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Wisconsin Living Will Form (Declaration to Physicians)

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The Wisconsin living will, or a ‘Declaration to Physicians’, is a legal document that is prepared in writing by the Declarant/Principal that would state their personal preferences with regard to how they would like their physician and/or medical team, to attend to the declarant’s wishes at an end of life scenario. This form may be revoked at any time. If the declarant is unsure about how to complete the document, they may choose to schedule a consultation with a qualified attorney for assistance.

Definition – § 154.03

Laws§ 155.30

Medical Power of Attorney – Create a relationship where another person is able to take care of your health care responsibilities in the chance you are not able to due to a coma, surgery, or being incapacitated.

How to Write

Download: Adobe PDF

Step 1 – Download The Wisconsin Declaration To Health Care Professionals

The template needed to issue a Wisconsin Declaration To Health Care Professionals otherwise referred to as a Wisconsin Living Will is an obtainable “PDF” file on this page. A button has been placed (see the labeled item “PDF”) underneath a sample image for easy access. Additionally, this declaration can be obtained using the “Adobe PDF” link above.

Step 2 – The Wisconsin Declarant Must Review The Introduction

This document shall open with a report on some valuable information ranging from the applicable laws to instances where this issue will be overlooked or superseded in favor of Wisconsin State Law. The Preparer of this form and the Wisconsin Declarant or Patient issuing it should set aside some time to become familiar with this information.   

 

Step 3 – Name The Wisconsin Declarant Behind The Living Will

The Wisconsin Declarant is considered the Patient who is intent on formally setting his or her medical preferences to paper so that if incapacitated, his or her instructions regarding medical intervention can be understood and complied with by the Wisconsin Physician and Medical Personnel in attendance at the time. Thus, the first paragraph of this declaration must be supplied with his or her full name. Locate the blank space that precedes the term “…Being Of Sound Mind,” then enter the full name of the Wisconsin Declarant (or Patient) to supplement this language properly. 

 

Step 4 – Discuss The Wisconsin Patient’s Preferred Level Of Care During A Terminal Condition

The Wisconsin Patient’s declaration will need his or her participation to be made known. While the first paragraph only required the Patient’s name to supplement its language the next few sections in this paperwork will require that specific choices be made to dictate the Wisconsin Declarant’s wishes. The first item, noted with the number “1,” presents the medical scenario where the Wisconsin Patient has contracted a “Terminal Condition.” This means that treatment to cure the medical condition will be unsuccessful (as declared by a Wisconsin Physician) and that regardless of medical intervention, the Wisconsin Patient’s death event is imminent. If the Wisconsin Patient is also dependent upon tube feedings, then he or she has the option of granting Medical Personnel approval to maintain his or her nutrients and fluids artificially or to specifically forbid it. If the Wisconsin Patient approves of nutrients and liquids being delivered artificially, then the first checkbox statement (“Yes, I Want Feeding Tubes…”) in item 1 must be marked. Find this item under the paragraph beginning with “If I have A Terminal Condition…”  If the Wisconsin Patient has decided that any artificial feedings being administered must halt when he or she has been subject to a “Terminal Condition” or that none should be administered once this becomes his or her official prognosis then the second checkbox item in this area must be selected. You may find this checkbox just before the words “No, I Do Not Want Feeding Tubes…”  Note the default status of this item if neither statement above is selected. In this case, tube feeding will be administered if the Wisconsin Patient has not ventured a declaration one way or the other, has become incapacitated during a terminal condition, and requires nutrients and liquids given to him through medical intervention (i.e. feeding tube down the throat or intravenously). 

 

Step 5 – Report If Life Support Is Approved When The Wisconsin Patient Is In A Coma

The second item of this declaration seeks the Wisconsin Patient’s position on life support or life-sustaining treatment when he or she is in a “Persistent Vegetative State.” Item 2 of this document describes a circumstance where the Wisconsin Patient or Declarant has been diagnosed as being a vegetable where “…All Functions Of The Cerebral Cortex” have ceased (see page 1). If the Wisconsin Patient approves of the Medical Staff or the attending Physician employing life-sustaining treatments to maintain his or her body function when he or she cannot then mark the “Yes…” checkbox in item 2.  If the Wisconsin Patient does not wish to have his or her body maintained with life-sustaining techniques (i.e. dialysis, artificial breathing) when struck with a permanent of “Persistent Vegetative State” then the “No…” checkbox in item 2 must be selected.  This item will also have a default setting should this section remain unattended. If the Wisconsin Declarant does not indicate whether he or she will approve of life-sustaining treatment when in a coma or permanent vegetative state, the Wisconsin Medical Staff will administer all treatment necessary to prolong the Patient’s life.

 

Step 6 – Set The Wisconsin Declarant’s Decision On Tube Feeding If In Suffering A Long-Term Coma

In addition to addressing the issue of life support when the Wisconsin Patient is in a permanent vegetative state, this declaration must also handle the topic of artificial nutrition during such a condition. Item 3 enables the Wisconsin Patient to solidify that he or she wishes to be kept well-fed and well-hydrated if incapacitated by being in a permanent coma. To accomplish this, mark the checkbox labeled “Yes, I Want Feeding Tubes Used…”   If the Wisconsin Declarant does not wish to have his or her body’s nutrition and hydration levels maintained during a permanent vegetative state, then the second checkbox in item 3 must be selected (“No, I Do Not Want Feeding Tubes Used…”). Be advised this will remove approval for any nutrition or hydration treatment including the intravenous delivery of nutrients.   Should the Wisconsin Patient not wish to make a statement in this document on the topic of being fed artificially when in a permanent vegetative state and no other document (i.e. Medical Power Of Attorney) addresses this issue, then Wisconsin Health Care Professionals will maintain the Patient’s nutrient and fluid levels to a comfortable degree when he or she is in a coma.  

 

Step 7 – Present The Wisconsin Declarant’s Executing Signature And Date

This living will must be executed by the Wisconsin Patient or Declarant while two Witnesses look on. A few items will be needed from each of these Parties beginning with the Wisconsin Patient/Declarant. He or she must locate the first signature area at the end of this document then sign and date it on the blank lines labeled “Signed” and “Date.” It is imperative that the Wisconsin Patient have read this document in full after completing it, then provide the signature as verification of its accuracy. The “Date” filled out adjacent to this will be considered the signing “Date.” This will indicate to Reviewers (i.e. Doctors) how long ago the Patient/Declarant agreed to the statements in this document. After the act of signing has been completed by the Wisconsin Declarant, this Party must document his or her residential address on the line labeled “Address” then present his or her birth date on the lane labeled “Date Of Birth.” These items will serve to further validate the identity of the Wisconsin Patient issuing this declaration.   

 

Step 8 – Obtain A Witness Testimony To Validate This Document’s Authenticity

Once the Wisconsin Declarant’s signature area has been completed, he or she must give this paperwork to the attending Witnesses so that Witness One can read the testimony beginning with “I Believe That The Person Signing…” then sign the first “Witness Signature” line that follows. In addition to signing this area, Witness One must record the current date as the “Date Signed” This second line refers to the signature date of Witness One, must be filled out immediately after signing, and must correspond with the date of the Wisconsin Declarant’s signature. Witness One must also print his or her name on the “Print Name” line below as a clarification of his or her identity. After the Wisconsin Patient and Witness have provided their respective signatures, Witness Two must take control of this paperwork. He or she must read and agree to the same testimonial that Witness One agreed to by signing the “Witness Signature” still available. Additionally, the “Date Signed” line must be used to dispense the current calendar date. This, naturally, should be the same date of signature as reported by the Wisconsin Patient/Declarant and Witness One. Witness Two must also fill in the “Print Name” line underneath the provided signature with the printed version of his or her own name.

 

Step 9 – Record The Keepers Of The Wisconsin Directive

The final set of blank lines beneath the dividing symbols “****” have been supplied so that a listing of every Party the Wisconsin Declarant stores a copy of this document with can be distributed. It is recommended that in addition to the name of the Declaration’s Recipient, his or her contact information be supplied as well.


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