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(c) The requester has made an informed decision under s. 156.05 (1).
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13(8) Document or file all of the following in the requester's patient health care
14record:
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(a) All occasions that the requester orally asks for medication under s. 156.05
16(2) (a) or (c) as well as all written requests for medication under s. 156.05 (2) (b) that
17are made by the requester.
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(b) The attending physician's diagnosis of and prognosis for the requester and
19determination as to whether the requester is incapacitated, is acting voluntarily, and
20has made an informed decision under s. 156.05 (1).
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(c) The consulting physician's diagnosis of and prognosis for the requester and
22determination as to whether the requester is incapacitated, is acting voluntarily, and
23has made an informed decision under s. 156.05 (1).
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(d) A certification of the outcome and determinations made during any review
25and counseling for which the requester was referred under s. 156.13.
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1(e) A certification as to whether the attending physician offered the requester
2an opportunity to revoke the request for medication, as required under sub. (6).
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(f) Evidence of a revocation, if made, as specified in s. 156.17 (2).
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(g) A certification as to whether the requirements of this chapter are met and
5indicating the steps taken to fulfill the request for medication, including a notation
6of any medication that is prescribed. The attending physician shall report the
7information under this paragraph to the department on a form prescribed by the
8department. Information reported to the department under this paragraph that
9could identify the requester, the attending physician, the consulting physician, or the
10psychiatrist or psychologist to whom referral was made under s. 156.13, if any, is
11confidential and may not be disclosed by the department except under an
12investigation of an alleged violation of this chapter. The report of information under
13this paragraph is not a violation of any person's responsibility for maintaining the
14confidentiality of patient health care records under s. 146.82.
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15(9) If the attending physician refuses to fulfill the requester's request for
16medication that meets the requirements of this chapter, the attending physician
17shall make a good faith attempt to transfer the requester's care and treatment to
18another physician who will act as the attending physician under this chapter and will
19fulfill the requester's request for medication. If a transfer is made, the attending
20physician to whom the requester's care and treatment is transferred shall comply
21with the requirements of this section.
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22156.11 Consulting physician confirmation. Before an attending physician
23may fulfill a request for medication under this chapter, a consulting physician shall
24examine the requester and his or her relevant patient health care records and shall
25medically confirm the attending physician's determinations that the requester
1suffers from a terminal disease, does not have incapacity, is making a request for
2medication voluntarily, and has made an informed decision. The consulting
3physician shall complete a written report regarding his or her findings and provide
4it to the attending physician for filing in the requester's patient health care record
5in compliance with the certification requirement of s. 156.09 (8) (g).
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6156.13 Referral for review and counseling. If in the opinion of the
7attending physician or the consulting physician a requester may be suffering from
8a psychiatric or psychological disorder, including depression, that causes impaired
9judgment, the attending physician or consulting physician shall refer the requester
10for review and counseling to a physician specializing in psychiatry or a licensed
11psychologist, as defined in s. 455.01 (4). If a referral is made by the attending or
12consulting physician, no request for medication may be fulfilled under this chapter
13unless the physician specializing in psychiatry, or the psychologist, to whom referral
14was made, determines and certifies in writing that the requester is not suffering from
15a psychiatric or psychological disorder, including depression, that causes impaired
16judgment. The attending physician shall file the certification in the requester's
17patient health care record under s. 156.09 (8) (d).
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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:
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REQUEST FOR MEDICATION
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AUTHORIZATION TO END MY LIFE IN A
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HUMANE AND DIGNIFIED MANNER
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I, .... (insert name), am an adult of sound mind, do not have incapacity, and am
9a resident of Wisconsin.
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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.
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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.
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I request that my attending physician prescribe medication that will end my life
17in a humane and dignified manner.
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INITIAL ONE OF THE FOLLOWING 3 STATEMENTS:
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.... I have informed my family members of my decision and taken their opinions
20into consideration.
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.... I have decided not to inform my family of my decision.
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.... I have no family to inform of my decision.
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I understand that I have the right to revoke this request at any time.
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I understand the full import of this request and I expect to die when I take the
25medication to be prescribed.
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1I make this request voluntarily and without reservation, and I accept full moral
2responsibility for my actions.