Wisconsin Advance Directive Form

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A Wisconsin advance directive is a document that outlines a person’s health care treatment preferences in the event they can’t speak for themselves. This also establishes an “agent” to be able to speak on the person’s behalf (usually a spouse or family member). An advance directive only comes into use when the person cannot speak for themselves and may be used after signing with two (2) witnesses.

Table of Contents

Laws

StatuteChapter 154 (Advance Directives)

Signing Requirements (§ 155.10(1)(c), § 154.03(1)) – Two (2) witnesses.

State Definition (§ 154.02(1)) – “Declaration” means a written, witnessed document voluntarily executed by the declarant under s. 154.03 (1), but is not limited in form or substance to that provided in s. 154.03 (2).

Versions (9)


AARP

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Aspirus Health Care

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Aurora Health Care

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How to Write

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(1) Formal Date Of Declaration. The date when you wish your appointment to be formally acknowledged should be dispensed at the beginning of this appointment.

(2) Print Name, Address, And Date Of Birth. Attach your full name, address, and your date of birth to define yourself as the Wisconsin Principal.

(3) Wisconsin Health Care Agent Appointment. Confirm that your choice for Wisconsin Health Care Agent is able, willing, reliable, and trustworthy in wielding the authority granted here to present Medical Providers with your instructions on treatment. Naturally, your Wisconsin Health Care Agent should be someone close to you with whom an open line of communication on your medical needs is present. To appoint this Person as your Wisconsin Health Care Agent, furnish his or her name and current address along with the telephone number(s) where Wisconsin Health Care Providers can reach him or her.

(4) Alternate Wisconsin Health Care Agent. The Wisconsin Health Care Agent that you will appoint by signing this paperwork may not be able to serve as such when the time comes through no fault of his or her own. If he or she is unable to represent you or is no longer qualified, then your Alternate Wisconsin Health Care Agent will be given the power to make your treatment decisions through this paperwork. The identity of your Alternate Wisconsin Agent should be produced with his or her address and phone number. This will not give him or her the ability to act as your Agent immediately. The Alternate Wisconsin Health Care Agent is only granted this power if it is needed.

Admission To Nursing Homes Or Community Based Residential Facilities

(5) Nursing Home. There may come a time when the question of being admitted to a nursing home better equipped to provide your medical needs may need to be addressed. You may do so in this document by either granting your Wisconsin Health Care Agent the ability to admit you when needed by marking the “Yes” box or restricting this decision-making ability from his or her principal powers by selecting the “No” box.

(6) Community-Based Residential Facility. Your Wisconsin Health Care Agent can also be granted the authority to admit you to a Community-Based Residential Facility should you require this level of care but only if you select the “Yes” box in this article. If you do not wish him or her to have this type of principal authority, then select the box labeled “No.”

Provision Of Feeding Tube

(7) Withhold Or Withdraw A Feeding Tube. Generally, if you have been diagnosed with a life-threatening or permanently debilitating medical condition that has no cure or if you have fallen into a permanent state of unconsciousness, then your body will need significant aid to intake food. You may not be able to chew, swallow, or even absorb nutrients without the aid of a machine that produces or stores artificial nutrition and hydration then delivers it to your system. You can opt-out of this treatment by selecting the word “Yes” to inform Wisconsin Health Providers that you would like to deny feeding tubes or have them detached upon your incapacitation by marking the “No” box.

Health Care Decisions For Pregnant Women

(8) Health Care Decision If I Am Pregnant. A Wisconsin Health Care Agent must be given the specific authority to represent the Principal when it is known the Principal is pregnant. Naturally, this may complicate the treatment of the Wisconsin Principal considerably. Therefore, to inform Wisconsin Medical Providers that you authorize your Health Care Agent to represent you even if he or she knows you are pregnant, you must select the “Yes” box. To inform Wisconsin Medical Providers that your Health Care Agent is no longer authorized to present your treatment decisions once it is known you are pregnant, you must mark the “No” box.

Statement Of Desires, Special Provisions Or Limitations

(9) Direct Instructions And Provisions. Specific instructions over your medical care in specific situations as well as general instructions can be given to your Wisconsin Health Care Agent. Any such documented instructions will need to be followed and can also be reviewed by the Wisconsin Medical Providers seeking the level of authority this document gives. This limits the decisions that your Wisconsin Health Care Agent because they are direct instructions from you. If desired, you may simply choose to restrict certain decisions from the Wisconsin Health Care Agent’s powers by limiting his or her powers without giving further instructions. Document any instructions or provisions applying to the decision-making powers being granted to the numbered lines provided. Continue on an attachment if more room is required.

Signature Of Principal

(10) Wisconsin Principal Signature And Date. After making sure that you have named the appropriate Parties to the positions above and that all your directives and attachments are properly presented, sign and date this paperwork before two Witnesses. If you cannot find two impartial Witnesses, you can execute this paperwork under the observance of a registered Notary Public.

Statement Of Witnesses

(11) Witness Number 1 Printed Name And Address. Only an impartial Party that knows you, is not related to you, does not stand to benefit from an inheritance upon your death, is not responsible for paying for your medical care, is not employed/owns/affiliated with your Health Care Provider may act as the Witness to your Signature. The only exception is a Chaplain or Counselor that is employed by the Facility where you receive care. The first of these Witnesses will need to read the statement displayed beneath your signature then verify its content as true by completing the signature area beginning with a record of his or her printed name then address.

(12) Signature Date Of Witness 1.

(13) Address Of Witness 1.

(14) Witness 1 Signature. Witness 1 must sign this document immediately after supplying the current date then release it to the next Witness in the room.

(15) Witness 2 Printed Name And Address. The next Witness must print his or her name and address as Witness 2.

(16) Signature Date Of Witness 2. Make note that the dates provided by the two Witnesses as signature dates must match your own signature date.

(17) Address Of Witness 2.

(18) Signature Of Witness 2. Upon agreement with the “Statement Of Witness” section, Witness 2 must sign his or her name.

Statement Of Health Care Agent And Alternative Health Care Agent

(19) Name Of Principal. In addition to your witnessed execution of this document, the Wisconsin Health Care Agent and his or her Successor (the Alternate Agent) should acknowledge this paperwork and the responsibility it delivers. Prepare the next section with your full name (as the Wisconsin Principal) to the areas where it is requested.

(20) Agent’s Signature And Address. The Wisconsin Health Care Agent should sign his or her name then document his or her address once he or she acknowledges the prepared statement.

(21) Alternate’s Signature And Address. The Wisconsin Health Care Agent is also expected to verify his or her understanding of the granted powers and his or her responsibilities as dictated by the prepared statement. To this end, he or she is expected to sign this area and enter furnish his or her address of residence.

Anatomical Gifts

(22) Directed Donations. The Wisconsin Health Care Principal issuing these directives has the option of declaring the intention to be an Organ Donor in this state. This will need some definitions as well as an authorizing signature. If you wish to make anatomical gifts (after death) of only organs or body parts that you approve of then select the first option in the “Anatomical Gifts” section. Space is provided to this option so that you can list all the organs, body tissues, and parts that you approve of for donation.

(23) Basic Donation Statement. If you are willing to donate any body part or organ for any reason, then select the second option’s checkbox.

(24) Donation To Science And Anatomical Study. The third option should be selected only if you wish to make your entire body available as an anatomical study donation.

Wisconsin Declarant Signature

(25) Wisconsin Declarant Signature And Date. If you have completed this section, you must sign your name and provide the current date as proof of your intention to be a Wisconsin Organ Donor. It should be mentioned that if you do not fill out this section, you may still make a statement to donate your organs in the future.

Wisconsin Living Will

(26) Wisconsin Declarant Identity. This directive includes a statement of intent to voluntarily request that natural death occur if you are in a terminal (untreatable) condition resulting in death without life-support machines and procedures employed or a condition where you are permanently unconscious. Some specifics will be needed to issue this statement, beginning with your full name as the Wisconsin Declarant behind it.

Article 1 Terminal Condition

(27) Tube Feeding Requirement. Your body can only go so long without food and water. If you are experiencing a terminal condition that results in death, then the organs required to intake and absorb such nourishment may be severely compromised or shut down altogether. If this happens such extensive dehydration and/or malnourishment will lead to death quickly. This may result in significant pain and discomfort, thus, to authorize tube feedings when you are in a terminal condition that warrants the withdrawal of life support maneuvers, you must select the checkbox corresponding to the first directive option in Article 1.

(28) Tube Feeding Refusal. If you are in a terminal condition, you have the option of authorizing tube feedings even while other life-sustaining procedures are halted. To do so, select the second directive in Article 1.

Persistent Vegetative State

Article 2

(29) Life-Sustaining Treatment Authorization. When diagnosed as being in a lifelong vegetative state, also referred to as a permanent coma, your body will eventually be unable to maintain certain functions. While some functions may not have an impact on your overall health, others will be life-threatening should they cease (i.e. renal failure). You can prematurely provide the authorization Wisconsin Medical Providers will need to place you on life-support or engage in invasive life-sustaining procedures that would be required to prevent death while you are permanently unconscious by selecting the first statement of Article 2.

(30) Refuse Life-Sustaining Treatment. As the Wisconsin Declarant, you may also deny all life-sustaining treatment when you are in a permanent state of unconsciousness by selecting the second statement.

Article 3

(31)Tube Feeding Acceptance. The decision on artificially produced and supplied nutrition will also need to be made when you are in a permanent coma or lifelong vegetative state. Naturally, hand feedings would present a dangerous choking hazard in this condition. Additionally, depending upon your medical status, you may be incapable of absorbing nutrients or liquids through your gastrointestinal tract. If you wish Wisconsin Medical Staff to administer tube feedings when there is no other way to maintain your nutrient and hydration levels (when in a lifelong coma), then select the first checkbox of the second article.

(32) Denying Tube Feeding When Permanently Unconscious. The opportunity to deny tube feedings when you have been pronounced to be in a lifelong coma by either two Physicians or a Physician, Physician’s Assistant, APR Nurse, and confirmed by an (additional) Physician can be engaged by selecting the third statement in Article 3.

Wisconsin Declarant Signature

(33) Signed. You must prove your declaration to allow a natural death when in a permanently unconscious state or with a terminal condition by signing your name before two adults, qualifying in the State of Wisconsin, as Witnesses to your act.

(34) Signature Date. Document the current date as soon as you sign this form. This will allow future Reviewers to follow this directive over those issued before it.

(35) Address. Dispense your residential address where below your signature and signature date.

(36) Date Of Birth. Your birth date is a valuable piece of identifying information.

(37) First Witness Signature. The First Witness must sign his or her name then display it in print. Additionally, he or she must note the current date. This act will demonstrate his or her agreement to the statement regarding his or her Wisconsin Witness qualifications and your act of signing.

(38) Printed Name Of First Witness

(39) Second Witness Signature. A separate area is available for the Second Witness to supply his or her signed and printed name along with the date of his or her signature acknowledgment to the content of the Witness declaration statement.

(40) Printed Name Of Second Witness.

(41) Wisconsin Directive Recipients. Present the name, address, phone number, and e-mail of each Party or Entity to whom you shall dispense a copy of your directives.

Authorization For Final Disposition

(42) Declarant Name And Address. The final form of this packet enables you to appoint a Disposition Representative. By doing so, you will give this Party the authorization to take control of your remains for the funeral, cremation, memorial, or donation you have arranged, or wish to complete. Identify yourself as the Wisconsin Declarant to begin.

(43) Representative Name And Address. Your Wisconsin Disposition Representative may not be a Funeral Director, Crematory Authority, Cemetery Authority, Health Care Provider, Social Worker, or even an Employee of any of these Entities (if that Entity is responsible for your care or disposition arrangements). The only exception would be someone who is related to you. The Party you choose as your Disposition Representative should be extremely reliable and ready to serve in this capacity. Produce his or her name, address, and phone number to appoint him or her as your Wisconsin Disposition Representative.

Section 1 First Successor Agent

(44) Successor To Disposition Representative. You may require your Disposition Representative to take control of your remains at a time when he or she is unavailable or disqualified (i.e., revoked). Similarly, the Wisconsin Disposition Representative may decline for any reason. A valuable precaution available through this document enables you to appoint an additional Agent which can be held in reserve. This Successor Disposition Representative will only be granted the authority to take control of your remains at the time your Wisconsin Disposition Representative declines or is otherwise ineffective. Present the name and address of your Wisconsin Successor Disposition Representative along with the phone number(s) where he or she can be reached.

Section 2 Second Successor Representative

(45) Second Successor To Disposition Representative. As mentioned earlier, there is the possibility of your intended Disposition Representative becoming ineffective. This is also true of the First Successor to the  Disposition Representative. Therefore, a second Reserve Agent can be named as the Second Successor Wisconsin Disposition Representative. This Party will receive the authority to take control of your body (post-death) and carry out your wishes only when the previous two Disposition Agents decline or are ineffective. This appointment also requires that you furnish the full name, address, and current phone number of the intended Second Successor Wisconsin Disposition Agent to this paperwork.

(46) Suggested Special Directions. Whether you have discussed your post-death preferences at length (recommended) or are relying on this paperwork, many would consider it wise to document your instructions regarding the memorial, funeral, graveside, last rite, and any other service that you have either arranged or would like arranged. If you have already made such arrangements and only need your Wisconsin Disposition Agent to carry them out on your behalf, then make sure the names and contact information for the necessary Parties are reported (i.e., the Funeral Home and Cemetery where you have arranged for burial.

(47) Suggested Instructions Concerning Religious Observances. If you have obligations to a certain faith regarding your death, make sure to dispense any needed instructions to make sure your spiritual or religious needs are met when you have died (i.e., last rites).

(48) Suggest Source Of Funds. If you have not paid for the post-death arrangements you have made already then your Wisconsin Disposition Representative may need advice on how to arrange for the finance of your post-death requests. Deliver any suggestions or instructions needed to obtain such funds. For instance, you may have a trust fund set up for this purpose.

Disposition Principal Signature

(49) Signature Date.

(50) Signature Of Declarant. This document makes declarations that will be carried out after your death. Therefore, it is especially important that you sign this paperwork to prove that it represents your post-death wishes. Additionally, two Witnesses should be located to verify your signature. If you cannot find two qualifying Wisconsin Witnesses, then you may verify this document’s execution with a Notary Public. Sign your name when you have reviewed this paperwork to your satisfaction before the Party(ies) needed to authenticate your signature. 

(51) Disposition Representative Signature Date.

(52) Wisconsin Representative Signature. The Wisconsin Disposition Representative must acknowledge this delegation by signing and dating this appointment.

(53) Signature Date Of First Successor.

(54) First Successor Signature. The Wisconsin First Successor Agent to the Disposition Representative should sign his or her name to show that he or she accepts the potential of this appointment being designated to him or her. Once done, the Wisconsin First Successor must dispense the current date.

(55) Signature Date Of Second Successor.

(56) Second Successor Signature. Lastly, the Wisconsin Second Successor should also acknowledge the possibility of this appointment being passed to him or her by his or her signature and signature date.

(57) First Witness Verification. The 1st Witness who has observed the Signature Parties sign their names above must print his or her name, sign this paperwork, dispense his or her residential address, and record the current date beneath the declaration statement summarizing his or her qualifications as a Wisconsin Witness and the circumstances of your directive’s execution.

(58) Second Witness Verification. The 2nd Witness must complete the authentication process of your signature by completing the second signature area beneath the Witness’s confirmation statement. The 2nd Witness must print his or her name, submit his or her signature, then document his or her residential address and signature date.

(59) Notary Public Option. Having your signature notarized is an ideal way of showing it was authentically provided. This will require a registered Notary Public (preferably in the State of Wisconsin) to observe the signature execution of this directive. When satisfied, he or she will produce evidence of the notarization process to the reserved area.

 

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