.... YES, I want life-sustaining procedures used if I am in a persistent vegetative state.
.... NO, I do not want life-sustaining procedures used if I am in a persistent vegetative state.
If you have not checked either box, life-sustaining procedures will be used.
3. If I am in a PERSISTENT VEGETATIVE STATE, as determined by a physician, physician assistant, or advanced practice registered nurse who has personally examined me, and if a physician who has also personally examined me agrees with that determination, the following are my directions regarding the use of feeding tubes:
.... YES, I want feeding tubes used if I am in a persistent vegetative state.
.... NO, I do not want feeding tubes used if I am in a persistent vegetative state.
If you have not checked either box, feeding tubes will be used.
If you are interested in more information about the significant terms used in this document, see section 154.01 of the Wisconsin Statutes or the information accompanying this document.
ATTENTION: You and the 2 witnesses must sign the document at the same time.
Signed .... Date ....
Address .... Date of birth ....
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.
Witness signature .... Date signed ....
Print name ....
Witness signature .... Date signed ....
Print name ....
DIRECTIVES TO ATTENDING PHYSICIAN,
PHYSICIAN ASSISTANT, OR ADVANCED PRACTICE REGISTERED NURSE
1. This document authorizes the withholding or withdrawal of life-sustaining procedures or of feeding tubes when a physician and another physician, physician assistant, or advanced practice registered nurse, one of whom is the attending health care professional, have personally examined and certified in writing that the patient has a terminal condition or is in a persistent vegetative state.
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.
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, physician assistant, or advanced practice registered nurse who will comply. Refusal or failure to make a good faith attempt to do so constitutes unprofessional conduct.
4. If you know that the patient is pregnant, this document has no effect during her pregnancy.
* * * * *
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:
.................................................................
.................................................................
.................................................................
154.03(3)(3) For purposes of this section, “presence” includes the simultaneous remote appearance by 2-way, real-time audiovisual communication technology if all of the following conditions are satisfied: 154.03(3)(a)(a) The signing is supervised by an attorney in good standing licensed by this state. The supervising attorney may serve as one of the remote witnesses. 154.03(3)(b)(b) The declarant attests to being physically located in this state during the 2-way, real-time audiovisual communication. 154.03(3)(c)(c) Each remote witness attests to being physically located in this state during the 2-way, real-time audiovisual communication. 154.03(3)(d)(d) The declarant and each of the remote witnesses identify themselves. If the declarant and remote witnesses are not personally known to each other and to the supervising attorney, the declarant and each of the remote witnesses display photo identification. 154.03(3)(e)(e) The declarant identifies anyone else present in the same physical location as the declarant and, if possible, the declarant makes a visual sweep of the declarant’s physical surroundings so that the supervising attorney and each remote witness can confirm the presence of any other person. 154.03(3)(f)(f) The declarant displays the declaration to health care professionals, confirms the total number of pages and the page number of the page on which the declarant’s signature will be affixed, and declares to the remote witnesses and the supervising attorney all of the following: 154.03(3)(f)2.2. That the document is a declaration to health care professionals. 154.03(3)(f)3.3. That the document is being executed as a voluntary act. 154.03(3)(g)(g) The declarant, or an individual 18 years of age or older at the express direction and in the physical presence of the declarant, dates and signs the declaration to health care professionals in a manner that allows each of the remote witnesses and the supervising attorney to see the execution. 154.03(3)(h)(h) The audiovisual communication technology used allows communication by which a person is able to see, hear, and communicate in an interactive way with another person in real time using electronic means, except that if the declarant, a remote witness, or the supervising attorney has an impairment that affects hearing, sight, or speech, assistive technology or learned skills may be substituted for audio or visual if it allows that person to actively participate in the signing in real time. 154.03(3)(i)(i) The declaration to health care professionals indicates that it is being executed pursuant to this subsection. 154.03(3)(j)1.1. The declarant, or another person at the direction of the declarant, personally delivers or transmits by U.S. mail or commercial courier service the entire signed original declaration to health care professionals to the supervising attorney within a reasonable time after execution. The supervising attorney then personally delivers or transmits by U.S. mail or commercial courier service the entire signed original declaration to health care professionals to the remote witnesses within a reasonable time. The first remote witness to receive the original declaration to health care professionals signs and dates the original declaration to health care professionals as a witness and forwards the entire signed original declaration to health care professionals by personal delivery or U.S. mail or commercial courier service within a reasonable time to the 2nd remote witness, who signs and dates it as a witness and forwards the entire signed original declaration to health care professionals by personal delivery or U.S. mail or commercial courier service within a reasonable time to the supervising attorney. 154.03(3)(j)2.2. The declarant, or another person at the direction of the declarant, personally delivers or transmits by U.S. mail or commercial courier service the entire signed original declaration to health care professionals to the supervising attorney within a reasonable time after execution, and transmits by facsimile or electronic means a legible copy of the entire signed declaration to health care professionals directly to each remote witness within a reasonable time after execution. Each remote witness then signs the transmitted copy of the declaration to health care professionals as a witness and personally delivers or transmits by U.S. mail or commercial courier service the entire signed copy of the declaration to health care professionals to the supervising attorney within a reasonable time after witnessing. The signed original and signed copies together shall constitute one original document, unless the supervising attorney, within a reasonable time after receiving the signed original and signed copies, compiles the signed original and signed copies into one document by attaching the signature pages of each remote witness to the original signed by or on behalf of the declarant, in which case the compiled document shall constitute the original. 154.03(3)(j)3.3. The declarant and each of the remote witnesses sign identical copies of the original. The declarant, or another person at the direction of the declarant, and each of the remote witnesses personally deliver or transmit by U.S. mail or commercial courier service the signed originals to the supervising attorney within a reasonable time after execution. All of the signed originals together shall constitute one original document, unless the supervising attorney, within a reasonable time after receiving all signed originals, compiles the originals into one document by attaching the signature pages of each remote witness to the original signed by or on behalf of the declarant, in which case the compiled document shall constitute the original. 154.03(3)(k)(k) The supervising attorney completes an affidavit of compliance that contains the following information: 154.03(3)(k)2.2. The name and residential or business address of each remote witness. 154.03(3)(k)3.3. The address within this state where the declarant was physically located at the time the declarant signed the declaration to health care professionals. 154.03(3)(k)4.4. The address within this state where each remote witness was physically located at the time the remote witness witnessed the declarant’s execution of the declaration to health care professionals. 154.03(3)(k)5.5. A statement that the declarant and remote witnesses were all known to each other and the supervising attorney or a description of the form of photo identification used to confirm the identity of the declarant and each remote witness. 154.03(3)(k)6.6. Confirmation that the declarant declared that the declarant is 18 years of age or older, that the document is the declarant’s declaration to health care professionals, and that the document was being executed as the declarant’s voluntary act. 154.03(3)(k)7.7. Confirmation that each of the remote witnesses and the supervising attorney were able to see the declarant, or an individual 18 years of age or older at the express direction and in the physical presence of the declarant, sign, and that the declarant appeared to be 18 years of age or older and acting voluntarily. 154.03(3)(k)8.8. A description of the audiovisual technology used for the signing process. 154.03(3)(k)9.9. If the declaration to health care professionals was not signed in counterpart, a description of the method used to forward the declaration to health care professionals to each remote witness for signing and to the supervising attorney after signing. 154.03(3)(k)10.10. If the declaration to health care professionals was signed in counterpart, a description of the method used to forward each counterpart to the supervising attorney and, if applicable, how and when the supervising attorney physically compiled the signed paper counterparts into a single document containing the declaration to health care professionals, the signature of the declarant, and the signatures of the remote witnesses. 154.03(3)(k)11.11. The name, state bar number, and business or residential address of the supervising attorney. 154.03(3)(k)12.12. Any other information that the supervising attorney considers to be material with respect to the declarant’s capacity to sign a valid declaration to health care professionals, the declarant’s and witnesses’ compliance with this section, or any other information that the supervising attorney deems relevant to the execution of the declaration to health care professionals. 154.03(3)(L)(L) The affidavit of compliance is attached to the declaration to health care professionals. 154.03(3)(m)(m) An affidavit of compliance described in this subsection shall be substantially in the following form: AFFIDAVIT OF COMPLIANCE
State of ....
County of ....
The undersigned, being first duly sworn under oath, states as follows:
This Affidavit of Compliance is executed pursuant to Wis. Stat. § 154.03 (3) to document the execution of the declaration to health care professionals of [name of declarant] via remote appearance by 2-way, real-time audiovisual communication technology on [date]. 1. The name and residential address of the declarant is ....
2. The name and [residential or business] address of remote witness 1 is ....
3. The name and [residential or business] address of remote witness 2 is ....
4. The address within the state of Wisconsin where the declarant was physically located at the time the declarant signed the declaration to health care professionals is ....
5. The address within the state of Wisconsin where remote witness 1 was physically located at the time the remote witness witnessed the declarant’s execution of the declaration to health care professionals is ....
6. The address within the state of Wisconsin where remote witness 2 was physically located at the time the remote witness witnessed the declarant’s execution of the declaration to health care professionals is ....
7. The declarant and remote witnesses were all known to each other and to the supervising attorney. - OR - The declarant and remote witnesses were not all known to each other and to the supervising attorney. Each produced the following form of photo identification to confirm his or her identity:
....
8. The declarant declared that the declarant is 18 years of age or older, that the document is the declarant’s declaration to health care professionals, and that the document was being executed as the declarant’s voluntary act.
9. Each of the remote witnesses and the supervising attorney were able to see the declarant sign. The declarant appeared to be 18 years of age or older and acting voluntarily.
10. The audiovisual technology used for the signing process was ....
11. The declaration to health care professionals was not signed in counterpart. The following methods were used to forward the declaration to health care professionals to each remote witness for signing and to the supervising attorney after signing. - OR - The declaration to health care professionals was signed in counterpart. The following methods were used to forward each counterpart to the supervising attorney. [If applicable] - The supervising attorney physically compiled the signed paper counterparts into a single document containing the declaration to health care professionals, the signature of the declarant, and the signatures of the remote witnesses on [date] by [e.g., attaching page 7 from each counterpart signed by a remote witness to the back of the declaration to health care professionals signed by the declarant].
12. The name, state bar number, and [business or residential] address of the supervising attorney is ....
13. [Optional] Other information that the supervising attorney considers to be material is as follows: ....
.... (signature of supervising attorney)
Subscribed and sworn to before me on .... (date) by .... (name of supervising attorney).
.... (signature of notarial officer)
Stamp
.... (Title of office)
[My commission expires: ....]
154.03 AnnotationWisconsin statutes provide 3 instruments through which an individual may state healthcare wishes in the event of incapacitation: a “declaration to physicians,” a “do-not-resuscitate order,” and a “health care power of attorney.” These statutory instruments apply under specific circumstances, have their own signature requirements, and may be limited in the extent of authorization they afford. A form will trigger no statutory immunities for healthcare providers when it lacks the features of these statutory documents. A court might conclude, however, that such a form is relevant in discerning a person’s intent. OAG 10-14 154.03 AnnotationLiving will statutes: The first decade. Gelfand. 1987 WLR 737.
154.03 AnnotationPlanning Ahead for Incapacity. Shapiro. Wis. Law. Aug. 1991.
154.03 AnnotationWisconsin’s New Living Will Act. Gilbert. Wis. Law. March 1992.
154.05154.05 Revocation of declaration.
