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AB552,11,4 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:
AB552,11,55 REQUEST FOR MEDICATION
AB552,11,66 AUTHORIZATION TO END MY LIFE IN A
AB552,11,77 HUMANE AND DIGNIFIED MANNER
AB552,11,98 I, .... (insert name), am an adult of sound mind, do not have incapacity, and am
9a resident of Wisconsin.
AB552,11,1210 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.
AB552,11,1513 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.
AB552,11,1716 I request that my attending physician prescribe medication that will end my life
17in a humane and dignified manner.
AB552,11,1818 INITIAL ONE OF THE FOLLOWING 3 STATEMENTS:
AB552,11,2019 .... I have informed my family members of my decision and taken their opinions
20into consideration.
AB552,11,2121 .... I have decided not to inform my family of my decision.
AB552,11,2222 .... I have no family to inform of my decision.
AB552,11,2323 I understand that I have the right to revoke this request at any time.
AB552,11,2524 I understand the full import of this request and I expect to die when I take the
25medication to be prescribed.
AB552,12,2
1I make this request voluntarily and without reservation, and I accept full moral
2responsibility for my actions.
AB552,12,33 Signed: ....
AB552,12,44 Dated: ....
AB552,12,5 5Statement and signatures
AB552,12,6 6of witnesses
AB552,12,167 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.
AB552,12,1717 Witness No. 1:
AB552,12,1818 (print) Name: ....
AB552,12,1919 Address: ....
AB552,12,2020 Signature: ....
AB552,12,2121 Witness No. 2:
AB552,12,2222 (print) Name: ....
AB552,12,2323 Address: ....
AB552,12,2424 Signature: ....
AB552,12,2525 Witness No. 3:
AB552,13,1
1(print) Name: ....
AB552,13,22 Address: ....
AB552,13,33 Signature: ....
AB552,13,74 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.
AB552,13,9 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:
AB552,13,1210 (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.
AB552,13,1413 (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.
AB552,13,1615 (c) Orally expressing the requester's intent to revoke the request for
16medication, in the presence of 2 witnesses or the attending physician.
AB552,13,20 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.
AB552,14,2 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.
AB552,14,5 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:
AB552,14,106 (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.
AB552,14,1211 (b) In the absence of actual knowledge of a revocation, fulfilling a request for
12medication that is in compliance with this chapter.
AB552,14,1513 (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.
AB552,14,20 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.
AB552,14,23 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.
AB552,14,2524 (b) Paragraph (a) does not apply to a person who acts as a witness in violation
25of s. 156.07 (2) (a).
AB552,15,4
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.
AB552,15,75 (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.
AB552,15,10 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.
AB552,15,14 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.
AB552,15,17 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.
AB552,15,21 18(5) Nothing in this chapter may be construed to condone, authorize, approve,
19or permit any affirmative or deliberate act to end life other than through taking
20medication that is prescribed under a request for medication as provided in this
21chapter.
AB552,15,25 22156.25 Record review. The department shall annually examine a sampling
23of patient health care records of requesters for whom medication was prescribed in
24fulfillment of a request for medication and about whom the department has received
25information under s. 156.09 (8) (g).
AB552,16,4
1156.27 Penalties. (1) Any person who willfully conceals, cancels, defaces,
2obliterates, or damages the request for medication of another without the requester's
3consent may be fined not more than $500 or imprisoned for not more than 30 days,
4or both.
AB552,16,9 5(2) Any person who, with the intent to cause a requester to take medication that
6is prescribed under a request for medication contrary to the wishes of the requester,
7illegally falsifies or forges the request for medication of another or conceals a
8revocation under s. 156.17 shall be fined not more than $10,000 or imprisoned for not
9more than 10 years, or both.
AB552,16,14 10(3) Any responsible person who, with the intent to cause a requester to take
11medication that is prescribed under a request for medication contrary to the wishes
12of the requester, conceals personal knowledge of a revocation under s. 156.17 shall
13be fined not more than $10,000 or, except for a health care facility, imprisoned for not
14more than 10 years, or both.
AB552,4 15Section 4 . 979.01 (1) (intro.) of the statutes is amended to read:
AB552,16,2216 979.01 (1) (intro.) All Except as provided in sub. (1j), all physicians, authorities
17of hospitals, sanatoriums, public and private institutions, convalescent homes,
18authorities of any institution of a like nature, and other persons having knowledge
19of the death of any person who has died under any of the following circumstances,
20shall immediately report the death to the sheriff, police chief, or and medical
21examiner or coroner of the county and to the police chief of any community where the
22death took place:
AB552,5 23Section 5. 979.01 (1g) of the statutes is amended to read:
AB552,17,324 979.01 (1g) A sheriff or police chief shall, immediately upon notification under
25sub. (1) or s. 948.23 (1) (b) of a death, notify the coroner or the medical examiner, and

1the coroner or medical examiner of the county where death took place
, if the crime,
2injury, or event occurred in another county, shall immediately report the death to the
3coroner or medical examiner of that county.
AB552,6 4Section 6 . 979.01 (1j) of the statutes is created to read:
AB552,17,75 979.01 (1j) Subsection (1) does not apply to a death that results from taking
6medication under a fulfilled request for medication that meets the requirements of
7ch. 156.
AB552,7 8Section 7. 979.01 (1r) of the statutes is repealed.
AB552,17,99 (End)
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