154.01154.01 Definitions. In this chapter: 154.01(1g)(1g) “Advanced practice registered nurse” means a nurse licensed under ch. 441 who is currently certified by a national certifying body approved by the board of nursing as a nurse practitioner, certified nurse-midwife, certified registered nurse anesthetist, or clinical nurse specialist. 154.01(1r)(1r) “Attending health care professional” means a health care professional who has primary responsibility for the treatment and care of the patient. 154.01(2g)(2g) “Department” means the department of health services. 154.01(3)(3) “Health care professional” means any of the following: 154.01(4)(4) “Inpatient health care facility” has the meaning provided under s. 50.135 (1) and includes community-based residential facilities, as defined in s. 50.01 (1g). 154.01(5)(5) “Life-sustaining procedure” means any medical procedure or intervention that, in the judgment of the attending health care professional, would serve only to prolong the dying process but not avert death when applied to a qualified patient. “Life-sustaining procedure” includes assistance in respiration, artificial maintenance of blood pressure and heart rate, blood transfusion, kidney dialysis and other similar procedures, but does not include: 154.01(5)(a)(a) The alleviation of pain by administering medication or by performing any medical procedure. 154.01(5m)(5m) “Persistent vegetative state” means a condition that reasonable medical judgment finds constitutes complete and irreversible loss of all of the functions of the cerebral cortex and results in a complete, chronic and irreversible cessation of all cognitive functioning and consciousness and a complete lack of behavioral responses that indicate cognitive functioning, although autonomic functions continue. 154.01(8)(8) “Terminal condition” means an incurable condition caused by injury or illness that reasonable medical judgment finds would cause death imminently, so that the application of life-sustaining procedures serves only to postpone the moment of death. DECLARATION TO HEALTH CARE PROFESSIONALS
154.02154.02 Definitions. In this subchapter: 154.02(1)(1) “Declaration” means a written, witnessed document voluntarily executed by the declarant under s. 154.03 (1), but is not limited in form or substance to that provided in s. 154.03 (2). 154.02(2)(2) “Feeding tube” means a medical tube through which nutrition or hydration is administered into the vein, stomach, nose, mouth or other body opening of a qualified patient. 154.02(3)(3) “Qualified patient” means a declarant who has been diagnosed and certified in writing to be afflicted with a terminal condition or to be in a persistent vegetative state by 2 health care professionals, one of whom is the attending health care professional and one of whom is a physician, who have personally examined the declarant. 154.02 HistoryHistory: 1995 a. 200; 2019 a. 90. 154.03154.03 Declaration to health care professionals. 154.03(1)(1) Any person of sound mind and 18 years of age or older may at any time voluntarily execute a declaration, which shall take effect on the date of execution, authorizing the withholding or withdrawal of life-sustaining procedures or of feeding tubes when the person is in a terminal condition or is in a persistent vegetative state. A declarant may not authorize the withholding or withdrawal of any medication, life-sustaining procedure or feeding tube if the declarant’s attending health care professional advises that, in his or her professional judgment, the withholding or withdrawal will cause the declarant pain or reduce the declarant’s comfort and the pain or discomfort cannot be alleviated through pain relief measures. A declarant may not authorize the withholding or withdrawal of nutrition or hydration that is administered or otherwise received by the declarant through means other than a feeding tube unless the declarant’s attending health care professional advises that, in his or her professional judgment, the administration is medically contraindicated. A declaration must be signed by the declarant in the presence of 2 witnesses. If the declarant is physically unable to sign a declaration, the declaration must be signed in the declarant’s name by one of the witnesses or some other person at the declarant’s express direction and in his or her presence; such a proxy signing shall either take place or be acknowledged by the declarant in the presence of 2 witnesses. The declarant is responsible for notifying his or her attending health care professional of the existence of the declaration. An attending health care professional who is so notified shall make the declaration a part of the declarant’s medical records. No witness to the execution of the declaration may, at the time of the execution, be any of the following: 154.03(1)(a)(a) Related to the declarant by blood, marriage or adoption. 154.03(1)(b)(b) Have knowledge that he or she is entitled to or has a claim on any portion of the declarant’s estate. 154.03(1)(c)(c) Directly financially responsible for the declarant’s health care. 154.03(1)(d)(d) An individual who is a health care provider, as defined in s. 155.01 (7), who is serving the declarant at the time of execution, an employee, other than a chaplain or a social worker, of the health care provider or an employee, other than a chaplain or a social worker, of an inpatient health care facility in which the declarant is a patient. 154.03(2)(2) The department shall prepare and provide copies of the declaration and accompanying information for distribution in quantities to persons licensed, certified, or registered under ch. 441, 448, or 455, persons who hold a compact privilege under subch. XI of ch. 448, hospitals, nursing homes, county clerks and local bar associations and individually to private persons. The department shall include, in information accompanying the declaration, at least the statutory definitions of terms used in the declaration, statutory restrictions on who may be witnesses to a valid declaration, a statement explaining that valid witnesses acting in good faith are statutorily immune from civil or criminal liability, an instruction to potential declarants to read and understand the information before completing the declaration and a statement explaining that an instrument may, but need not be, filed with the register in probate of the declarant’s county of residence. The department may charge a reasonable fee for the cost of preparation and distribution. The declaration distributed by the department of health services shall be easy to read, the type size may be no smaller than 10 point, and the declaration shall be in the following form, setting forth on the first page the wording before the ATTENTION statement and setting forth on the 2nd page the ATTENTION statement and remaining wording: 154.03 NoteNOTE: The cross-reference to subch. XI of ch. 448 was changed from subch. X of ch. 448 by the legislative reference bureau under s. 13.92 (1) (bm) 2. to reflect the renumbering under s. 13.92 (1) (bm) 2. of subch. X of ch. 448.
Declaration to health care professionals
(WISCONSIN LIVING WILL)
I,...., being of sound mind, voluntarily state my desire that my dying not be prolonged under the circumstances specified in this document. Under those circumstances, I direct that I be permitted to die naturally. If I am unable to give directions regarding the use of life-sustaining procedures or feeding tubes, I intend that my family and physician, physician assistant, or advanced practice registered nurse honor this document as the final expression of my legal right to refuse medical or surgical treatment.
1. If I have a TERMINAL CONDITION, as determined by a physician, physician assistant, or advanced practice registered nurse who has personally examined me, and if a physician who has also personally examined me agrees with that determination, I do not want my dying to be artificially prolonged and I do not want life-sustaining procedures to be used. In addition, the following are my directions regarding the use of feeding tubes:
.... YES, I want feeding tubes used if I have a terminal condition.
.... NO, I do not want feeding tubes used if I have a terminal condition.
If you have not checked either box, feeding tubes will be used.
2. If I am in a PERSISTENT VEGETATIVE STATE, as determined by a physician, physician assistant, or advanced practice registered nurse who has personally examined me, and if a physician who has also personally examined me agrees with that determination, the following are my directions regarding the use of life-sustaining procedures:
.... YES, I want life-sustaining procedures used if I am in a persistent vegetative state.
.... NO, I do not want life-sustaining procedures used if I am in a persistent vegetative state.
If you have not checked either box, life-sustaining procedures will be used.
3. If I am in a PERSISTENT VEGETATIVE STATE, as determined by a physician, physician assistant, or advanced practice registered nurse who has personally examined me, and if a physician who has also personally examined me agrees with that determination, the following are my directions regarding the use of feeding tubes:
.... YES, I want feeding tubes used if I am in a persistent vegetative state.
.... NO, I do not want feeding tubes used if I am in a persistent vegetative state.
If you have not checked either box, feeding tubes will be used.
If you are interested in more information about the significant terms used in this document, see section 154.01 of the Wisconsin Statutes or the information accompanying this document.
ATTENTION: You and the 2 witnesses must sign the document at the same time.
Signed .... Date ....
Address .... Date of birth ....
I believe that the person signing this document is of sound mind. I am an adult and am not related to the person signing this document by blood, marriage or adoption. I am not entitled to and do not have a claim on any portion of the person’s estate and am not otherwise restricted by law from being a witness.
Witness signature .... Date signed ....
Print name ....
Witness signature .... Date signed ....
Print name ....
DIRECTIVES TO ATTENDING PHYSICIAN,
PHYSICIAN ASSISTANT, OR ADVANCED PRACTICE REGISTERED NURSE
1. This document authorizes the withholding or withdrawal of life-sustaining procedures or of feeding tubes when a physician and another physician, physician assistant, or advanced practice registered nurse, one of whom is the attending health care professional, have personally examined and certified in writing that the patient has a terminal condition or is in a persistent vegetative state.
2. The choices in this document were made by a competent adult. Under the law, the patient’s stated desires must be followed unless you believe that withholding or withdrawing life-sustaining procedures or feeding tubes would cause the patient pain or reduced comfort and that the pain or discomfort cannot be alleviated through pain relief measures. If the patient’s stated desires are that life-sustaining procedures or feeding tubes be used, this directive must be followed.
3. If you feel that you cannot comply with this document, you must make a good faith attempt to transfer the patient to another physician, physician assistant, or advanced practice registered nurse who will comply. Refusal or failure to make a good faith attempt to do so constitutes unprofessional conduct.
4. If you know that the patient is pregnant, this document has no effect during her pregnancy.
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The person making this living will may use the following space to record the names of those individuals and health care providers to whom he or she has given copies of this document:
.................................................................
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154.03(3)(3) For purposes of this section, “presence” includes the simultaneous remote appearance by 2-way, real-time audiovisual communication technology if all of the following conditions are satisfied: 154.03(3)(a)(a) The signing is supervised by an attorney in good standing licensed by this state. The supervising attorney may serve as one of the remote witnesses. 154.03(3)(b)(b) The declarant attests to being physically located in this state during the 2-way, real-time audiovisual communication. 154.03(3)(c)(c) Each remote witness attests to being physically located in this state during the 2-way, real-time audiovisual communication. 154.03(3)(d)(d) The declarant and each of the remote witnesses identify themselves. If the declarant and remote witnesses are not personally known to each other and to the supervising attorney, the declarant and each of the remote witnesses display photo identification. 154.03(3)(e)(e) The declarant identifies anyone else present in the same physical location as the declarant and, if possible, the declarant makes a visual sweep of the declarant’s physical surroundings so that the supervising attorney and each remote witness can confirm the presence of any other person. 154.03(3)(f)(f) The declarant displays the declaration to health care professionals, confirms the total number of pages and the page number of the page on which the declarant’s signature will be affixed, and declares to the remote witnesses and the supervising attorney all of the following: 154.03(3)(f)2.2. That the document is a declaration to health care professionals. 154.03(3)(f)3.3. That the document is being executed as a voluntary act. 154.03(3)(g)(g) The declarant, or an individual 18 years of age or older at the express direction and in the physical presence of the declarant, dates and signs the declaration to health care professionals in a manner that allows each of the remote witnesses and the supervising attorney to see the execution. 154.03(3)(h)(h) The audiovisual communication technology used allows communication by which a person is able to see, hear, and communicate in an interactive way with another person in real time using electronic means, except that if the declarant, a remote witness, or the supervising attorney has an impairment that affects hearing, sight, or speech, assistive technology or learned skills may be substituted for audio or visual if it allows that person to actively participate in the signing in real time. 154.03(3)(i)(i) The declaration to health care professionals indicates that it is being executed pursuant to this subsection. 154.03(3)(j)1.1. The declarant, or another person at the direction of the declarant, personally delivers or transmits by U.S. mail or commercial courier service the entire signed original declaration to health care professionals to the supervising attorney within a reasonable time after execution. The supervising attorney then personally delivers or transmits by U.S. mail or commercial courier service the entire signed original declaration to health care professionals to the remote witnesses within a reasonable time. The first remote witness to receive the original declaration to health care professionals signs and dates the original declaration to health care professionals as a witness and forwards the entire signed original declaration to health care professionals by personal delivery or U.S. mail or commercial courier service within a reasonable time to the 2nd remote witness, who signs and dates it as a witness and forwards the entire signed original declaration to health care professionals by personal delivery or U.S. mail or commercial courier service within a reasonable time to the supervising attorney. 154.03(3)(j)2.2. The declarant, or another person at the direction of the declarant, personally delivers or transmits by U.S. mail or commercial courier service the entire signed original declaration to health care professionals to the supervising attorney within a reasonable time after execution, and transmits by facsimile or electronic means a legible copy of the entire signed declaration to health care professionals directly to each remote witness within a reasonable time after execution. Each remote witness then signs the transmitted copy of the declaration to health care professionals as a witness and personally delivers or transmits by U.S. mail or commercial courier service the entire signed copy of the declaration to health care professionals to the supervising attorney within a reasonable time after witnessing. The signed original and signed copies together shall constitute one original document, unless the supervising attorney, within a reasonable time after receiving the signed original and signed copies, compiles the signed original and signed copies into one document by attaching the signature pages of each remote witness to the original signed by or on behalf of the declarant, in which case the compiled document shall constitute the original. 154.03(3)(j)3.3. The declarant and each of the remote witnesses sign identical copies of the original. The declarant, or another person at the direction of the declarant, and each of the remote witnesses personally deliver or transmit by U.S. mail or commercial courier service the signed originals to the supervising attorney within a reasonable time after execution. All of the signed originals together shall constitute one original document, unless the supervising attorney, within a reasonable time after receiving all signed originals, compiles the originals into one document by attaching the signature pages of each remote witness to the original signed by or on behalf of the declarant, in which case the compiled document shall constitute the original. 154.03(3)(k)(k) The supervising attorney completes an affidavit of compliance that contains the following information: 154.03(3)(k)2.2. The name and residential or business address of each remote witness. 154.03(3)(k)3.3. The address within this state where the declarant was physically located at the time the declarant signed the declaration to health care professionals. 154.03(3)(k)4.4. The address within this state where each remote witness was physically located at the time the remote witness witnessed the declarant’s execution of the declaration to health care professionals. 154.03(3)(k)5.5. A statement that the declarant and remote witnesses were all known to each other and the supervising attorney or a description of the form of photo identification used to confirm the identity of the declarant and each remote witness. 154.03(3)(k)6.6. Confirmation that the declarant declared that the declarant is 18 years of age or older, that the document is the declarant’s declaration to health care professionals, and that the document was being executed as the declarant’s voluntary act.
