SB655: Bill Text

SB655,6,15 Signed ....   Date ....

SB655,6,16 Address ....   Date of birth ....

SB655,6,20 I believe that the person signing this document is of sound mind. I am an adult and am not related to the person signing this document by blood, marriage or adoption. I am not entitled to and do not have a claim on any portion of the person's estate and am not otherwise restricted by law from being a witness.

SB655,6,21 Witness signature ....   Date signed ....

SB655,6,22 Print name ....

SB655,6,24 Witness signature ....   Date signed ....

SB655,6,25 Print name ....

SB655,7,1 Notarial officer:

SB655,7,2 (print) Name....

SB655,7,3 State of ....

SB655,7,4 County of ....

SB655,7,6 This document was acknowledged before me on .... (date), by .... (name of principal).

SB655,7,7 (Seal, if any)

SB655,7,8 Signature of notary ....

SB655,7,9 My commission expires: ....

SB655,7,10 DIRECTIVES TO ATTENDING PHYSICIAN

SB655,7,14 1. This document authorizes the withholding or withdrawal of life-sustaining procedures or of feeding tubes when 2 physicians, one of whom is the attending physician, have personally examined and certified in writing that the patient has a terminal condition or is in a persistent vegetative state.

SB655,7,20 2. The choices in this document were made by a competent adult. Under the law, the patient's stated desires must be followed unless you believe that withholding or withdrawing life-sustaining procedures or feeding tubes would cause the patient pain or reduced comfort and that the pain or discomfort cannot be alleviated through pain relief measures. If the patient's stated desires are that life-sustaining procedures or feeding tubes be used, this directive must be followed.

SB655,7,23 3. If you feel that you cannot comply with this document, you must make a good faith attempt to transfer the patient to another physician who will comply. Refusal or failure to make a good faith attempt to do so constitutes unprofessional conduct.

SB655,7,25 4. If you know that the patient is pregnant, this document has no effect during her pregnancy.

SB655,8,1 * * * * *

SB655,8,4 The person making this living will may use the following space to record the names of those individuals and health care providers to whom he or she has given copies of this document:

SB655,8,5 .................................................................

SB655,8,6 .................................................................

SB655,8,7 .................................................................

SB655,6 Section 6 . 154.07 (1) (b) 1. of the statutes is amended to read:

SB655,8,12 154.07 (1) (b) 1. No person who acts in good faith as a witness to a declaration or takes an acknowledgment of a declaration under this subchapter may be held civilly or criminally liable for participating in the withholding or withdrawal of life-sustaining procedures or feeding tubes under this subchapter.

SB655,7 Section 7 . 154.07 (1) (b) 2. of the statutes is amended to read:

SB655,8,15 154.07 (1) (b) 2. Subdivision 1. does not apply to a person who acts as a witness or takes an acknowledgment in violation of s. 154.03 (1).

SB655,8 Section 8 . 155.10 (title) of the statutes is amended to read:

SB655,8,18 155.10 (title) Power of attorney for health care instrument; execution; witnesses and notarial officers.

SB655,9 Section 9 . 155.10 (1) (c) of the statutes is amended to read:

SB655,8,23 155.10 (1) (c) Signed in the presence of 2 witnesses who meet the requirements of sub. (2) or the principal makes an acknowledgment of the instrument before a notarial officer authorized under s. 706.07 to take acknowledgments who meets the requirements of sub. (2).

SB655,10 Section 10 . 155.10 (2) (intro.) of the statutes is amended to read:

SB655,9,5 155.10 (2) (intro.) A witness to the execution of a valid power of attorney for health care instrument shall be an individual who has attained age 18. No witness to the execution or notarial officer who takes an acknowledgment of the power of attorney for health care instrument may, at the time of the execution, be any of the following:

SB655,11 Section 11 . 155.10 (2) (d) of the statutes is renumbered 155.10 (2) (d) (intro.) and amended to read:

SB655,9,8 155.10 (2) (d) (intro.) An individual who is a any of the following:

SB655,9,10 1. A health care provider who is serving the principal at the time of execution, an.

SB655,9,13 2. An employee, other than an employee authorized as a notarial officer under s. 706.07, a chaplain, or a social worker, of the a health care provider or an who is serving the principal at the time of execution.

SB655,9,16 3. An employee, other than an employee authorized as a notarial officer under s. 706.07, a chaplain, or a social worker, of an inpatient health care facility in which the principal is a patient.

SB655,12 Section 12 . 155.10 (2) (d) 4. of the statutes is created to read:

SB655,9,19 155.10 (2) (d) 4. A finance or billing officer of an inpatient health care facility in which the principal is a patient.

SB655,13 Section 13 . 155.30 (3) of the statutes is amended to read:

SB655,9,25 155.30 (3) The department shall prepare and provide copies of a power of attorney for health care instrument and accompanying information for distribution in quantities to health care professionals, hospitals, nursing homes, multipurpose senior centers, county clerks, and local bar associations and individually to private persons. The department shall include, in information accompanying the copy of the instrument, at least the statutory definitions of terms used in the instrument, statutory restrictions on who may be witnesses to or be a notarial officer that takes an acknowledgment of a valid instrument, a statement explaining that valid witnesses or notarial officers acting in good faith are statutorily immune from civil or criminal liability and a statement explaining that an instrument may, but need not, be filed with the register in probate of the principal's county of residence. The department may charge a reasonable fee for the cost of preparation and distribution. The power of attorney for health care instrument distributed by the department shall include the notice specified in sub. (1) and shall be in the following form:

SB655,10,10 POWER OF ATTORNEY FOR HEALTH CARE

SB655,10,11 Document made this.... day of.... (month),.... (year).

SB655,10,12 CREATION OF POWER OF ATTORNEY

SB655,10,13 FOR HEALTH CARE

SB655,10,21 I,.... (print name, address and date of birth), being of sound mind, intend by this document to create a power of attorney for health care. My executing this power of attorney for health care is voluntary. Despite the creation of this power of attorney for health care, I expect to be fully informed about and allowed to participate in any health care decision for me, to the extent that I am able. For the purposes of this document, “health care decision" means an informed decision to accept, maintain, discontinue or refuse any care, treatment, service or procedure to maintain, diagnose or treat my physical or mental condition.

SB655,10,23 In addition, I may, by this document, specify my wishes with respect to making an anatomical gift upon my death.

SB655,10,24 DESIGNATION OF HEALTH CARE AGENT

SB655,11,15 If I am no longer able to make health care decisions for myself, due to my incapacity, I hereby designate.... (print name, address and telephone number) to be my health care agent for the purpose of making health care decisions on my behalf. If he or she is ever unable or unwilling to do so, I hereby designate.... (print name, address and telephone number) to be my alternate health care agent for the purpose of making health care decisions on my behalf. Neither my health care agent nor my alternate health care agent whom I have designated is my health care provider, an employee of my health care provider, an employee of a health care facility in which I am a patient or a spouse of any of those persons, unless he or she is also my relative. For purposes of this document, “incapacity" exists if 2 physicians or a physician and a psychologist who have personally examined me sign a statement that specifically expresses their opinion that I have a condition that means that I am unable to receive and evaluate information effectively or to communicate decisions to such an extent that I lack the capacity to manage my health care decisions. A copy of that statement must be attached to this document.

SB655,11,16 GENERAL STATEMENT OF AUTHORITY GRANTED

SB655,11,23 Unless I have specified otherwise in this document, if I ever have incapacity I instruct my health care provider to obtain the health care decision of my health care agent, if I need treatment, for all of my health care and treatment. I have discussed my desires thoroughly with my health care agent and believe that he or she understands my philosophy regarding the health care decisions I would make if I were able. I desire that my wishes be carried out through the authority given to my health care agent under this document.

SB655,12,7 If I am unable, due to my incapacity, to make a health care decision, my health care agent is instructed to make the health care decision for me, but my health care agent should try to discuss with me any specific proposed health care if I am able to communicate in any manner, including by blinking my eyes. If this communication cannot be made, my health care agent shall base his or her decision on any health care choices that I have expressed prior to the time of the decision. If I have not expressed a health care choice about the health care in question and communication cannot be made, my health care agent shall base his or her health care decision on what he or she believes to be in my best interest.

SB655,12,8 LIMITATIONS ON MENTAL HEALTH TREATMENT

SB655,12,14 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 persons with an intellectual disability, 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.

SB655,12,15 ADMISSION TO NURSING HOMES OR

SB655,12,16 COMMUNITY-BASED RESIDENTIAL FACILITIES

SB655,12,18 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.

SB655,12,21 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:

SB655,12,22 1. A nursing home — Yes.... No....

SB655,12,23 2. A community-based residential facility — Yes.... No....

SB655,12,25 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.

SB655,13,1 PROVISION OF A FEEDING TUBE

SB655,13,6 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.

SB655,13,9 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.

SB655,13,10 Withhold or withdraw a feeding tube — Yes.... No....

SB655,13,12 If I have not checked either “Yes" or “No" immediately above, my health care agent may not have a feeding tube withdrawn from me.

SB655,13,13 HEALTH CARE DECISIONS FOR

SB655,13,14 PREGNANT WOMEN

SB655,13,18 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.

SB655,13,19 Health care decision if I am pregnant — Yes.... No....

SB655,13,22 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.

SB655,13,23 STATEMENT OF DESIRES,

SB655,13,24 SPECIAL PROVISIONS OR LIMITATIONS

SB655,14,4 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):

SB655,14,5 1) -

SB655,14,6 2) -

SB655,14,7 3) -

SB655,14,8 INSPECTION AND DISCLOSURE OF

SB655,14,9 INFORMATION RELATING TO MY PHYSICAL

SB655,14,10 OR MENTAL HEALTH

SB655,14,12 Subject to any limitations in this document, my health care agent has the authority to do all of the following:

SB655,14,14 (a) Request, review and receive any information, oral or written, regarding my physical or mental health, including medical and hospital records.

SB655,14,16 (b) Execute on my behalf any documents that may be required in order to obtain this information.

SB655,14,17 (c) Consent to the disclosure of this information.

SB655,14,18 (The principal and the witnesses all must sign the document at the same time.)