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SB655,5,1919 .... NO, I do not want feeding tubes used if I have a terminal condition.
SB655,5,2020 If you have not checked either box, feeding tubes will be used.
SB655,5,2321 2. If I am in a PERSISTENT VEGETATIVE STATE, as determined by 2
22physicians who have personally examined me, the following are my directions
23regarding the use of life-sustaining procedures:
SB655,5,2524 .... YES, I want life-sustaining procedures used if I am in a persistent
25vegetative state.
SB655,6,2
1.... NO, I do not want life-sustaining procedures used if I am in a persistent
2vegetative state.
SB655,6,33 If you have not checked either box, life-sustaining procedures will be used.
SB655,6,64 3. If I am in a PERSISTENT VEGETATIVE STATE, as determined by 2
5physicians who have personally examined me, the following are my directions
6regarding the use of feeding tubes:
SB655,6,77 .... YES, I want feeding tubes used if I am in a persistent vegetative state.
SB655,6,88 .... NO, I do not want feeding tubes used if I am in a persistent vegetative state.
SB655,6,99 If you have not checked either box, feeding tubes will be used.
SB655,6,1210 If you are interested in more information about the significant terms used in
11this document, see section 154.01 of the Wisconsin Statutes or the information
12accompanying this document.
SB655,6,1413 ATTENTION: You and the 2 witnesses or a notarial officer must sign the
14document at the same time.
SB655,6,1515 Signed ....   Date ....
SB655,6,1616 Address ....   Date of birth ....
SB655,6,2017 I believe that the person signing this document is of sound mind. I am an adult
18and am not related to the person signing this document by blood, marriage or
19adoption. I am not entitled to and do not have a claim on any portion of the person's
20estate and am not otherwise restricted by law from being a witness.
SB655,6,2121 Witness signature ....   Date signed ....
SB655,6,2222 Print name ....
SB655,6,2424 Witness signature ....   Date signed ....
SB655,6,2525 Print name ....
SB655,7,1
1Notarial officer:
SB655,7,2 2(print) Name....
SB655,7,3 3State of ....
SB655,7,4 4County of ....
SB655,7,6 5This document was acknowledged before me on .... (date), by .... (name of
6principal).
SB655,7,7 7(Seal, if any)
SB655,7,8 8Signature of notary ....
SB655,7,9 9My commission expires: ....
SB655,7,1010 DIRECTIVES TO ATTENDING PHYSICIAN
SB655,7,1411 1. This document authorizes the withholding or withdrawal of life-sustaining
12procedures or of feeding tubes when 2 physicians, one of whom is the attending
13physician, have personally examined and certified in writing that the patient has a
14terminal condition or is in a persistent vegetative state.
SB655,7,2015 2. The choices in this document were made by a competent adult. Under the
16law, the patient's stated desires must be followed unless you believe that withholding
17or withdrawing life-sustaining procedures or feeding tubes would cause the patient
18pain or reduced comfort and that the pain or discomfort cannot be alleviated through
19pain relief measures. If the patient's stated desires are that life-sustaining
20procedures or feeding tubes be used, this directive must be followed.
SB655,7,2321 3. If you feel that you cannot comply with this document, you must make a good
22faith attempt to transfer the patient to another physician who will comply. Refusal
23or failure to make a good faith attempt to do so constitutes unprofessional conduct.
SB655,7,2524 4. If you know that the patient is pregnant, this document has no effect during
25her pregnancy.
SB655,8,1
1* * * * *
SB655,8,42 The person making this living will may use the following space to record the
3names of those individuals and health care providers to whom he or she has given
4copies of this document:
SB655,8,55 .................................................................
SB655,8,66 .................................................................
SB655,8,77 .................................................................
SB655,6 8Section 6 . 154.07 (1) (b) 1. of the statutes is amended to read:
SB655,8,129 154.07 (1) (b) 1. No person who acts in good faith as a witness to a declaration
10or takes an acknowledgment of a declaration under this subchapter may be held
11civilly or criminally liable for participating in the withholding or withdrawal of
12life-sustaining procedures or feeding tubes under this subchapter.
SB655,7 13Section 7 . 154.07 (1) (b) 2. of the statutes is amended to read:
SB655,8,1514 154.07 (1) (b) 2. Subdivision 1. does not apply to a person who acts as a witness
15or takes an acknowledgment in violation of s. 154.03 (1).
SB655,8 16Section 8 . 155.10 (title) of the statutes is amended to read:
SB655,8,18 17155.10 (title) Power of attorney for health care instrument; execution;
18witnesses
and notarial officers.
SB655,9 19Section 9 . 155.10 (1) (c) of the statutes is amended to read:
SB655,8,2320 155.10 (1) (c) Signed in the presence of 2 witnesses who meet the requirements
21of sub. (2) or the principal makes an acknowledgment of the instrument before a
22notarial officer authorized under s. 706.07 to take acknowledgments who meets the
23requirements of sub. (2)
.
SB655,10 24Section 10 . 155.10 (2) (intro.) of the statutes is amended to read:
SB655,9,5
1155.10 (2) (intro.) A witness to the execution of a valid power of attorney for
2health care instrument shall be an individual who has attained age 18. No witness
3to the execution or notarial officer who takes an acknowledgment of the power of
4attorney for health care instrument may, at the time of the execution, be any of the
5following:
SB655,11 6Section 11 . 155.10 (2) (d) of the statutes is renumbered 155.10 (2) (d) (intro.)
7and amended to read:
SB655,9,88 155.10 (2) (d) (intro.) An individual who is a any of the following:
SB655,9,10 91. A health care provider who is serving the principal at the time of execution,
10an
.
SB655,9,13 112. An employee, other than an employee authorized as a notarial officer under
12s. 706.07,
a chaplain, or a social worker, of the a health care provider or an who is
13serving the principal at the time of execution.
SB655,9,16 143. An employee, other than an employee authorized as a notarial officer under
15s. 706.07,
a chaplain, or a social worker, of an inpatient health care facility in which
16the principal is a patient.
SB655,12 17Section 12 . 155.10 (2) (d) 4. of the statutes is created to read:
SB655,9,1918 155.10 (2) (d) 4. A finance or billing officer of an inpatient health care facility
19in which the principal is a patient.
SB655,13 20Section 13 . 155.30 (3) of the statutes is amended to read:
SB655,9,2521 155.30 (3) The department shall prepare and provide copies of a power of
22attorney for health care instrument and accompanying information for distribution
23in quantities to health care professionals, hospitals, nursing homes, multipurpose
24senior centers, county clerks, and local bar associations and individually to private
25persons. The department shall include, in information accompanying the copy of the

1instrument, at least the statutory definitions of terms used in the instrument,
2statutory restrictions on who may be witnesses to or be a notarial officer that takes
3an acknowledgment of
a valid instrument, a statement explaining that valid
4witnesses or notarial officers acting in good faith are statutorily immune from civil
5or criminal liability and a statement explaining that an instrument may, but need
6not, be filed with the register in probate of the principal's county of residence. The
7department may charge a reasonable fee for the cost of preparation and distribution.
8The power of attorney for health care instrument distributed by the department
9shall include the notice specified in sub. (1) and shall be in the following form:
SB655,10,1010 POWER OF ATTORNEY FOR HEALTH CARE
SB655,10,1111 Document made this.... day of.... (month),.... (year).
SB655,10,1212 CREATION OF POWER OF ATTORNEY
SB655,10,1313 FOR HEALTH CARE
SB655,10,2114 I,.... (print name, address and date of birth), being of sound mind, intend by this
15document to create a power of attorney for health care. My executing this power of
16attorney for health care is voluntary. Despite the creation of this power of attorney
17for health care, I expect to be fully informed about and allowed to participate in any
18health care decision for me, to the extent that I am able. For the purposes of this
19document, “health care decision" means an informed decision to accept, maintain,
20discontinue or refuse any care, treatment, service or procedure to maintain, diagnose
21or treat my physical or mental condition.
SB655,10,2322 In addition, I may, by this document, specify my wishes with respect to making
23an anatomical gift upon my death.
SB655,10,2424 DESIGNATION OF HEALTH CARE AGENT
SB655,11,15
1If I am no longer able to make health care decisions for myself, due to my
2incapacity, I hereby designate.... (print name, address and telephone number) to be
3my health care agent for the purpose of making health care decisions on my behalf.
4If he or she is ever unable or unwilling to do so, I hereby designate.... (print name,
5address and telephone number) to be my alternate health care agent for the purpose
6of making health care decisions on my behalf. Neither my health care agent nor my
7alternate health care agent whom I have designated is my health care provider, an
8employee of my health care provider, an employee of a health care facility in which
9I am a patient or a spouse of any of those persons, unless he or she is also my relative.
10For purposes of this document, “incapacity" exists if 2 physicians or a physician and
11a psychologist who have personally examined me sign a statement that specifically
12expresses their opinion that I have a condition that means that I am unable to receive
13and evaluate information effectively or to communicate decisions to such an extent
14that I lack the capacity to manage my health care decisions. A copy of that statement
15must be attached to this document.
SB655,11,1616 GENERAL STATEMENT OF AUTHORITY GRANTED
SB655,11,2317 Unless I have specified otherwise in this document, if I ever have incapacity I
18instruct my health care provider to obtain the health care decision of my health care
19agent, if I need treatment, for all of my health care and treatment. I have discussed
20my desires thoroughly with my health care agent and believe that he or she
21understands my philosophy regarding the health care decisions I would make if I
22were able. I desire that my wishes be carried out through the authority given to my
23health care agent under this document.
SB655,12,724 If I am unable, due to my incapacity, to make a health care decision, my health
25care agent is instructed to make the health care decision for me, but my health care

1agent should try to discuss with me any specific proposed health care if I am able to
2communicate in any manner, including by blinking my eyes. If this communication
3cannot be made, my health care agent shall base his or her decision on any health
4care choices that I have expressed prior to the time of the decision. If I have not
5expressed a health care choice about the health care in question and communication
6cannot be made, my health care agent shall base his or her health care decision on
7what he or she believes to be in my best interest.
SB655,12,88 LIMITATIONS ON MENTAL HEALTH TREATMENT
SB655,12,149 My health care agent may not admit or commit me on an inpatient basis to an
10institution for mental diseases, an intermediate care facility for persons with an
11intellectual disability, a state treatment facility or a treatment facility. My health
12care agent may not consent to experimental mental health research or
13psychosurgery, electroconvulsive treatment or drastic mental health treatment
14procedures for me.
SB655,12,1515 ADMISSION TO NURSING HOMES OR
SB655,12,1616 COMMUNITY-BASED RESIDENTIAL FACILITIES
SB655,12,1817 My health care agent may admit me to a nursing home or community-based
18residential facility for short-term stays for recuperative care or respite care.
SB655,12,2119 If I have checked “Yes" to the following, my health care agent may admit me for
20a purpose other than recuperative care or respite care, but if I have checked “No" to
21the following, my health care agent may not so admit me:
SB655,12,2222 1. A nursing home — Yes.... No....
SB655,12,2323 2. A community-based residential facility — Yes.... No....
SB655,12,2524 If I have not checked either “Yes" or “No" immediately above, my health care
25agent may admit me only for short-term stays for recuperative care or respite care.
SB655,13,1
1PROVISION OF A FEEDING TUBE
SB655,13,62 If I have checked “Yes" to the following, my health care agent may have a
3feeding tube withheld or withdrawn from me, unless my physician has advised that,
4in his or her professional judgment, this will cause me pain or will reduce my comfort.
5If I have checked “No" to the following, my health care agent may not have a feeding
6tube withheld or withdrawn from me.
SB655,13,97 My health care agent may not have orally ingested nutrition or hydration
8withheld or withdrawn from me unless provision of the nutrition or hydration is
9medically contraindicated.
SB655,13,1010 Withhold or withdraw a feeding tube — Yes.... No....
SB655,13,1211 If I have not checked either “Yes" or “No" immediately above, my health care
12agent may not have a feeding tube withdrawn from me.
SB655,13,1313 HEALTH CARE DECISIONS FOR
SB655,13,1414 PREGNANT WOMEN
SB655,13,1815 If I have checked “Yes" to the following, my health care agent may make health
16care decisions for me even if my agent knows I am pregnant. If I have checked “No"
17to the following, my health care agent may not make health care decisions for me if
18my health care agent knows I am pregnant.
SB655,13,1919 Health care decision if I am pregnant — Yes.... No....
SB655,13,2220 If I have not checked either “Yes" or “No" immediately above, my health care
21agent may not make health care decisions for me if my health care agent knows I am
22pregnant.
SB655,13,2323 STATEMENT OF DESIRES,
SB655,13,2424 SPECIAL PROVISIONS OR LIMITATIONS
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