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SB499,4,7 7(12) “Residence" has the meaning given in s. 46.27 (1) (d).
SB499,4,11 8(13) “Responsible person" means the attending physician, a health care
9provider serving the requester, an inpatient health care facility in which the
10requester is located, or the requester's spouse, child, parent, brother, sister,
11grandparent, or grandchild.
SB499,4,13 12(14) “Social worker" means a person certified under s. 457.08 as a social worker,
13advanced practice social worker, independent social worker, or clinical social worker.
SB499,4,16 14(15) “Terminal disease" means an incurable and irreversible disease that has
15been diagnosed by an individual's attending physician and medically confirmed and
16that will, within reasonable medical judgment, cause death within 6 months.
SB499,4,22 17156.03 Authorization to make request. An individual who is of sound mind,
18has attained age 18, has residence in this state, does not have incapacity, and has a
19terminal disease may voluntarily make a request for medication for the purpose of
20ending his or her life in a humane and dignified manner. An individual for whom an
21adjudication of incompetence and appointment of a guardian of the person is in effect
22under ch. 54 is presumed not to be of sound mind for purposes of this section.
SB499,5,4 23156.05 Requester rights, responsibilities, and limitations. (1) No
24requester may receive a prescription that fulfills a request for medication unless he
25or she has made an informed decision. An informed decision under this chapter

1means a decision by an individual to request and obtain a prescription for medication
2so as to end his or her life in a humane and dignified manner that is based on an
3appreciation of the relevant facts and is made after having been fully informed by
4the attending physician of all of the following:
SB499,5,55 (a) The individual's medical diagnosis.
SB499,5,66 (b) The individual's prognosis.
SB499,5,87 (c) The potential risks associated with taking the medication to be prescribed
8under this chapter.
SB499,5,109 (d) The probable result of taking the medication to be prescribed under this
10chapter.
SB499,5,1211 (e) The feasible alternatives, including comfort care, hospice care, and pain
12control.
SB499,5,14 13(2) In order to receive a prescription for medication to end his or her life, a
14requester shall do all of the following:
SB499,5,1615 (a) Make an oral request for medication for the purpose of ending his or her life
16to his or her attending physician.
SB499,5,2017 (b) No fewer than 15 days after making the oral request for medication under
18par. (a), complete a valid written request for medication under s. 156.07. The written
19request under this paragraph may not be completed until a consulting physician
20completes the examination and report required under s. 156.11.
SB499,5,2321 (c) After completing a written request for medication under par. (b), make a 2nd
22oral request for medication for the purpose of ending his or her life to his or her
23attending physician.
SB499,6,3
1(3) No requester may be required to notify his or her next of kin regarding his
2or her request for medication, and no request for medication may be denied because
3the requester has failed to notify his or her next of kin.
SB499,6,6 4156.07 Valid written request for medication; requirements. (1) A
5written request for medication under s. 156.05 (2) (b) is valid only if it is all of the
6following:
SB499,6,77 (a) In writing.
SB499,6,98 (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.
SB499,6,1010 (c) Signed in the presence of 3 witnesses who meet the requirements of sub. (2).
SB499,6,1111 (d) Made voluntarily.
SB499,6,1212 (e) Substantially in the form specified in s. 156.15.
SB499,6,1613 (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.
SB499,6,20 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:
SB499,6,2121 1. Related to the requester by blood, marriage, or adoption.
SB499,6,2322 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.
SB499,6,2424 3. Directly financially responsible for the requester's health care.
SB499,7,4
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.
SB499,7,75 (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.
SB499,7,9 8156.09 Attending physician; responsibilities, and limitations. The
9attending physician shall do all of the following:
SB499,7,11 10(1) Determine whether the requester has a terminal disease, does not have
11incapacity, and is making a request under this chapter voluntarily.
SB499,7,12 12(2) Inform the requester of all of the following:
SB499,7,1313 (a) The requester's medical diagnosis.
SB499,7,1414 (b) The requester's prognosis.
SB499,7,1615 (c) The potential risks associated with taking the medication to be prescribed
16under this chapter.
SB499,7,1817 (d) The probable result of taking the medication to be prescribed under this
18chapter.
SB499,7,2019 (e) The feasible alternatives to taking the medication to be prescribed under
20this chapter, including comfort care, hospice care, and pain control.
SB499,7,22 21(3) Refer the requester to a consulting physician under the requirements of s.
22156.11.
SB499,7,24 23(4) Refer the requester for review and counseling if the referral is determined
24to be appropriate under s. 156.13.
SB499,8,2
1(5) Ask the requester to notify his or her next of kin with respect to the request
2for medication.
SB499,8,6 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).
SB499,8,8 7(7) Before writing a prescription that fulfills a request for medication, verify
8that all of the following have occurred:
SB499,8,99 (a) The requester has fulfilled the requirements of s. 156.05 (2).
SB499,8,1110 (b) No fewer than 48 hours have elapsed since the requester made a 2nd oral
11request for medication under s. 156.05 (2) (c).
SB499,8,1212 (c) The requester has made an informed decision under s. 156.05 (1).
SB499,8,14 13(8) Document or file all of the following in the requester's patient health care
14record:
SB499,8,1715 (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.
SB499,8,2018 (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).
SB499,8,2321 (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).
SB499,8,2524 (d) A certification of the outcome and determinations made during any review
25and counseling for which the requester was referred under s. 156.13.
SB499,9,2
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).
SB499,9,33 (f) Evidence of a revocation, if made, as specified in s. 156.17 (2).
SB499,9,144 (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.
SB499,9,21 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.
SB499,9,25 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).
SB499,10,17 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).
SB499,11,4 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:
SB499,11,55 REQUEST FOR MEDICATION
SB499,11,66 AUTHORIZATION TO END MY LIFE IN A
SB499,11,77 HUMANE AND DIGNIFIED MANNER
SB499,11,98 I, .... (insert name), am an adult of sound mind, do not have incapacity, and am
9a resident of Wisconsin.
SB499,11,1210 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.
SB499,11,1513 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.
SB499,11,1716 I request that my attending physician prescribe medication that will end my life
17in a humane and dignified manner.
SB499,11,1818 INITIAL ONE OF THE FOLLOWING 3 STATEMENTS:
SB499,11,2019 .... I have informed my family members of my decision and taken their opinions
20into consideration.
SB499,11,2121 .... I have decided not to inform my family of my decision.
SB499,11,2222 .... I have no family to inform of my decision.
SB499,11,2323 I understand that I have the right to revoke this request at any time.
SB499,11,2524 I understand the full import of this request and I expect to die when I take the
25medication to be prescribed.
SB499,12,2
1I make this request voluntarily and without reservation, and I accept full moral
2responsibility for my actions.
SB499,12,33 Signed: ....
SB499,12,44 Dated: ....
SB499,12,5 5Statement and signatures
SB499,12,6 6of witnesses
SB499,12,167 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.
SB499,12,1717 Witness No. 1:
SB499,12,1818 (print) Name: ....
SB499,12,1919 Address: ....
SB499,12,2020 Signature: ....
SB499,12,2121 Witness No. 2:
SB499,12,2222 (print) Name: ....
SB499,12,2323 Address: ....
SB499,12,2424 Signature: ....
SB499,12,2525 Witness No. 3:
SB499,13,1
1(print) Name: ....
SB499,13,22 Address: ....
SB499,13,33 Signature: ....
SB499,13,74 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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