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Wisconsin Medical Power of Attorney Form

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Wisconsin Medical Power of Attorney Form is documentation one must produce when representing an unconscious patient with medical professionals. Only the patient who has issued this document can define its instructions and grant the authority it grants to an agent or health care representative. Generally, such an agent is someone who the principal, or patient, feels comfortable with and has an ongoing rapport with (such as a spouse or a sibling). The powers or authority is granted to the agent will focus on decisions the principal patient wishes made regarding treatment during times when a medical event has rendered the patient with severely impaired judgment, unconscious, or otherwise unable to communicate. One can be quite vulnerable at such times particularly when a questionable on nonstandard medical procedure must be employed. This document will provide a way for you to make sure that you have someone in place ready to make medical decisions for you when you have reached the point when you cannot make your own decisions. Many agree it is both reassuring and wise to have such an agent in place with the signed authority required to behave in the manner you decide.

Definition – § 155.01(10)

LawsChapter 155 (Power of Attorney for Health Care)

Living Will – Gives a directive to physicians if and when a patient should become in a persistent vegetative state.

Durable (Financial) Power of Attorney – Gives your agent the legal authority to act on your behalf in financial matters.

How to Write

Download: Adobe PDF

Step 1 – Acquire The Wisconsin Power Of Attorney For Health Care

The Wisconsin Power Of Attorney For Health Care is downloadable using the “PDF” button presented in the caption area of the preview image or the “Adobe PDF” link in this section.

Step 2 – Review The Preliminary Information Presented By this Document

The information packet included with the living shall present several valuable statements to define how the declaration will operate and how it should be executed. Additionally, some definitions of the terms used will be included in this introductory discussion. The Wisconsin Principal is encouraged to read through this introduction before completing the living will. 

 

Step 3 – Attach A Document Date To This Wisconsin Authority

Once the initial pages of this packet have been reviewed and understood by the Wisconsin Principal, locate the page title “Power Of Attorney For Health Care.” This document should be associated with a filing date. This can be the same calendar day it is executed or it can be a date that is before the Wisconsin Principal signs the concerned directive into effect. This date will be the first definition required and is reserved by the three spaces directly underneath the title. The first space following the term “Document Made This” requires the two-digit calendar day reported while the month and year should be furnished to the two spaces that follow.  

 

Step 4 – Present The Wisconsin Principal’s Identity

The first set of lines following the bold heading “Creation Of Power Of Attorney For Health Care” will set a specific Party to the role of a Wisconsin Principal delegating the authority to represent him or her before Medical Personnel. Produce the name of the Wisconsin Principal along with his or her residential address and birth date to the first available space after the word “I…”

 

Step 5 – Name The Wisconsin Health Care Agent Receiving Authority

Now, seek out the section titled “Designation Of Health Care Agent” (found after the Wisconsin Principal’s introduction). Here, the language shall inform Wisconsin Physicians and other Health Care Professionals that the concerned Principal has determined a Health Care Agent as a representative with the authority (and knowledge) to make medical decisions in the State of Wisconsin when or if the Wisconsin Principal is unable to communicate in any way or is unconscious. The words “…I Hereby Designate” can be found in the first paragraph of the “Designation Of Health Care Agent” and will lead to a set of empty lines where the name of the Wisconsin Health Care Agent, his or her residential address, and immediate contact information (i.e. cell phone number, home phone number, etc.) must be documented. 

 

Step 6 – Assign An Alternate Health Care Agent For The Wisconsin Principal

If the Wisconsin Health Care Agent is unavailable or unable to make the medical decisions needed for the Principal when it is necessary to do so, this can leave the Principal without representation and Wisconsin Medical Staff with no choice but to employ medical treatments according to the Facility’s policy and the governing law. This template will allow a precautionary measure to be taken to offset the possibility of the Wisconsin Principal being unable to answer medical treatment questions and (suddenly) having no representation. The blank lines following the statement “If He Or She Is Ever Unable Or Unwilling To Do So” should be used to assign an Alternate Health Care Agent who can step up to the full role should the Wisconsin Principal’s first choice be unable to fulfill it. Set this reserve agent in place by recording his or her full “Name, Address, and Telephone Number” accordingly. Be advised, the Alternate Health Care Agent will not be granted any decision making powers with attending Wisconsin Medical Staff if the Wisconsin Principal’s first choice is able and allowed to represent the Principal. 

 

Step 7 – Become Familiar With The Level Of Principal Authority Granted

The Wisconsin Principal is encouraged to read the next few passages (beginning with “General Statement Of Authority Granted” through “Limitations On Mental Health Treatment”) where a discussion on what powers the State of Wisconsin will allow, and limit, is presented. The Wisconsin Principal will be expected to have read these passages to full comprehension. 

 

Step 8 – Establish The Wisconsin Agent’s Principal Authority With Nursing Homes

The next area that requires content is titled “Admission To Nursing Homes Or Community-Based Residential Facilities.” This section will require a discussion on the designated Health Care Agent’s ability to admit the Wisconsin Principal as a patient to nursing homes and community-based residential facilities. To produce these definitions two items must be tended to. The first of which, Item 1, is labeled “A Nursing Home” and allows the Wisconsin Principal to either approve of the Health Care Agent’s power to admit him or her to a “Nursing Home” by marking the corresponding “Yes” checkbox or selecting the “No” checkbox to withhold this decision making power. In the example below the Wisconsin Principal grants the Health Care Agent the power to admit him or her to nursing homes “For A Purpose Other than Recuperative Care Or Respite Care.” Thus the “Yes” checkbox has been selected. This means that if the Principal is unable to communicate or remain coherent, the Health Care Agent will carry the authority to admit him or her to a nursing home regardless of whether the nursing home will be the facility to provide medical treatment or care.  If the Wisconsin Principal does not wish to grant the Health Care Agent, the authority to admit him or her to a nursing home may not be needed for recuperative/respite care then the “No” checkbox should be marked in item 1 “A Nursing Home.” 

 

Step 9 – Report The Agent’s Decision Making Powers With Residential Facilities

If the Wisconsin Principal has determined the Health Care Agent should possess the authority to decide if he or she should be admitted to “A Community-Based Residential Facility” without recuperative or respite care as the reason for this admittance, then mark the “Yes” box in the second item of this section.    Mark the “No” box in the second item (“A Community Based Residential Facility) if the Wisconsin Principal can refrain from granting the Health Care Agent with the authority to admit him or her to a “Community-Based Residential Facility” for reasons other than the Wisconsin Principal receiving medical treatment or care.   It should be mentioned that if the Wisconsin Principal refrains from attending to this section, then Medical Providers reviewing this paperwork will be obligated to believe the Health Care Agent should not have the Wisconsin Principal’s approval to effecting admittance to either of these facilities without a valid medical need. 

 

Step 10 – Define The Health Care Agent’s Power Regarding Tube Feedings 

The “Provision Of Feeding Tube” section allows the Wisconsin Principal to document whether the Health Care Agent can instruct Medical Providers to remove feeding tubes or prevent them from being administered when the Wisconsin Principal cannot communicate this decision. Locate the term “Withhold Or Withdrawal Of Feeding Tube,” then mark the “Yes” box if the Health Care Agent can decide whether feeding tubes should be allowed to keep the issuing Wisconsin Principal fed and hydrated while incapacitated.  If the Health Care Agent does not have the Wisconsin Principal’s approval to decide upon whether feeding tubes should be allowed or not, then mark the “No” box in the “Provision Of Feeding Time” section. Wisconsin Health Professionals responsible for the Principal’s care will by default keep the Patient as well-fed and hydrated as possible in nearly every scenario by default. If the Wisconsin Principal has not used this section to indicate his or her preferences on this topic then Health Professionals in this state will assume the Health Care Agent does not have this authority and follow the standard procedure dictated by the State of Wisconsin and the concerned Medical Facility. 

 

Step 11 – Address The Issue Of A Wisconsin Principal’s Pregnancy

The Principal will need to make a statement on whether the Health Care Agent can still act in the capacity this document defines if the Wisconsin Principal is pregnant. If the Health Care Agent has the representational powers this document provides even when the Principal is pregnant then mark the box labeled “Yes” in the “Health Care Decisions For Pregnant Women” section. If the Wisconsin Principal wishes authority to be withheld from the Health Care Agent should the Health Care Agent become aware that the Wisconsin Principal is pregnant then mark the box labeled “No” in the “Health Care Decisions For Pregnant Women” section.   If neither of these definitions has been selected, it will be assumed that the medical principal powers given to the Health Care Agent will be automatically revoked when he or she becomes aware that the Principal is pregnant.

 

Step 12 – Include Additional Health Directives From The Wisconsin Principal

The Wisconsin Principal can place certain conditions or define additional scenarios where his or her wishes should dictate the medical decisions that need to be made while unconscious or incapacitated. He or she can also limit the Health Care Agent’s powers in certain scenarios. In the section “Statement Of Desires, Special Provisions Or Limitations” several blank lines are provided for any such statements on medical care or the Health Care Agent’s principal authority can be made directly from the Wisconsin Principal. If no additional attention is needed through this section, then strike it out or write in the word “None.” 

 

Step 13 – Complete This Designation With The Wisconsin Principal’s Signature

The act of signing this paperwork to effect can only be performed by the Wisconsin Principal. The “Signature” line provided must bear his or her signature and the “Date” line next to it requires the “Date” the Wisconsin Principal signed this document. These items must be supplied by the Wisconsin Principal in the presence of two Witnesses who are not related to the Wisconsin Principal by blood or marriage, do not work for any Medical Facility in charge of the Wisconsin Principal’s care, is not related to anyone working at such a facility, and remains unaware of gaining any material or intangible goods upon the Principal’s death.

 

Step 14 – Produce A Valid Witness Statement To Support The Principal’s Execution

Witness Number 1 should read the paragraph beneath the Wisconsin Principal’s signature. If Witness 1 agrees with the contents of this paragraph, then the “(Print) Name” and “Date” lines must be filled in with Witness 1’s full printed name and the current date.  The “Address” where the Wisconsin Witness maintains his or her residence should be produced on the next line down.  The Wisconsin Principal must agree to the above paragraph by signing his or her name on the “Signature” line in the section labeled “Witness 1.” After signing this paperwork Witness 1 must allow Witness 2 to take control of it.  Witness 2 must attest that the statement above his or her signature area is true by printing his or her name and supplying the signature “Date” on the first two lines under the title “Witness 2.” After self-reporting, Witness 2 must document his or her residential “Address” on the next line. Finally, Witness 2 must sign the “Signature” line to prove that he or she acknowledges and agrees with the provided statement.  

 

Step 15 – Confirm The Principal’s Identity In The Health Care Agent’s Statement

The page holding the “Statement Of Health Care Agent And Alternate Health Care Agent” title serves as a written acknowledgment that both the Health Care Agent being designated with power and the Alternate Health Care Agent held in reserve are aware of their roles and agree to accepting this responsibility. Before these acknowledgments can be delivered, some preparations are required. Find the first blank line of this page found after the term “I Understand That,” then furnish it with the full name of the Wisconsin Principal. The second blank line which precedes the language “(Name Of Principal) Has Discussed…” also requires documentation of the Wisconsin Principal’s full name entered.  

 

Step 16 – Acquire The Health Care Agent’s Signature

The Health Care Agent must review the “Statement Of Health Care Agent And Alternate Health Care Agent” that has been supplemented with the name of the Wisconsin Principal, then sign the “Agent’s Signature” line as an acceptance of the concerned text.  The Health Care Agent should also deliver his or her home address on the next available blank line. 

 

Step 17 – Obtain The Wisconsin Alternate Health Care Agent Signature

The Alternate Health Care Agent must also review the acknowledgment statement. If he or she agrees with the language in “Statement Of Health Care Agent And Alternate Health Care Agent,” then the Alternate Health Care Agent must sign the “Alternate’s Signature” line as proof of this. In addition, after signing his or her name, the Alternate Health Care Agent’s “Address” must be supplied to the space that follows. 

 

Step 18 – Present The Wisconsin Principal’s Instructions On Anatomical Gifts

The final section of this document is optional. In “Anatomical Gifts” the Wisconsin Principal can opt to define his or her position on post-mortem donations of organs, tissues, and body parts. This section may be left blank or crossed out if it is inapplicable to the Wisconsin Principal’s purpose for drafting this paperwork. If the Wisconsin Principal does wish his or her wishes to make specific anatomical gifts, then the first checkbox after the words “Upon My Death” should be selected.   If the Wisconsin Principal has determined (and reported) that specific tissues, organs, and body parts may be donated upon death, then a list of the donations should be included with this option. Thus, a blank line is available directly underneath this checkbox statement so that such a list may be documented. The Wisconsin Principal can indicate that he or she wishes to donate any body part that is needed by selecting the second checkbox (“I Wish To Donate Any Needed Organ…”). If the Wisconsin Principal has determined that a donation of body parts, organs, and tissues for the purpose of “Anatomical Study” then the third checkbox should be marked. The language provided beneath the choices above sets the Wisconsin Principal’s refusal to make an anatomical donation to paper. If none of the choices above are selected and the “Anatomical Gifts” section is executed, then it will be assumed the Wisconsin Principal does not authorize any anatomical gifts made after death. If the Wisconsin Principal wishes to solidify his or her position on making anatomical gifts through this section, then he or she must sign the blank line labeled “Signature” then immediately record the current “Date.”



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