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SB254,18,2523 If I have checked “Yes" to the following, my health care agent may admit me for
24a purpose other than recuperative care or respite care, but if I have checked “No" to
25the following, my health care agent may not so admit me:
SB254,19,1
11. A nursing home — Yes.... No....
SB254,19,22 2. A community-based residential facility — Yes.... No....
SB254,19,43 If I have not checked either “Yes" or “No" immediately above, my health care
4agent may admit me only for short-term stays for recuperative care or respite care.
SB254,19,55 PROVISION OF A FEEDING TUBE
SB254,19,116 If I have checked “Yes" to the following, my health care agent may have a
7feeding tube withheld or withdrawn from me, unless my physician, physician
8assistant, or nurse practitioner
has advised that, in his or her professional judgment,
9this will cause me pain or will reduce my comfort. If I have checked “No" to the
10following, my health care agent may not have a feeding tube withheld or withdrawn
11from me.
SB254,19,1412 My health care agent may not have orally ingested nutrition or hydration
13withheld or withdrawn from me unless provision of the nutrition or hydration is
14medically contraindicated.
SB254,19,1515 Withhold or withdraw a feeding tube — Yes.... No....
SB254,19,1716 If I have not checked either “Yes" or “No" immediately above, my health care
17agent may not have a feeding tube withdrawn from me.
SB254,19,1918 HEALTH CARE DECISIONS FOR
19 PREGNANT WOMEN
SB254,19,2320 If I have checked “Yes" to the following, my health care agent may make health
21care decisions for me even if my agent knows I am pregnant. If I have checked “No"
22to the following, my health care agent may not make health care decisions for me if
23my health care agent knows I am pregnant.
SB254,19,2424 Health care decision if I am pregnant — Yes.... No....
SB254,20,3
1If I have not checked either “Yes" or “No" immediately above, my health care
2agent may not make health care decisions for me if my health care agent knows I am
3pregnant.
SB254,20,54 STATEMENT OF DESIRES,
5 SPECIAL PROVISIONS OR LIMITATIONS
SB254,20,96 In exercising authority under this document, my health care agent shall act
7consistently with my following stated desires, if any, and is subject to any special
8provisions or limitations that I specify. The following are specific desires, provisions
9or limitations that I wish to state (add more items if needed):
SB254,20,1010 1) -
SB254,20,1111 2) -
SB254,20,1212 3) -
SB254,20,1513 INSPECTION AND DISCLOSURE OF
14 INFORMATION RELATING TO MY PHYSICAL
15 OR MENTAL HEALTH
SB254,20,1716 Subject to any limitations in this document, my health care agent has the
17authority to do all of the following:
SB254,20,1918 (a) Request, review and receive any information, oral or written, regarding my
19physical or mental health, including medical and hospital records.
SB254,20,2120 (b) Execute on my behalf any documents that may be required in order to obtain
21this information.
SB254,20,2222 (c) Consent to the disclosure of this information.
SB254,20,2323 (The principal and the witnesses all must sign the document at the same time.)
SB254,20,2424 SIGNATURE OF PRINCIPAL
SB254,20,2525 (person creating the power of attorney for health care)
SB254,21,1
1Signature....  Date....
SB254,21,32 (The signing of this document by the principal revokes all previous powers of
3attorney for health care documents.)
SB254,21,44 STATEMENT OF WITNESSES
SB254,21,155 I know the principal personally and I believe him or her to be of sound mind and
6at least 18 years of age. I believe that his or her execution of this power of attorney
7for health care is voluntary. I am at least 18 years of age, am not related to the
8principal by blood, marriage, or adoption, am not the domestic partner under ch. 770
9of the principal, and am not directly financially responsible for the principal's health
10care. I am not a health care provider who is serving the principal at this time, an
11employee of the health care provider, other than a chaplain or a social worker, or an
12employee, other than a chaplain or a social worker, of an inpatient health care facility
13in which the declarant is a patient. I am not the principal's health care agent. To
14the best of my knowledge, I am not entitled to and do not have a claim on the
15principal's estate.
SB254,21,1616 Witness No. 1:
SB254,21,1717 (print) Name.... Date....
SB254,21,1818 Address....
SB254,21,1919 Signature....
SB254,21,2020 Witness No. 2:
SB254,21,2121 (print) Name.... Date....
SB254,21,2222 Address....
SB254,21,2323 Signature....
SB254,21,2524 STATEMENT OF HEALTH CARE AGENT AND
25 ALTERNATE HEALTH CARE AGENT
SB254,22,4
1I understand that.... (name of principal) has designated me to be his or her
2health care agent or alternate health care agent if he or she is ever found to have
3incapacity and unable to make health care decisions himself or herself. .... (name of
4principal) has discussed his or her desires regarding health care decisions with me.
SB254,22,55 Agent's signature....
SB254,22,66 Address....
SB254,22,77 Alternate's signature....
SB254,22,88 Address....
SB254,22,119 Failure to execute a power of attorney for health care document under chapter
10155 of the Wisconsin Statutes creates no presumption about the intent of any
11individual with regard to his or her health care decisions.
SB254,22,1312 This power of attorney for health care is executed as provided in chapter 155
13of the Wisconsin Statutes.
SB254,22,1414 ANATOMICAL GIFTS (optional)
SB254,22,1515 Upon my death:
SB254,22,1716 .... I wish to donate only the following organs or parts: .... (specify the organs or
17parts).
SB254,22,1818 .... I wish to donate any needed organ or part.
SB254,22,1919 .... I wish to donate my body for anatomical study if needed.
SB254,22,2220 .... I refuse to make an anatomical gift. (If this revokes a prior commitment that
21I have made to make an anatomical gift to a designated donee, I will attempt to notify
22the donee to which or to whom I agreed to donate.)
SB254,22,2423 Failing to check any of the lines immediately above creates no presumption
24about my desire to make or refuse to make an anatomical gift.
SB254,22,2525 Signature....     Date....
SB254,31
1Section 31. 155.50 (1) (b) of the statutes is amended to read:
SB254,23,72 155.50 (1) (b) Failing to comply with a power of attorney for health care
3instrument or the decision of a health care agent, except that failure of a physician
4health care professional, as defined in s. 154.01 (3), to comply constitutes
5unprofessional conduct if the physician health care professional refuses or fails to
6make a good faith attempt to transfer the principal to another physician health care
7professional
who will comply.
SB254,32 8Section 32 . 165.77 (1) (a) of the statutes is amended to read:
SB254,23,109 165.77 (1) (a) “Health care professional" has the meaning given in s. 154.01 (3)
10means a person licensed, certified, or registered under ch. 441, 448, or 455.
SB254,33 11Section 33 . 302.384 of the statutes is renumbered 302.384 (2m), and 302.384
12(2m) (a), as renumbered, is amended to read:
SB254,23,1413 302.384 (2m) (a) A sheriff, jailer, keeper or officer arranges for a health care
14professional, as defined in s. 154.01 (3), to observe the prisoner.
SB254,34 15Section 34 . 302.384 (1m) of the statutes is created to read:
SB254,23,1716 302.384 (1m) In this section, “health care professional” means a person
17licensed, certified, or registered under ch. 441, 448, or 455.
SB254,35 18Section 35 . 441.07 (1g) (d) (intro.) of the statutes is amended to read:
SB254,23,2319 441.07 (1g) (d) (intro.) Misconduct or unprofessional conduct. In this
20paragraph, “unprofessional conduct” includes making a determination under ch. 154
21or 155 if the person does not have sufficient education, training, and experience to
22make the determination.
In this paragraph, “misconduct" and “unprofessional
23conduct" do not include any of the following:
SB254,36 24Section 36. 448.015 (4) (am) 2m. of the statutes is created to read:
SB254,24,3
1448.015 (4) (am) 2m. A determination made by a physician assistant under ch.
2154 or 155 if the physician assistant does not have sufficient education, training, and
3experience to make the determination.
SB254,24,44 (End)
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