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. 154.05(1)(1) Method of revocation. A declaration may be revoked at any time by the declarant by any of the following methods: 154.05(1)(a)(a) By being canceled, defaced, obliterated, burned, torn or otherwise destroyed by the declarant or by some person who is directed by the declarant and who acts in the presence of the declarant. 154.05(1)(b)(b) By a written revocation of the declarant expressing the intent to revoke, signed and dated by the declarant. 154.05(1)(c)(c) By a verbal expression by the declarant of his or her intent to revoke the declaration. This revocation becomes effective only if the declarant or a person who is acting on behalf of the declarant notifies the attending health care professional of the revocation. 154.05(2)(2) Recording the revocation. The attending health care professional shall record in the patient’s medical record the time, date and place of the revocation and the time, date and place, if different, that he or she was notified of the revocation. 154.07154.07 Duties and immunities. 154.07(1)(a)(a) No health care professional, inpatient health care facility, or person who is licensed, certified, or registered under ch. 441, 448, or 455 or holds a compact privilege under subch. XI of ch. 448 and who is acting under the direction of a health care professional may be held criminally or civilly liable, or charged with unprofessional conduct, for any of the following: 154.07 NoteNOTE: The cross-reference to subch. XI of ch. 448 was changed from subch. X of ch. 448 by the legislative reference bureau under s. 13.92 (1) (bm) 2. to reflect the renumbering under s. 13.92 (1) (bm) 2. of subch. X of ch. 448.
154.07(1)(a)1.1. Participating in the withholding or withdrawal of life-sustaining procedures or feeding tubes under this subchapter. 154.07(1)(a)2.2. Failing to act upon a revocation unless the person or facility has actual knowledge of the revocation. 154.07(1)(a)3.3. Failing to comply with a declaration, except that failure by a health care professional to comply with a declaration of a qualified patient constitutes unprofessional conduct if the health care professional refuses or fails to make a good faith attempt to transfer the qualified patient to another health care professional who will comply with the declaration. 154.07(1)(b)1.1. No person who acts in good faith as a witness to 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. 154.07(1)(c)(c) Pars. (a) and (b) apply to acts or omissions in connection with a provision of a document that is executed in another jurisdiction if the provision is valid and enforceable under s. 154.11 (9). 154.07(2)(2) Effect of declaration. The desires of a qualified patient who is competent supersede the effect of the declaration at all times. If a qualified patient is adjudicated incompetent at the time of the decision to withhold or withdraw life-sustaining procedures or feeding tubes, a declaration executed under this subchapter is presumed to be valid. The declaration of a qualified patient who is diagnosed as pregnant by the attending health care professional has no effect during the course of the qualified patient’s pregnancy. For the purposes of this subchapter, a health care professional or inpatient health care facility may presume in the absence of actual notice to the contrary that a person who executed a declaration was of sound mind at the time. 154.11154.11 General provisions. 154.11(1)(1) Suicide. The withholding or withdrawal of life-sustaining procedures or feeding tubes from a qualified patient under this subchapter does not, for any purpose, constitute suicide. Execution of a declaration under this subchapter does not, for any purpose, constitute attempted suicide. 154.11(2)(2) Life insurance. Making a declaration under s. 154.03 may not be used to impair in any manner the procurement of any policy of life insurance, and may not be used to modify the terms of an existing policy of life insurance. No policy of life insurance may be impaired in any manner by the withholding or withdrawal of life-sustaining procedures or feeding tubes from an insured qualified patient. 154.11(3)(3) Health insurance. No person may be required to execute a declaration as a condition prior to being insured for, or receiving, health care services. 154.11(4)(4) Other rights. This subchapter does not impair or supersede any of the following: 154.11(4)(a)(a) A person’s right to withhold or withdraw life-sustaining procedures or feeding tubes. 154.11(4)(b)(b) The right of any person who does not have a declaration in effect to receive life-sustaining procedures or feeding tubes. 154.11(5)(5) Intent. Failure to execute a declaration under this subchapter creates no presumption that the person consents to the use or withholding of life-sustaining procedures or feeding tubes in the event that the person suffers from a terminal condition or is in a persistent vegetative state. 154.11(5m)(5m) Valid declaration. A declaration that is in its original form or is a legible photocopy or electronic facsimile copy is presumed to be valid. 154.11(6)(6) Construction. Nothing in this subchapter condones, authorizes or permits any affirmative or deliberate act to end life other than to permit the natural process of dying. 154.11(7)(a)(a) A declaration under s. 154.03 (2), 1983 stats., that is executed before April 22, 1986, and that is not subsequently revoked or has not subsequently expired is governed by the provisions of ch. 154, 1983 stats. 154.11(7)(b)(b) A declaration under s. 154.03 (2), 1983 stats., that is executed after April 22, 1986, is void. 154.11(7)(c)(c) A declaration under s. 154.03 (2), 1989 stats., that is executed before, on or after December 11, 1991, and that is not subsequently revoked or has not subsequently expired is governed by the provisions of ch. 154, 1989 stats. 154.11(7)(d)(d) Nothing in this chapter, except par. (b), may be construed to render invalid a declaration that was validly executed under this chapter before April 6, 1996. 154.11(8)(8) Inclusion in medical record. Upon receipt of a declaration, a health care facility, as defined in s. 155.01 (6), or a health care provider, as defined in s. 155.01 (7), shall, if the declarant is a patient of the health care facility or health care provider, include the declaration in the medical record of the declarant. 154.11(9)(9) Declaration from other jurisdiction. A valid document that authorizes the withholding or withdrawal of life-sustaining procedures or of feeding tubes and that is executed in another state or jurisdiction in compliance with the law of that state or jurisdiction is valid and enforceable in this state to the extent that the document is consistent with the laws of this state. 154.13154.13 Filing declaration. 154.13(1)(1) A declarant or an individual authorized by the declarant may, for a fee, file the declarant’s declaration, for safekeeping, with the register in probate of the county in which the declarant resides. 154.13(2)(2) If a declarant or authorized individual has filed the declarant’s declaration as specified in sub. (1), the following persons may have access to the declaration without first obtaining consent from the declarant: 154.13(2)(b)(b) A health care provider who is providing care to the declarant. 154.13(2)(c)(c) The court and all parties involved in proceedings in this state for adjudication of incompetency and appointment of a guardian for the declarant, for emergency detention under s. 51.15, for involuntary commitment under s. 51.20, or for protective placement or protective services under ch. 55. 154.13(2)(d)(d) Any person under the order of a court for good cause shown. 154.13(3)(3) Failure to file a declaration under sub. (1) creates no presumption about the intent of an individual with regard to his or her health care decisions. 154.13 HistoryHistory: 1991 a. 281; 2005 a. 387. 154.15(1)(1) Any person who intentionally conceals, cancels, defaces, obliterates or damages the declaration of another without the declarant’s consent may be fined not more than $500 or imprisoned not more than 30 days or both. 154.15(2)(2) Any person who, with the intent to cause a withholding or withdrawal of life-sustaining procedures or feeding tubes contrary to the wishes of the declarant, illegally falsifies or forges the declaration of another or conceals a declaration revoked under s. 154.05 (1) (a) or (b) or any person who intentionally withholds actual knowledge of a revocation under s. 154.05 is guilty of a Class F felony. DO-NOT-RESUSCITATE ORDERS
154.17154.17 Definitions. In this subchapter: 154.17(1)(1) “Do-not-resuscitate bracelet” means a standardized identification bracelet that meets the specifications established under s. 154.27 (1), or that is approved by the department under s. 154.27 (2), that bears the inscription “Do Not Resuscitate” and signifies that the wearer is a qualified patient who has obtained a do-not-resuscitate order and that the order has not been revoked. 154.17(2)(2) “Do-not-resuscitate order” means a written order issued under the requirements of this subchapter that directs emergency medical services practitioners, emergency medical responders, and emergency health care facilities personnel not to attempt cardiopulmonary resuscitation on a person for whom the order is issued if that person suffers cardiac or respiratory arrest. 154.17(3)(3) “Emergency medical services practitioner” has the meaning given under s. 256.01 (5). 154.17(4)(4) “Qualified patient” means a person who has attained the age of 18 and to whom any of the following conditions applies: 154.17(4)(b)(b) The person has a medical condition such that, were the person to suffer cardiac or pulmonary failure, resuscitation would be unsuccessful in restoring cardiac or respiratory function or the person would experience repeated cardiac or pulmonary failure within a short period before death occurs. 154.17(4)(c)(c) The person has a medical condition such that, were the person to suffer cardiac or pulmonary failure, resuscitation of that person would cause significant physical pain or harm that would outweigh the possibility that resuscitation would successfully restore cardiac or respiratory function for an indefinite period of time.
