MENTAL HEALTH TREATMENT
My health care agent may not admit or commit me on an inpatient basis to an institution for mental diseases, an intermediate care facility for the mentally retarded, a state treatment facility or a treatment facility. My health care agent may not consent to experimental mental health research or psychosurgery, electroconvulsive treatment or drastic mental health treatment procedures for me.
ADMISSION TO NURSING HOMES
OR COMMUNITY-BASED RESIDENTIAL FACILITIES
My health care agent may admit me to a nursing home or community-based residential facility for short-term stays for recuperative care or respite care.
If I have checked "Yes" to the following, my health care agent may admit me for a purpose other than recuperative care or respite care, but if I have checked "No" to the following, my health care agent may not so admit me:
1. A nursing home — Yes.... No....
2. A community-based residential facility — Yes.... No....
If I have not checked either "Yes" or "No" immediately above, my health care agent may admit me only for short-term stays for recuperative care or respite care.
PROVISION OF A FEEDING TUBE
If I have checked "Yes" to the following, my health care agent may have a feeding tube withheld or withdrawn from me, unless my physician has advised that, in his or her professional judgment, this will cause me pain or will reduce my comfort. If I have checked "No" to the following, my health care agent may not have a feeding tube withheld or withdrawn from me.
My health care agent may not have orally ingested nutrition or hydration withheld or withdrawn from me unless provision of the nutrition or hydration is medically contraindicated.
Withhold or withdraw a feeding tube — Yes.... No....
If I have not checked either "Yes" or "No" immediately above, my health care agent may not have a feeding tube withdrawn from me.
HEALTH CARE DECISIONS
FOR PREGNANT WOMEN
If I have checked "Yes" to the following, my health care agent may make health care decisions for me even if my agent knows I am pregnant. If I have checked "No" to the following, my health care agent may not make health care decisions for me if my health care agent knows I am pregnant.
Health care decision if I am pregnant — Yes.... No....
If I have not checked either "Yes" or "No" immediately above, my health care agent may not make health care decisions for me if my health care agent knows I am pregnant.
STATEMENT OF DESIRES, SPECIAL
PROVISIONS OR LIMITATIONS
In exercising authority under this document, my health care agent shall act consistently with my following stated desires, if any, and is subject to any special provisions or limitations that I specify. The following are specific desires, provisions or limitations that I wish to state (add more items if needed):
1) -
2) -
3) -
INSPECTION AND DISCLOSURE OF INFORMATION
RELATING TO MY PHYSICAL OR MENTAL HEALTH
Subject to any limitations in this document, my health care agent has the authority to do all of the following:
155.30(3)(a)
(a) Request, review and receive any information, oral or written, regarding my physical or mental health, including medical and hospital records.
155.30(3)(b)
(b) Execute on my behalf any documents that may be required in order to obtain this information.
155.30(3)(c)
(c) Consent to the disclosure of this information.
(The principal and the witnesses all must sign the document at the same time.)
SIGNATURE OF PRINCIPAL
(person creating the power
of attorney for health care)
Signature.... Date....
(The signing of this document by the principal revokes all previous powers of attorney for health care documents.)
STATEMENT OF WITNESSES
I know the principal personally and I believe him or her to be of sound mind and at least 18 years of age. I believe that his or her execution of this power of attorney for health care is voluntary. I am at least 18 years of age, am not related to the principal by blood, marriage or adoption and am not directly financially responsible for the principal's health care. I am not a health care provider who is serving the principal at this time, an employee of the health care provider, other than a chaplain or a social worker, or an employee, other than a chaplain or a social worker, of an inpatient health care facility in which the declarant is a patient. I am not the principal's health care agent. To the best of my knowledge, I am not entitled to and do not have a claim on the principal's estate.
Witness No. 1:
(print) Name.... Date....
Address....
Signature....
Witness No. 2:
(print) Name.... Date....
Address....
Signature....
STATEMENT OF HEALTH CARE AGENT
AND ALTERNATE HEALTH CARE AGENT
I understand that.... (name of principal) has designated me to be his or her health care agent or alternate health care agent if he or she is ever found to have incapacity and unable to make health care decisions himself or herself. .... (name of principal) has discussed his or her desires regarding health care decisions with me.
Agent's signature....
Address....
Alternate's signature....
Address....
Failure to execute a power of attorney for health care document under chapter 155 of the Wisconsin Statutes creates no presumption about the intent of any individual with regard to his or her health care decisions.
This power of attorney for health care is executed as provided in chapter 155 of the Wisconsin Statutes.
ANATOMICAL GIFTS (optional)
Upon my death:
.... I wish to donate only the following organs or parts: .... (specify the organs or parts).
.... I wish to donate any needed organ or part.
.... I wish to donate my body for anatomical study if needed.
.... I refuse to make an anatomical gift. (If this revokes a prior commitment that I have made to make an anatomical gift to a designated donee, I will attempt to notify the donee to which or to whom I agreed to donate.)
Failing to check any of the lines immediately above creates no presumption about my desire to make or refuse to make an anatomical gift.
Signature.... Date....
155.40
155.40
Revocation of power of attorney for health care. 155.40(1)(1) A principal may revoke his or her power of attorney for health care and invalidate the power of attorney for health care instrument at any time by doing any of the following:
155.40(1)(a)
(a) Canceling, defacing, obliterating, burning, tearing or otherwise destroying the power of attorney for health care instrument or directing another in the presence of the principal to so destroy the power of attorney for health care instrument.
155.40(1)(b)
(b) Executing a statement, in writing, that is signed and dated by the principal, expressing the principal's intent to revoke the power of attorney for health care.
155.40(1)(c)
(c) Verbally expressing the principal's intent to revoke the power of attorney for health care, in the presence of 2 witnesses.
155.40(1)(d)
(d) Executing a subsequent power of attorney for health care instrument.
155.40(2)
(2) If the health care agent is the principal's spouse and, subsequent to the execution of a power of attorney for health care instrument, the marriage is annulled or divorce from the spouse is obtained, the power of attorney for health care is revoked and the power of attorney for health care instrument is invalid.
155.40(3)
(3) If an individual knows that the power of attorney for health care that named him or her as health care agent has been revoked, he or she shall communicate this fact to any health care provider for the principal that he or she knows has a copy of the power of attorney for health care instrument.
155.40(4)
(4) The principal's health care provider shall, upon notification of revocation of the principal's power of attorney for health care instrument, record in the principal's medical record the time, date and place of the revocation and the time, date and place, if different, of the notification to the health care provider of the revocation.
155.40 History
History: 1989 a. 200.
155.50
155.50
Duties and immunities. 155.50(1)
(1) No health care facility or health care provider may be charged with a crime, held civilly liable or charged with unprofessional conduct for any of the following:
155.50(1)(a)
(a) Certifying incapacity under
s. 155.05 (2), if the certification is made in good faith based on a thorough examination of the principal.
155.50(1)(b)
(b) Failing to comply with a power of attorney for health care instrument or the decision of a health care agent, except that failure of a physician to comply constitutes unprofessional conduct if the physician refuses or fails to make a good faith attempt to transfer the principal to another physician who will comply.
155.50(1)(c)
(c) Complying, in the absence of actual knowledge of a revocation, with the terms of a power of attorney for health care instrument that is in compliance with this chapter or the decision of a health care agent that is made under a power of attorney for health care that is in compliance with this chapter.
155.50(1)(d)
(d) Acting contrary to or failing to act on a revocation of a power of attorney for health care, unless the health care facility or health care provider has actual knowledge of the revocation.
155.50(1)(e)
(e) Failing to obtain the health care decision for a principal from the principal's health care agent, if the health care facility or health care provider has made a reasonable attempt to contact the health care agent and obtain the decision but has been unable to do so.
155.50(2)
(2) In the absence of actual notice to the contrary, a health care facility or health care provider may presume that a principal was authorized to execute the principal's power of attorney for health care under the requirements of this chapter and that the power of attorney for health care instrument is valid.
155.50(3)
(3) No health care agent may be charged with a crime or held civilly liable for making a decision in good faith under a power of attorney for health care instrument that is in compliance with this chapter. No health care agent who is not the spouse of the principal may be held personally liable for any goods or services purchased or contracted for under a power of attorney for health care instrument.
155.50 History
History: 1989 a. 200.
155.60(1)(1) Nothing in this chapter prohibits an individual from petitioning a court under
ch. 880 for a determination of incompetency and for appointment of a guardian for an individual who is a principal under this chapter.
155.60(2)
(2) If a court under
s. 880.33 determines that an individual who is a principal is incompetent or makes a finding of limited incompetency under
s. 880.33 (3) and appoints a guardian for the individual, the power of attorney for health care executed under this chapter by the principal is revoked and the power of attorney for health care instrument is invalid, unless the court finds that the power of attorney for health care and power of attorney for health care instrument should remain in effect. If the court makes this finding, the guardian for the individual may not make health care decisions for the ward that may be made by the health care agent, unless the guardian is the health care agent.
155.60(3)
(3) Upon receipt of a power of attorney for health care instrument or a statement of incapacity under
s. 155.05 (2), a health care facility or health care provider shall acknowledge this receipt in writing and, if the principal is a patient of the health care provider, the health care provider shall include the instrument or the statement in the medical record of the principal.
