24residential facility for short-term stays for recuperative care or respite care.
AB861,10,3
1If I have checked "Yes" to the following, my health care agent may admit me for
2a purpose other than recuperative care or respite care, but if I have checked "No" to
3the following, my health care agent may not so admit me:
AB861,10,44 1. A nursing home — Yes.... No....
AB861,10,55 2. A community-based residential facility — Yes.... No....
AB861,10,76 If I have not checked either "Yes" or "No" immediately above, my health care
7agent may admit me only for short-term stays for recuperative care or respite care.
AB861,10,88 PROVISION OF A FEEDING TUBE
AB861,10,139 If I have checked "Yes" to the following, my health care agent may have a
10feeding tube withheld or withdrawn from me, unless my physician has advised that,
11in his or her professional judgment, this will cause me pain or will reduce my comfort.
12If I have checked "No" to the following, my health care agent may not have a feeding
13tube withheld or withdrawn from me.
AB861,10,1614 My health care agent may not have orally ingested nutrition or hydration
15withheld or withdrawn from me unless provision of the nutrition or hydration is
16medically contraindicated.
AB861,10,1717 Withhold or withdraw a feeding tube — Yes.... No....
AB861,10,1918 If I have not checked either "Yes" or "No" immediately above, my health care
19agent may not have a feeding tube withdrawn from me.
AB861,10,2120 HEALTH CARE DECISIONS FOR
21 PREGNANT WOMEN
AB861,10,2522 If I have checked "Yes" to the following, my health care agent may make health
23care decisions for me even if my agent knows I am pregnant. If I have checked "No"
24to the following, my health care agent may not make health care decisions for me if
25my health care agent knows I am pregnant.
AB861,11,1
1Health care decision if I am pregnant — Yes.... No....
AB861,11,42 If I have not checked either "Yes" or "No" immediately above, my health care
3agent may not make health care decisions for me if my health care agent knows I am
4pregnant.
AB861,11,65 STATEMENT OF DESIRES, SPECIAL
6 PROVISIONS OR LIMITATIONS
AB861,11,107 In exercising authority under this document, my health care agent shall act
8consistently with my following stated desires, if any, and is subject to any special
9provisions or limitations that I specify. The following are specific desires, provisions
10or limitations that I wish to state (add more items if needed):
AB861,11,1111 1) -
AB861,11,1212 2) -
AB861,11,1313 3) -
AB861,11,1614 INSPECTION AND DISCLOSURE OF
15 INFORMATION RELATING TO MY
16 PHYSICAL OR MENTAL HEALTH
AB861,11,1817 Subject to any limitations in this document, my health care agent has the
18authority to do all of the following:
AB861,11,2019 (a) Request, review and receive any information, oral or written, regarding my
20physical or mental health, including medical and hospital records.
AB861,11,2221 (b) Execute on my behalf any documents that may be required in order to obtain
22this information.
AB861,11,2323 (c) Consent to the disclosure of this information.
AB861,11,2424 (The principal and the witnesses all must sign the document at the same time.)
AB861,11,2525 SIGNATURE OF PRINCIPAL
AB861,12,1
1(person creating the power of attorney for health care)
AB861,12,22 Signature....  Date....
AB861,12,43 (The signing of this document by the principal revokes all previous powers of
4attorney for health care documents.)
AB861,12,55 STATEMENT OF WITNESSES
AB861,12,166 I know the principal personally and I believe him or her to be of sound mind and
7at least 18 years of age. I believe that his or her execution of this power of attorney
8for health care is voluntary. I am at least 18 years of age, am not related to the
9principal by blood, marriage, or adoption, am not the domestic partner under ch. 770
10of the principal, and am not directly financially responsible for the principal's health
11care. I am not a health care provider who is serving the principal at this time, an
12employee of the health care provider, other than a chaplain or a social worker, or an
13employee, other than a chaplain or a social worker, of an inpatient health care facility
14in which the declarant is a patient. I am not the principal's health care agent. To
15the best of my knowledge, I am not entitled to and do not have a claim on the
16principal's estate.
AB861,12,1717 Witness No. 1:
AB861,12,1818 (print) Name.... Date....
AB861,12,1919 Address....
AB861,12,2020 Signature....
AB861,12,2121 Witness No. 2:
AB861,12,2222 (print) Name.... Date....
AB861,12,2323 Address....
AB861,12,2424 Signature....
AB861,13,2
1STATEMENT OF HEALTH CARE AGENT
2 AND ALTERNATE HEALTH CARE AGENT
AB861,13,63 I understand that.... (name of principal) has designated me to be his or her
4health care agent or alternate health care agent if he or she is ever found to have
5incapacity and unable to make health care decisions himself or herself. .... (name of
6principal) has discussed his or her desires regarding health care decisions with me.
AB861,13,77 Agent's signature....
AB861,13,88 Address....
AB861,13,99 Alternate's signature....
AB861,13,1010 Address....
AB861,13,1311 Failure to execute a power of attorney for health care document under chapter
12155 of the Wisconsin Statutes creates no presumption about the intent of any
13individual with regard to his or her health care decisions.
AB861,13,1514 This power of attorney for health care is executed as provided in chapter 155
15of the Wisconsin Statutes.
AB861,13,1616 ANATOMICAL GIFTS (optional)
AB861,13,1717 Upon my death:
AB861,13,1918 .... I wish to donate only the following organs or parts: .... (specify the organs or
19parts).
AB861,13,2020 .... I wish to donate any needed organ or part.
AB861,13,2121 .... I wish to donate my body for anatomical study if needed.
AB861,13,2422 .... I refuse to make an anatomical gift. (If this revokes a prior commitment that
23I have made to make an anatomical gift to a designated donee, I will attempt to notify
24the donee to which or to whom I agreed to donate.)
AB861,14,2
1Failing to check any of the lines immediately above creates no presumption
2about my desire to make or refuse to make an anatomical gift.
AB861,14,33 Signature....     Date....
AB861,7 4Section 7. Initial applicability.
AB861,14,75 (1) This act first applies to declarations to physicians, do-not-resuscitate
6orders, and power of attorney for health care instruments executed on the effective
7date of this subsection.
AB861,8 8Section 8. Effective date.
AB861,14,109 (1) This act takes effect on the first day of the 4th month beginning after
10publication.
AB861,14,1111 (End)
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