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(b) Dated and signed by the requester or, at the express direction and in the
9presence of the requester, by an individual who has attained age 18.
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(c) Signed in the presence of 3 witnesses who meet the requirements of sub. (2).
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(d) Made voluntarily.
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(e) Substantially in the form specified in s. 156.15.
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(f) Filed in the requester's patient health care record in the custody of the
14requester's attending physician and, if the requester is an inpatient of a health care
15facility, in the requester's patient health care record in the custody of the health care
16facility.
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17(2) (a) A witness to the making of a valid written request for medication under
18this section shall be an individual who has attained age 18. No witness to the making
19of a valid written request for medication may, at the time of the witnessing, be any
20of the following:
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1. Related to the requester by blood, marriage, or adoption.
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2. An individual who has knowledge that he or she is entitled to or has a claim
23on any portion of the requester's estate.
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3. Directly financially responsible for the requester's health care.
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14. An individual who is a health care provider who is serving the requester at
2the time of the witnessing; an employee, other than a chaplain or a social worker, of
3the health care provider; or an employee, other than a chaplain or a social worker,
4of a health care facility in which the requester is a patient.
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(b) If a requester is a resident of a nursing home or community-based
6residential facility, at least one of the witnesses to the request shall be a residents'
7advocate designated under s. 156.19.
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8156.09 Attending physician; responsibilities, and limitations. The
9attending physician shall do all of the following:
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10(1) Determine whether the requester has a terminal disease, does not have
11incapacity, and is making a request under this chapter voluntarily.
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12(2) Inform the requester of all of the following:
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(a) The requester's medical diagnosis.
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(b) The requester's prognosis.
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(c) The potential risks associated with taking the medication to be prescribed
16under this chapter.
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(d) The probable result of taking the medication to be prescribed under this
18chapter.
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(e) The feasible alternatives to taking the medication to be prescribed under
20this chapter, including comfort care, hospice care, and pain control.
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21(3) Refer the requester to a consulting physician under the requirements of s.
22156.11.
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23(4) Refer the requester for review and counseling if the referral is determined
24to be appropriate under s. 156.13.
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1(5) Ask the requester to notify his or her next of kin with respect to the request
2for medication.
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3(6) Inform the requester that he or she may revoke the request for medication
4at any time; explain the methods of revocation that are specified under s. 156.17 (1);
5and offer the requester an opportunity to revoke the request at the time, if any, that
6the requester orally asks for medication under s. 156.05 (2) (c).
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7(7) Before writing a prescription that fulfills a request for medication, verify
8that all of the following have occurred:
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(a) The requester has fulfilled the requirements of s. 156.05 (2).
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(b) No fewer than 48 hours have elapsed since the requester made a 2nd oral
11request for medication under s. 156.05 (2) (c).
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(c) The requester has made an informed decision under s. 156.05 (1).
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13(8) Document or file all of the following in the requester's patient health care
14record:
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(a) All occasions that the requester orally asks for medication under s. 156.05
16(2) (a) or (c) as well as all written requests for medication under s. 156.05 (2) (b) that
17are made by the requester.
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(b) The attending physician's diagnosis of and prognosis for the requester and
19determination as to whether the requester is incapacitated, is acting voluntarily, and
20has made an informed decision under s. 156.05 (1).
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(c) The consulting physician's diagnosis of and prognosis for the requester and
22determination as to whether the requester is incapacitated, is acting voluntarily, and
23has made an informed decision under s. 156.05 (1).
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(d) A certification of the outcome and determinations made during any review
25and counseling for which the requester was referred under s. 156.13.
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1(e) A certification as to whether the attending physician offered the requester
2an opportunity to revoke the request for medication, as required under sub. (6).
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(f) Evidence of a revocation, if made, as specified in s. 156.17 (2).
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(g) A certification as to whether the requirements of this chapter are met and
5indicating the steps taken to fulfill the request for medication, including a notation
6of any medication that is prescribed. The attending physician shall report the
7information under this paragraph to the department on a form prescribed by the
8department. Information reported to the department under this paragraph that
9could identify the requester, the attending physician, the consulting physician, or the
10psychiatrist or psychologist to whom referral was made under s. 156.13, if any, is
11confidential and may not be disclosed by the department except under an
12investigation of an alleged violation of this chapter. The report of information under
13this paragraph is not a violation of any person's responsibility for maintaining the
14confidentiality of patient health care records under s. 146.82.
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15(9) If the attending physician refuses to fulfill the requester's request for
16medication that meets the requirements of this chapter, the attending physician
17shall make a good faith attempt to transfer the requester's care and treatment to
18another physician who will act as the attending physician under this chapter and will
19fulfill the requester's request for medication. If a transfer is made, the attending
20physician to whom the requester's care and treatment is transferred shall comply
21with the requirements of this section.
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22156.11 Consulting physician confirmation. Before an attending physician
23may fulfill a request for medication under this chapter, a consulting physician shall
24examine the requester and his or her relevant patient health care records and shall
25medically confirm the attending physician's determinations that the requester
1suffers from a terminal disease, does not have incapacity, is making a request for
2medication voluntarily, and has made an informed decision. The consulting
3physician shall complete a written report regarding his or her findings and provide
4it to the attending physician for filing in the requester's patient health care record
5in compliance with the certification requirement of s. 156.09 (8) (g).
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6156.13 Referral for review and counseling. If in the opinion of the
7attending physician or the consulting physician a requester may be suffering from
8a psychiatric or psychological disorder, including depression, that causes impaired
9judgment, the attending physician or consulting physician shall refer the requester
10for review and counseling to a physician specializing in psychiatry or a licensed
11psychologist, as defined in s. 455.01 (4). If a referral is made by the attending or
12consulting physician, no request for medication may be fulfilled under this chapter
13unless the physician specializing in psychiatry, or the psychologist, to whom referral
14was made, determines and certifies in writing that the requester is not suffering from
15a psychiatric or psychological disorder, including depression, that causes impaired
16judgment. The attending physician shall file the certification in the requester's
17patient health care record under s. 156.09 (8) (d).
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18156.15 Written request for medication; form. The department shall
19prepare and provide copies of a request for medication authorization form and
20accompanying information for distribution in quantities to health care providers,
21hospitals, nursing homes, multipurpose senior centers, county clerks, and local bar
22associations and individually to private persons. The department shall include, in
23information accompanying the copy of the request for medication authorization
24form, at least the statutory definitions of terms used in the request for medication
25authorization form, statutory restrictions on who may be witnesses to a valid request
1for medication under s. 156.07, and a statement explaining that valid witnesses
2acting in good faith are statutorily immune from civil or criminal liability. The
3request for medication authorization form distributed by the department shall be in
4the following form:
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REQUEST FOR MEDICATION
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AUTHORIZATION TO END MY LIFE IN A
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HUMANE AND DIGNIFIED MANNER
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I, .... (insert name), am an adult of sound mind, do not have incapacity, and am
9a resident of Wisconsin.
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I am suffering from .... (insert description of terminal disease), which my
11attending physician has determined is a terminal disease and which has been
12medically confirmed by a consulting physician.
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I have been fully informed of my diagnosis, prognosis, the nature of medication
14to be prescribed and potential associated risks, the expected result, and the feasible
15alternatives, including comfort care, hospice care, and pain control.
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I request that my attending physician prescribe medication that will end my life
17in a humane and dignified manner.
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INITIAL ONE OF THE FOLLOWING 3 STATEMENTS:
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.... I have informed my family members of my decision and taken their opinions
20into consideration.
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.... I have decided not to inform my family of my decision.
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.... I have no family to inform of my decision.
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I understand that I have the right to revoke this request at any time.
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I understand the full import of this request and I expect to die when I take the
25medication to be prescribed.
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1I make this request voluntarily and without reservation, and I accept full moral
2responsibility for my actions.
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5Statement and signatures
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I know the requester personally or I have received proof of his or her identity
8and I believe him or her to be of sound mind and at least 18 years of age. I believe
9that the requester makes this request voluntarily. I am at least 18 years of age, am
10not related to the requester by blood, marriage, or adoption, and am not directly
11financially responsible for the requester's health care. I am not a health care
12provider who is serving the requester at this time; an employee of the health care
13provider, other than a chaplain or a social worker; or an employee, other than a
14chaplain or a social worker, of a health care facility in which the requester is a
15patient. To the best of my knowledge, I am not entitled to and do not have a claim
16on the requester's estate.
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Witness No. 1:
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(print) Name: ....
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Address: ....
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Signature: ....
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Witness No. 2:
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(print) Name: ....
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Address: ....
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Signature: ....
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Witness No. 3:
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1(print) Name: ....
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Address: ....
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Signature: ....
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If the requester is a resident of a nursing home or community-based residential
5facility, at least one of the above witnesses must be a residents' advocate designated
6by the board on aging and long-term care. A residents' advocate who is a witness
7should print “residents' advocate" after the printing of his or her name above.
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8156.17 Revocation of request for medication. (1) A requester may revoke
9his or her request for medication at any time by doing any of the following:
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(a) Canceling, defacing, obliterating, burning, tearing, or otherwise destroying
11the written request for medication or directing another in the presence of the
12requester to destroy, in the same manner, the request for medication.
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(b) Executing a statement, in writing, that is signed and dated by the requester,
14expressing the requester's intent to revoke the request for medication.
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(c) Orally expressing the requester's intent to revoke the request for
16medication, in the presence of 2 witnesses or the attending physician.
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17(2) A health care provider shall, upon notification of revocation of the
18requester's request for medication, record in the requester's medical record the time,
19date, and place of the revocation and the time, date, and place, if different, of the
20notification to the health care provider of the revocation.
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21156.19 Designation of residents' advocates. The board on aging and
22long-term care shall designate staff of the long-term care ombudsman program as
23residents' advocates. A person so designated shall serve as a witness to a request for
24medication of a requester who is a resident of a nursing home or community-based
25residential facility, as required under s. 156.07 (2) (b), and shall speak on behalf of
1the requester to ensure that his or her needs or wants are communicated to and
2addressed by his or her attending physician.
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3156.21 Duties and immunities.
(1) No health care facility or health care
4provider may be charged with a crime, held civilly liable, or charged with
5unprofessional conduct for any of the following:
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(a) Failing to fulfill a request for medication, except that failure of an attending
7physician to fulfill a request for medication constitutes unprofessional conduct if the
8attending physician refuses or fails to make a good faith attempt to transfer the
9requester's care and treatment to another physician who will act as attending
10physician under this chapter and fulfill the request for medication.
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(b) In the absence of actual knowledge of a revocation, fulfilling a request for
12medication that is in compliance with this chapter.
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(c) Acting contrary to or failing to act on a revocation of a request for medication,
14unless the health care facility or health care provider has actual knowledge of the
15revocation.
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16(2) In the absence of actual notice to the contrary, a health care facility or a
17health care provider, other than a physician acting as the requester's attending
18physician under this chapter, may presume that a requester was authorized to make
19his or her request for medication under the requirements of this chapter and that the
20request for medication is valid.
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21(3) (a) No person who acts in good faith as a witness to a request for medication
22under this chapter may be held civilly or criminally liable for a death that results
23from taking medication under a fulfilled request for medication under this chapter.
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(b) Paragraph (a) does not apply to a person who acts as a witness in violation
25of s. 156.07 (2) (a).
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1156.23 General provisions. (1) (a) The making of a request for medication
2under this chapter does not, for any purpose, constitute attempted suicide. Taking
3medication under a fulfilled request for medication under this chapter does not, for
4any purpose, constitute suicide.
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(b) Paragraph (a) does not prohibit an insurer from making a determination
6that a requester has attempted suicide or committed suicide if the requester has so
7acted, apart from a request for medication.
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8(2) The making of a request for medication under this chapter does not revoke
9or otherwise modify a power of attorney for health care or declaration to physicians
10that the requester may have executed.
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11(3) No individual may be required to make a request for medication as a
12condition for receipt of health care or admission to a health care facility. The making
13of a request for medication is not a bar to the receipt of health care or the admission
14to a health care facility.
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15(4) A written request for medication that has not been revoked and that is in
16its original form or is a legible photocopy or electronic facsimile copy is presumed to
17be valid.