AB399,3,147 154.03 (1) (intro.) Any person of sound mind and 18 years of age or older may
8at any time voluntarily execute a declaration, which shall take effect on the date of
9execution, authorizing the withholding or withdrawal of life-sustaining procedures
10or of feeding tubes when the person is in a terminal condition or is in a persistent
11vegetative state. A declarant may not authorize the withholding or withdrawal of
12any medication, life-sustaining procedure or feeding tube if the declarant's
13attending physician advises that, in his or her professional judgment, the
14withholding or withdrawal will cause the declarant pain or reduce the declarant's

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1comfort, despite the administration of pain relief medication. A declarant may not
2authorize the withholding or withdrawal of nutrition or hydration that is
3administered or otherwise received by the declarant through means other than a
4feeding tube unless the declarant's attending physician advises that, in his or her
5professional judgment, the administration is medically contraindicated. A
6declaration must be signed by the declarant in the presence of 2 witnesses. If the
7declarant is physically unable to sign a declaration, the declaration must be signed
8in the declarant's name by one of the witnesses or some other person at the
9declarant's express direction and in his or her presence; such a proxy signing shall
10either take place or be acknowledged by the declarant in the presence of 2 witnesses.
11The declarant is responsible for notifying his or her attending physician of the
12existence of the declaration. An attending physician who is so notified shall make
13the declaration a part of the declarant's medical records. No witness to the execution
14of the declaration may, at the time of the execution, be any of the following:

AB399,4,616 154.03 (2) The department shall prepare and provide copies of the declaration
17and accompanying information for distribution in quantities to health care
18professionals, hospitals, nursing homes, county clerks and local bar associations and
19individually to private persons. The department shall include, in information
20accompanying the declaration, at least the statutory definitions of terms used in the
21declaration, statutory restrictions on who may be witnesses to a valid declaration,
22a statement explaining that valid witnesses acting in good faith are statutorily
23immune from civil or criminal liability, an instruction to potential declarants to read
24and understand the information before completing the declaration and a statement
25explaining that an instrument may, but need not be, filed with the register in probate

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1of the declarant's county of residence. The department may charge a reasonable fee
2for the cost of preparation and distribution. The declaration distributed by the
3department of health and social services shall be easy to read, the type size may be
4no smaller than 10 point, and the declaration shall be in the following form, setting
5forth on the first page the wording before the ATTENTION statement and setting
6forth on the 2nd page the ATTENTION statement and remaining wording:

AB399,4,8 7Declaration to physicians
8(WISCONSIN LIVING WILL)

AB399,4,15 91. I,...., being of sound mind, voluntarily state my desire that my dying may not
10be prolonged under the circumstances specified in this document. Under those
11circumstances, I direct that I be permitted to die naturally. If I am unable to give
12directions regarding the use of life-sustaining procedures or feeding tubes, I intend
13that my family and physician honor this document as the final expression of my legal
14right to refuse medical or surgical treatment and to accept the consequences from
15this refusal.

AB399,4,20 162. 1. If I have a TERMINAL CONDITION, as determined by 2 physicians who
17have personally examined me, I do not want my dying to be artificially prolonged and
18I do not want life-sustaining procedures to be used. In addition, if I have such a
19terminal condition, the following are my directions regarding the use of feeding tubes
20(check only one):

AB399,4,21 21a. Use .... YES, I want feeding tubes used if I have a terminal condition.....

AB399,4,23 22b. Do not use .... NO, I do not want feeding tubes used if I have a terminal
23condition.....

AB399,4,24 24c. If I you have not checked either box, feeding tubes will be used.

AB399,5,3

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13. 2. If I am in a PERSISTENT VEGETATIVE STATE, as determined by 2
2physicians who have personally examined me, the following are my directions
3regarding the use of life-sustaining procedures and feeding tubes:

AB399,5,4 4a. Check only one:

AB399,5,6 5Use .... YES, I want life-sustaining procedures used if I am in a persistent
6vegetative state.....

AB399,5,8 7Do not use .... NO, I do not want life-sustaining procedures used if I am in a
8persistent vegetative state.....

AB399,5,99 If I you have not checked either box, life-sustaining procedures will be used.

AB399,5,10 10b. Check only one:

AB399,5,11 11Use feeding tubes if I am in a persistent vegetative state....

AB399,5,13 12Do not use 3. If I am in a PERSISTENT VEGETATIVE STATE, the following
13are my directions regarding the use of feeding tubes:

AB399,5,14 14.... YES, I want feeding tubes used if I am in a persistent vegetative state.

AB399,5,16 15.... NO, I do not want feeding tubes used if I am in a persistent vegetative
16state.....

AB399,5,1717 If I you have not checked either box, feeding tubes will be used.

AB399,5,22 184. By law, this document cannot be used to authorize: a) withholding or
19withdrawal of any medication, procedure or feeding tube if to do so would cause me
20pain or reduce my comfort; and b) withholding or withdrawal of nutrition or
21hydration that is administered to me through means other than a feeding tube
22unless, in my physician's opinion, this administration is medically contraindicated.

AB399,5,24 235. If I have been diagnosed as pregnant and my physician knows of this
24diagnosis, this document has no effect during the course of my pregnancy.

AB399,5,25 25Signed ....

AB399,6,1

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1Date ....

AB399,6,2 2Address ....

AB399,6,5 3If you are interested in more information about the significant terms used in
4this document, see section 154.01 of the Wisconsin Statutes or the information
5accompanying this document.

AB399,6,7 6ATTENTION: You and the 2 witnesses must sign the document at the same
7time.

AB399,6,8 8Signed .... Date ....

AB399,6,9 9Address .... Date of birth ....

AB399,6,1410 I know believe that the person signing this document personally and I believe
11him or her to be is of sound mind. I am an adult and am not related to the person
12signing this document by blood, marriage or adoption, and. I am not entitled to and
13do not have a claim on any portion of the persons's estate and am not otherwise
14restricted by law from being a witness.

AB399,6,15 15Witness ....

AB399,6,16 16Witness ....

AB399,6,17 17Witness signature .... Date signed ....

AB399,6,18 18Print name ....

AB399,6,20 20Witness signature .... Date signed ....

AB399,6,21 21Print name ....

AB399,6,22 22This document is executed as provided in chapter 154, Wisconsin Statutes.

AB399,6,24 23DIRECTIVES TO ATTENDING
24PHYSICIAN

AB399,7,4

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11. This document authorizes the withholding or withdrawal of life-sustaining
2procedures or of feeding tubes when 2 physicians, one of whom is the attending
3physician, have personally examined and certified in writing that the patient has a
4terminal condition or is in a persistent vegetative state.

AB399,7,10 52. The choices in this document were made by a competent adult. Under the
6law, the patient's stated desires must be followed unless you believe that to do so
7would cause the patient pain or reduced comfort despite the administration of pain
8relief medication. If you feel that you cannot comply with this document, you must
9make a good faith attempt to transfer the patient to another physician who will
10comply.

AB399,7,12 113. If you know that the patient is pregnant, this document has no effect during
12her pregnancy.

AB399,7,13 13* * * * *

AB399,7,16 14The person making this living will may use the following space to record the
15names of those individuals and health care providers to whom he or she has given
16copies of this document:

AB399,7,17 17.................................................................

AB399,7,18 18.................................................................

AB399,7,19 19.................................................................

AB399,7,2121 154.05 (1) (d) By executing a subsequent declaration.

AB399,8,3

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1154.07 (1m) Duty. A physician who refuses to comply with a declaration shall
2make a good faith attempt to transfer the declarant to another physician who will
3comply.

AB399,8,75 154.11 (7) (d) Nothing in this chapter, except par. (b), may be construed to
6render invalid a declaration that was validly executed under this chapter before the
7effective date of this paragraph .... [revisor inserts date].

AB399,8,129 154.11 (8) Inclusion in medical record. Upon receipt of a declaration, a health
10care facility, as defined in s. 155.01 (6), or a health care provider, as defined in s.
11155.01 (7), shall, if the declarant is a patient of the health care facility or health care
12provider, include the declaration in the medical record of the declarant.

AB399,8,17 13(9) Declaration from other jurisdiction. A valid document that authorizes
14the withholding or withdrawal of life-sustaining procedures or of feeding tubes and
15that is executed in another state or jurisdiction in compliance with the law of that
16state or jurisdiction is valid and enforceable in this state to the extent that the
17document is consistent with the laws of this state.

AB399,8,2119 154.15 (1) Any person who wilfully intentionally conceals, cancels, defaces,
20obliterates or damages the declaration of another without the declarant's consent
21may be fined not more than $500 or imprisoned not more than 30 days or both.

AB399,9,323 154.15 (2) Any person who, with the intent to cause a withholding or
24withdrawal of life-sustaining procedures or feeding tubes contrary to the wishes of
25the declarant, illegally falsifies or forges the declaration of another or conceals a

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1declaration revoked under s. 154.05 (1) (a) or (b) or any responsible person who
2intentionally withholds personal actual knowledge of a revocation under s. 154.05
3shall be fined not more than $10,000 or imprisoned not more than 10 years or both.

AB399,9,65[1991 Wisconsin Act 84] Section 19 (title) Initial applicability and
6applicability.

AB399,9,1310[1991 Wisconsin Act 84] Section 19 (2) Notwithstanding subsection (1) and
11section 154.11 (7) (c) of the statutes, the treatment of section 154.11 (5m) of the
12statutes applies to any declarations executed under chapter 154 of the statutes,
13regardless of the date of execution.