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Wisconsin ________________________ _________________________________________________ -2- health care providers to whom he or she has given copies of this document: _________________________________________________ _________________________________________________ _________________________If you know that the patient is pregnant, this document has no effect during her pregnancy. The person making this living will may use the following space to record the names of those individuals and ument, you must make a good faith attempt to transfer the patient to another physician who will comply. Refusal or failure to make a good faith attempt to do so constitutes unprofessional conduct. 4. pain relief measures. If the patient's stated desires are that life-sustaining procedures or feeding tubes be used, this directive must be followed. 3. If you feel that you cannot comply with this docss you believe that withholding or withdrawing life-sustaining procedures or feeding tubes would cause the patient pain or reduced comfort and that the pain or discomfort cannot be alleviated through tient has a terminal condition or is in a persistent vegetative state. 2. The choices in this document were made by a competent adult. Under the law, the patient's stated desires must be followed unlethe withholding or withdrawal of life-sustaining procedures or of feeding tubes when 2 physicians, one of whom is the attending physician, have personally examined and certified in writing that the paignature: ______________________________________ Print Name: ____________________________________________ Date Signed _________________ DIRECTIVES TO ATTENDING PHYSICIAN 1. This document authorizes se restricted by law from being a witness. Witness Signature: ______________________________________ Print Name: ____________________________________________ Date Signed _________________ Witness Sam an adult and am not related to the person signing this document by blood, marriage or adoption. I am not entitled to and do not have a claim on any portion of the person's estate and am not otherwi_____________ Address _______________________________________________ Date Signed _________________ Date of Birth ________________ I believe that the person signing this document is of sound mind. I 1 of the Wisconsin Statutes or the information accompanying this document. -1- ATTENTION : You and the 2 witnesses must sign the document at the same time. Signed ___________________________________stent vegetative state. If you have not checked either box, feeding tubes will be used. If you are interested in more information about the significant terms used in this document, see section 154.0e following are my directions regarding the use of feeding tubes: o o YES, I want feeding tubes used if I am in a persistent vegetative state. NO, I do not want feeding tubes used if I am in a persiive state. If you have not checked either box, life-sustaining procedures will be used. 3. If I am in a PERSISTENT VEGETATIVE STATE, as determined by 2 physicians who have personally examined me, thife-sustaining procedures: o o YES, I want life-sustaining procedures used if I am in a persistent vegetative state. NO, I do not want life-sustaining procedures used if I am in a persistent vegetather box, feeding tubes will be used. 2. If I am in a PERSISTENT VEGETATIVE STATE, as determined by 2 physicians who have personally examined me, the following are my directions regarding the use of lgarding the use of feeding tubes: o o YES, I want feeding tubes used if I have a terminal condition. NO, I do not want feeding tubes used if I have a terminal condition. If you have not checked eitphysicians who have personally examined me, I do not want my dying to be artificially prolonged and I do not want life-sustaining procedures to be used. In addition, the following are my directions rees, I intend that my family and physician honor this document as the final expression of my legal right to refuse medical or surgical treatment. 1. If I have a TERMINAL CONDITION, as determined by 2 s specified in this document. Under those circumstances, I direct that I be permitted to die naturally. If I am unable to give directions regarding the use of life-sustaining procedures or feeding tubn to Physicians (Living Will) I,________________________________________________________________, being of sound mind, voluntarily state my desire that my dying not be prolonged under the circumstanceith a tax professional. Living Will Information & Instructions ­ Page 4 [_] The purchase and use of these forms is subject to the Disclaimers and Terms of Use found at findlegalforms.com Declaratioour particular situation. Advice from a local attorney is always recommended when dealing with estate planning matters. Any possible tax consequences arising out of this document should be discussed we. Laws vary from time to time and from state to state. These forms should only be a starting point for you and should not be used or signed without consulting an attorney first to make sure it fits yn made or are provided as to their suitability for any specific purpose or as to their legal effect or completeness. [_]These forms are not intended and are not a substitute for legal and/or tax advicd place of the revocation and the time, date and place, if different, that he or she was notified of the revocation. [_] These forms are provided "as is" and no implied or express warranties have beee attending physician of the revocation. (d) By executing a subsequent declaration. (2) Recording the revocation. The attending physician shall record in the patient's medical record the time, date anbal expression by the declarant of his or her intent to revoke the declaration. This revocation becomes effective only if the declarant or a person who is acting on behalf of the declarant notifies ths directed by the declarant and who acts in the presence of the declarant. (b) By a written revocation of the declarant expressing the intent to revoke, signed and dated by the declarant. (c) By a vern may be revoked at any time by the declarant by any of the following methods: (a) By being canceled, defaced, obliterated, burned, torn or otherwise destroyed by the declarant or by some person who i employee, other than a chaplain or a social worker, of an inpatient health care facility in which the declarant is a patient. 154.05 Revocation of declaration. (1) Method of revocation. A declaratio is a health care provider, as defined in s. 155.01 (7), who is serving the declarant at the time of execution, an employee, other than a chaplain or a social worker, of the health care provider or an3 (b) Have knowledge that he or she is entitled to or has a claim on any portion of the declarant's estate. (c) Directly financially responsible for the declarant's health care. (d) An individual whohe execution of the declaration may, at the time of the execution, be any of the following: (a) Related to the declarant by blood, marriage or adoption. Living Will Information & Instructions ­ Page ying his or her attending physician of the existence of the declaration. An attending physician who is so notified shall make the declaration a part of the declarant's medical records. No witness to t's express direction and in his or her presence; such a proxy signing shall either take place or be acknowledged by the declarant in the presence of 2 witnesses. The declarant is responsible for notifesence of 2 witnesses. If the declarant is physically unable to sign a declaration, the declaration must be signed in the declarant's name by one of the witnesses or some other person at the declarante unless the declarant's attending physician advises that, in his or her professional judgment, the administration is medically contraindicated. A declaration must be signed by the declarant in the prelief measures. A declarant may not authorize the withholding or withdrawal of nutrition or hydration that is administered or otherwise received by the declarant through means other than a feeding tub that, in his or her professional judgment, the withholding or withdrawal will cause the declarant pain or reduce the declarant's comfort and the pain or discomfort cannot be alleviated through pain rn a persistent vegetative state. A declarant may not authorize the withholding or withdrawal of any medication, life-sustaining procedure or feeding tube if the declarant's attending physician advisesration, which shall take effect on the date of execution, authorizing the withholding or withdrawal of life-sustaining procedures or of feeding tubes when the person is in a terminal condition or is ittending physician, who have personally examined the declarant. 154.03 Declaration to physicians. (1) Any person of sound mind and 18 years of age or older may at any time voluntarily execute a declaied patient" means a declarant who has been diagnosed and certified in writing to be afflicted with a terminal condition or to be in a persistent vegetative state by 2 physicians, one of whom is the a. 154.03 (2). (2) "Feeding tube" means a medical tube through which nutrition or hydration is administered into the vein, stomach, nose, mouth or other body opening of a qualified patient. (3) "Qualifions. In this subchapter: (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 snjury or illness that reasonable medical judgment finds would cause death imminently, so that the application of life-sustaining procedures serves only to postpone the moment of death. 154.02 Definitesponses that indicate cognitive functioning, although autonomic functions continue. Living Will Information & Instructions ­ Page 2 (8) "Terminal condition" means an incurable condition caused by ible loss of all of the functions of the cerebral cortex and results in a complete, chronic and irreversible cessation of all cognitive functioning and consciousness and a complete lack of behavioral rming any medical procedure. (b) The provision of nutrition or hydratio n. (5m) "Persistent vegetative state" means a condition that reasonable medical judgment finds constitutes complete and irreversiaintenance of blood pressure and heart rate, blood transfusion, kidney dialysis and other similar procedures, but does not include: (a) The alleviation of pain by administering medication or by perforattending physician, would serve only to prolong the dying process but not avert death when applied to a qualified patient. "Life-sustaining procedure" includes assistance in respiration, artificial m. 50.135 (1) and includes community-based residential facilities, as defined in s. 50.01 (1g). (5) "Life-sustaining procedure" means any medical procedure or intervention that, in the judgment of the th and family services. (3) "Health care professional" means a person licensed, certified or registered under ch. 441, 448 or 455. (4) "Inpatient health care facility" has the meaning provided under shis chapter: (1) "Attending physician" means a physician licensed under ch. 448 who has primary responsibility for the treatment and care of the patient. (2g) "Department" means the department of healonsin Living Will) is based on the Wisconsin Statutes Chapter 154. For your convenience, we have included useful excerpts from the Wisconsin Statutes relating to Living Wills. 154.01 Definitions. In trmation and Instruction for Wisconsin Declaration to Physicians (Wisconsin Living Will); (2) Wisconsin Declaration to Physicians (Wisconsin Living Will). This Wisconsin Declaration to Physicians (Wisc. Signature ___________________________________ Date ______________________ 7 Information and Instructions Wisconsin Declaration to Physicians (Wisconsin Living Will) This package contains (1) Infompt to notify the Donee to which or to whom I agreed to donate.) Failing to check any of the lines immediately above creates no presumption about my desire to make or refuse to make an anatomical giftdonate my body for anatomical study if needed. o I refuse to make an anatomical gift. (If this revokes a prior commitment that I have made to make an anatomical gift to a designated Donee, I will atteo donate only the following organs or parts: ____________________________________________ ____________________. (specify the organs or parts). o I wish to donate any needed organ or part. o I wish to o his or her health care decisions. 6 This power of attorney for health care is executed as provided in chapter 155 of the Wisconsin Statutes. ANATOMICAL GIFTS (optional) Upon my death: o I wish t____________________ Failure to execute a power of attorney for health care document under chapter 155 of the Wisconsin Statutes creates no presumption about the intent of any individual with regard tress ________________________________________________________________ Alternate's signature ______________________________________________________ Address ______________________________________________________________________ (name of principal) has discussed his or her desires regarding health care decisions with me. Agent's signature _________________________________________________________ Addesignated me to be his or her health care agent or alternate health care agent if he or she is ever found to have incapacity and unable to make health care decisions himself or herself. ______________(Witness Signature) Date: _______________ STATEMENT OF HEALTH CARE AGENT AND ALTERNATE HEALTH CARE AGENT I understand that __________________________________________________ (name of principal) has d(Witness Signature) Date: _______________ Witness No. 2: Print Name: ___________________________________ Address: ______________________________________ _____________________________________________ t have a claim on the principal's estate. Witness No. 1: Print Name: ___________________________________ Address: ______________________________________ _____________________________________________ in or a social worker, of an inpatient health care facility in which the declarant is a patient. I am not the principal's health care agent. To the best of my knowledge, I am not entitled to and do no care. I am not a health care provider who is serving the principal at this time, an employee of the health care provider, other than a chaplain or a social worker, or an employee, other than a chaplay for health care is voluntary. I am at least 18 years of age, am not related to the principal by blood, marriage or adoption and am not directly financially responsible for the principal's health 5 uments.) STATEMENT OF WITNESSES I know the principal personally and I believe him or her to be of sound mind and at least 18 years of age. I believe that his or her execution of this power of attorne_________________________________________________ Date _____________________________________ (The signing of this document by the principal revokes all previous powers of attorney for health care docure of this information. (The principal and the witnesses all must sign the document at the same time.) SIGNATURE OF PRINCIPAL (person creating the power of attorney for health care) Signature.. ___arding my physical or mental health, including medical and hospital records. (b) Execute on my behalf any documents that may be required in order to obtain this information. (c) Consent to the disclosny limitations in this document, my health care agent has the authority to do all of the following (pursuant to Section 155.30(3): (a) Request, review and receive any information, oral or written, reg__________________________________ _____________________________________________________________________ INSPECTION AND DISCLOSURE OF INFORMATION RELATING TO MY PHYSICAL OR MENTAL HEALTH Subject to a______________________ 2) ___________________________________________________________________ _____________________________________________________________________ 3) _________________________________s, provisions or limitations that I wish to state (add more items if needed): 1) ___________________________________________________________________ 4 _______________________________________________ocument, my health care agent shall act consistently with my following stated desires, if any, and is subject to any special provisions or limitations that I specify. The following are specific desirey health care agent may not make health care decisions for me if my health care agent knows I am pregnant. STATEMENT OF DESIRES, SPECIAL PROVISIONS OR LIMITATIONS In exercising authority under this dmay not make health care decisions for me if my health care agent knows I am pregnant. Health care decision if I am pregnant Yes o. No o If I have not checked either "Yes" or "No" immediately above, mf I have checked "Yes" to the following, my health care agent may make health care decisions for me even if my agent knows I am pregnant. If I have checked "No" to the following, my health care agent a feeding tube Yes o. No o If I have not checked either "Yes" or "No" immediately above, my health care agent may not have a feeding tube withdrawn from me. HEALTH CARE DECISIONS FOR PREGNANT WOMEN Iy health care agent may not have orally ingested nutrition or hydration withheld or withdrawn from me unless provision of the nutrition or hydration is medically contraindicated. Withhold or withdraw her professional judgment, this will cause me pain or will reduce my comfort. If I have checked "No" to the following, my health care agent may not have a feeding tube withheld or withdrawn from me. Mare. PROVISION OF A FEEDING TUBE If I have checked "Yes" to the following, my health care agent may have a feeding tube withheld or withdrawn from me, unless my physician has advised that, in his or -based residential facility Yes o. No o 3 If I have not checked either "Yes" or "No" immediately above, my health care agent may admit me only for short-term stays for recuperative care or respite cadmit me for a purpose other than recuperative care or respite care, but if I have checked "No" to the following, my health care agent may not so admit me: 1. A nursing home Yes o. No o 2. A communityt may admit me to a nursing home or community-based residential facility for short-term stays for recuperative care or respite care. If I have checked "Yes" to the following, my health care agent may h research or psychosurgery, electroconvulsive treatment or drastic mental health treatment procedures for me. ADMISSION TO NURSING HOMES OR COMMUNITY-BASED RESIDENTIAL FACILITIES My health care agention for mental diseases, an intermediate care facility for the mentally retarded, a state treatment facility or a treatment facility. My health care agent may not consent to experimental mental healtr health care decision on what he or she believes to be in my best interest. LIMITATIONS ON MENTAL HEALTH TREATMENT My health care agent may not admit or commit me on an inpatient basis to an institu expressed prior to the time of the decision. If I have not expressed a health care choice about the health care in question and communication cannot be made, my health care agent shall base his or he I am able to communicate in any manner, including by blinking my eyes. If this communication cannot be made, my health care agent shall base his or her decision on any health care choices that I have to make a health care decision, my health care agent is instructed to make the health care decision for me, but my health care agent should try to discuss with me any specific proposed health care ifhealth care decisions I would make if I were able. I desire that my wishes be carried out through the authority given to my health care agent under this document. If I am unable, due to my incapacity,gent, if I need treatment, for all of my health care and treatment. I have discussed my desires thoroughly with my health care agent and believe that he or she understands my philosophy regarding the L STATEMENT OF AUTHORITY GRANTED Unless I have specified otherwise in this document, if I ever have incapacity I instruct my health care provider to obtain the health care decision of my health care anformation effectively or to communicate decisions to such an extent that I lack the capacity to manage my health care decisions. A copy of that statement must be attached to this document. 2 GENERA a physician and a psychologist who have personally examined me sign a statement that specifically expresses their opinion that I have a condition that means that I am unable to receive and evaluate iloyee of a health care facility in which I am a patient or a spouse of any of those persons, unless he or she is also my relative. For purposes of this document, "incapacity" exists if 2 physicians orng health care decisions on my behalf. Neither my health care agent nor my alternate health care agent whom I have designated is my health care provider, an employee of my health care provider, an emp___________________________________ ____________________________________________________________ (print name, address and telephone number) to be my alternate health care agent for the purpose of makind telephone number) to be my health care agent for the purpose of making health care decisions on my behalf. If he or she is ever unable or unwilling to do so, I hereby designate ____________________isions for myself, due to my incapacity, I hereby designate. _______________________________________________________ ____________________________________________________________ (print name, address aition. In addition, I may, by this document, specify my wishes with respect to making an anatomical gift upon my death. DESIGNATION OF HEALTH CARE AGENT If I am no longer able to make health care deccument, "health care decision" means an informed decision to accept, maintain, discontinue or refuse any care, treatment, service or procedure to maintain, diagnose or treat my physical or mental cond of this power of attorney for health care, I expect to be fully informed about and allowed to participate in any health care decision for me, to the extent that I am able. For the purposes of this dos and date of birth), being of sound mind, intend by this document to create a power of attorney for health care. My executing this power of attorney for health care is voluntary. Despite the creation this ____________________ day of _________ (month), _________ (year). CREATION OF POWER OF ATTORNEY FOR HEALTH CARE I, ___________________________________________________________ (print name, addres NOT SIGN THIS DOCUMENT UNLESS YOU CLEARLY UNDERSTAND IT. IT IS SUGGESTED THAT YOU KEEP THE ORIGINAL OF THIS DOCUM ENT ON FILE WITH YOUR PHYSICIAN." 1 Power Of Attorney for Health Care Document madeVOKES ANY PRIOR DOCUMENT OF GIFT THAT YOU MAY HAVE MADE. YOU MAY REVOKE OR CHANGE ANY ANATOMICAL GIFT THAT YOU MAKE BY THIS DOCUMENT BY CROSSING OUT THE ANATOMICAL GIFTS PROVISION IN THIS DOCUMENT. DOOCUMENT IS INVALID. YOU MAY ALSO USE THIS DOCUMENT TO MAKE OR REFUSE TO MAKE AN ANATOMICAL GIFT UPON YOUR DEATH. IF YOU USE THIS DOCUMENT TO MAKE OR REFUSE TO MAKE AN ANATOMICAL GIFT, THIS DOCUMENT RE AGENT, YOUR HEALTH CARE PROVIDERS AND ANY OTHER PERSON TO WHOM YOU HAVE GIVEN A COPY. IF YOUR AGENT IS YOUR SPOUSE AND YOUR MARRIAGE IS ANNULLED OR YOU ARE DIVORCED AFTER SIGNING THIS DOCUMENT, THE DRECTING ANOTHER PERSON TO DESTROY IT IN YOUR PRESENCE, BY SIGNING A WRITTEN AND DATED STATEMENT OR BY STATING THAT IT IS REVOKED IN THE PRESENCE OF TWO WITNESSES. IF YOU REVOKE, YOU SHOULD NOTIFY YOURVOKES ANY PRIOR POWER OF ATTORNEY FOR HEALTH CARE THAT YOU MAY HAVE MADE. IF YOU WISH TO CHANGE YOUR POWER OF ATTORNEY FOR HEALTH CARE, YOU MAY REVOKE THIS DOCUMENT AT ANY TIME BY DESTROYING IT, BY DIIS REQUIRED TO DETERMINE WHAT WOULD BE IN YOUR BEST INTERESTS IN MAKING THE DECISION. THIS IS AN IMPORTANT LEGAL DOCUMENT. IT GIVES YOUR AGENT BROAD POWERS TO MAKE HEALTH CARE DECISIONS FOR YOU. IT RET YOU DO OR DO NOT DESIRE, AND YOU MAY LIMIT THE AUTHORITY OF YOUR HEALTH CARE AGENT. IF YOUR HEALTH CARE AGENT IS UNAWARE OF YOUR DESIRES WITH RESPECT TO A PARTICULAR HEALTH CARE DECISION, HE OR SHE . YOU SHOULD TAKE SOME TIME TO DISCUSS YOUR THOUGHTS AND BELIEFS ABOUT MEDICAL TREATMENT WITH THE PERSON OR PERSONS WHOM YOU HAVE SPECIFIED. YOU MAY STATE IN THIS DOCUMENT ANY TYPES OF HEALTH CARE THA SIGN THIS LEGAL DOCUMENT TO SPECIFY THE PERSON WHOM YOU WANT TO MAKE HEALTH CARE DECISIONS FOR YOU IF YOU ARE UNABLE TO MAKE THOSE DECISIONS PERSONALLY. THAT PERSON IS KNOWN AS YOUR HEALTH CARE AGENT VALUES AND THE DETAILS OF YOUR FAMILY RELATIONSHIPS. THIS POSES A PROBLEM IF YOU BECOME PHYSICALLY OR MENTALLY UNABLE TO MAKE DECISIONS ABOUT YOUR HEALTH CARE. IN ORDER TO AVOID THIS PROBLEM, YOU MAYITHHELD IF YOU OBJECT. BECAUSE YOUR HEALTH CARE PROVIDERS IN SOME CASES MAY NOT HAVE HAD THE OPPORTUNITY TO ESTABLISH A LONG-TERM RELATIONSHIP WITH YOU, THEY ARE OFTEN UNFAMILIAR WITH YOUR BELIEFS ANDPOWER OF ATTORNEY FOR HEALTH CARE YOU HAVE THE RIGHT TO MAKE DECISIONS ABOUT YOUR HEALTH CARE. NO HEALTH CARE MAY BE GIVEN TO YOU OVER YOUR OBJECTION, AND NECESSARY HEALTH CARE MAY NOT BE STOPPED OR Wcument should be discussed with a tax professional. [_] The purchase and use of these forms is subject to the Disclaimers and Terms of Use found at findlegalforms.com 6 NOTICE TO PERSON MAKING THIS first to make sure it fits your particular situation. Advice from a local attorney is always recommended when dealing with estate planning matters. Any possible tax consequences arising out of this doe for legal and/or tax advice. Laws vary from time to time and from state to state. These forms should only be a starting point for you and should not be used or signed without consulting an attorney express warranties have been made or are provided as to their suitability for any specific purpose or as to their legal effect or completeness. [_]These forms are not intended and are not a substitut health care instrument under sub. (1) creates no presumption about the intent of an individual with regard to his or her health care decisions. [_] These forms are provided "as is" and no implied or commitment under s. 51.20, or for protective placement or protective services under ch. 55. (d) Any person under the order of a court for good cause shown. (3) Failure to file a power of attorney forr who is providing care to the principal. (c) The court and all parties involved in proceedings for guardianship of the principal under ch. 880, for emergency detention under s. 51.15, for involuntarypecified in sub. (1), the following persons may have access to the instrument without first obtaining consent from the principal: (a) The health care agent for the principal. (b) A health care provideekeeping, with the register in probate of the county in which the principal resides. (2) If a principal or health care agent has filed the principal's power of attorney for health care instrument as sevocation. 5 155.65 Filing power of attorney instrument. (1) A principal or a principal's health care agent may, for a fee, file the principal's power of attorney for health care instrument, for safare instrument, record in the principal's medical record the time, date and place of the revocation and the time, date and place, if different, of the notification to the health care provider of the r knows has a copy of the power of attorney for health care instrument. (4) The principal's health care provider shall, upon notification of revocation of the principal's power of attorney for health cat the power of attorney for health care that named him or her as health care agent has been revoked, he or she shall communicate this fact to any health care provider for the principal that he or sheiage is annulled or divorce from the spouse is obtained, the power of attorney for health care is revoked and the power of attorney for health care instrument is invalid. (3) If an individual knows thequent power of attorney for health care instrument. (2) If the health care agent is the principal's spouse and, subsequent to the execution of a power of attorney for health care instrument, the marrnt to revoke the power of attorney for health care. (c) Verbally expressing the principal's intent to revoke the power of attorney for health care, in the presence of 2 witnesses. (d) Executing a subssence of the principal to so destroy the power of attorney for health care instrument. (b) Executing a statement, in writing, that is signed and dated by the principal, expressing the principal's inteany time by doing any of the following: (a) Canceling, defacing, obliterating, burning, tearing or otherwise destroying the power of attorney for health care instrument or directing another in the preft. 155.40 Revocation of power of attorney for health care. (1) A principal may revoke his or her power of attorney for health care and invalidate the power of attorney for health care instrument at nt may make an anatomical gift under s. 157.06 (3) (a) 7. of all or a part of the principal's body after the principal's death unless the principal made an unrevoked refusal to make that anatomical giaccordance with the desires of the principal, the health care agent may sign or otherwise execute any documents, waivers or releases related to the principal's care or treatment. (8) A health care ageehalf of the principal that the power of attorney for health care instrument authorizes. 4 (7) If necessary to implement the health care decisions that a health care agent is authorized to make, in , in good faith, act in the best interests of the principal in exercising his or her authority. (6) If the principal is known to be pregnant, the health care agent may make a health care decision on ba valid declaration executed by the principal under subch. II of ch. 154. In the absence of a specific directive by the principal or if the principal's desires are unknown, the health care agent shall executed by the principal under subch. II of ch. 154, except that the provisions of a principal's valid power of attorney for health care instrume nt supersede any directly conflicting provisions of ealth care instrument or as otherwise specifically directed by the principal to the health care agent at any time. The health care agent shall act in good faith consistently with any valid declarationof the nutrition or hydration is medically contraindicated. (5) The health care agent shall act in good faith consistently with the desires of the principal as expressed in the power of attorney for hdrawal will cause the principal pain or reduce the principal's comfort. A health care agent may not consent to the withholding or withdrawal of orally ingested nutrition or hydration unless provision r the principal if the power of attorney for health care instrument so authorizes, unless the principal's attending physician advises that, in his or her professional judgment, the withholding or withto psychosurgery, electroconvulsive treatment or drastic mental health treatment procedures for the principal. (4) A health care agent may consent to the withholding or withdrawal of a feeding tube fopal is not diagnosed as developmentally disabled or as having a mental illness at the time of the proposed admission. (3) A health care agent may not consent to experimental mental health research or a community-based residential facility, for purposes other than those specified in subd. 2. a. and b., if the power of attorney for health care instrument specifically so authorizes and if the princis a temporary placement not to exceed 30 days, in order to provide the health care agent with a vacation or to release temporarily the health care agent for a family emergency. c. To a nursing home orital inpatient unit, unless the hospital admission was for psychiatric care. b. If the principal lives with his or her health care agent, to a nursing home or a community-based residential facility, arincipal to the following facilities, under the following conditions: a. To a nursing home, for recuperative care for a period not to exceed 3 months, if the principal is admitted directly from a hosp. "Community-based residential facility" has the meaning given in s. 50.01 (1g). 3 b. "Nursing home" has the meaning given in s. 50.01 (3). 2. A health care agent may consent to the admission of a p19). (b) A principal may be admitted or committed on an inpatient basis to a facility specified in par. (a) 1. to 4. only under the applicable requirements of ch. 51 or 55. (c) 1. In this paragraph: an intermediate care facility for the mentally retarded, as defined in s. 46.278 (1m) (am). 3. A state treatment facility, as defined in s. 51.01 (15). 4. A treatment facility, as defined in s. 51.01 (ions. (2) (a) A health care agent may not consent to admission of the principal on an inpatient basis to any of the following: 1. An institution for mental diseases, as defined in s. 49.43 (6m). 2. Aagent who is known to the health care provider to be available to make health care decisions for the principal has priority over any individual other than the principal to make these health care decist; powers; limitations. (1) Unless the power of attorney for health care instrument otherwise provides and except as specified in subs. (2) (a) and (b), (3) and (4) and s. 155.60 (2), the health care vidual who has attained age 18, at the express direction and in the presence of the principal. (c) Signed in the presence of 2 witnesses who meet the requirements of sub. (2). 155.20 Health care agenealth care instrument; execution; witnesses. (1) A valid power of attorney for health care instrument shall be all of the following: (a) In writing. (b) Dated and signed by the principal or by an indi designate an alternate individual to serve as his or her health care agent in the event that the health care agent first designated is unable or unwilling to do so. 2 155.10 Power of attorney for hoyee is a relative of the individual. (4) The desires of a principal who does not have incapacity supersede the effect of his or her power of attorney for health care at all times. (5) A principal mayt or resides, or a spouse of any of those providers or employees, may be designated by the individual as a health care agent unless the health care provider, employee or spouse of the provider or empler of attorney for health care instrument. (3) No health care provider for an individual, employee of that health care provider or employee of a health care facility in which an individual is a patieny be a relative of the principal or have knowledge that he or she is entitled to or has a claim on any portion of the principal's estate. A copy of the statement, if made, shall be appended to the powcapacity. Mere old age, eccentricity or physical disability, either singly or together, are insufficient to make a finding of incapacity. Neither of the individuals who make a finding of incapacity maas defined in s. 448.01 (5), or one physician and one licensed psychologist, as defined in s. 455.01 (4), who personally examine the principal and sign a statement specifying that the principal has inction. (2) Unless otherwise specified in the power of attorney for health care instrument, an individual's power of attorney for health care takes effect upon a finding of incapacity by 2 physicians, ealth care. An individual for whom an adjudication of incompetence and appointment of a guardian of the person is in effect under ch. 880 is presumed not to be of sound mind for purposes of this subseve" has the meaning given in s. 242.01 (11). 155.05 Power of attorney for health care. (1) An individual who is of sound mind and has attained age 18 may voluntarily execute a power of attorney for hse of making health care decisions on his or her behalf if the individual cannot, due to incapacity. (11) "Principal" means an individual who executes a power of attorney for health care. (12) "Relati60 or older for purposes of the state plan under 42 USC 3027. (10) "Power of attorney for health care" means the designation, by an individual, of another as his or her health care agent for the purpoacks the capacity to manage his or her health care decisions. (9) "Multipurpose senior center" means a facility that is the focal point for the delivery of services in a community to individuals aged lth agency, as defined in s. 50.49 (1) (a). 1 (8) "Incapacity" means the inability to receive and evaluate information effectively or to communicate decisions to such an extent that the individual lhealth care services, an operational cooperative sickness care plan organized under ss. 185.981 to 185.985 that directly provides services through salaried employees in its own facility, or a home heacing Christian Science treatment, an optometrist licensed under ch. 449, a psychologist licensed under ch. 455, a partnership thereof, a corporation or limited liability company thereof that provides icensed under ch. 447, a physician, physician assistant, perfusionist, podiatrist, physical therapist, occupational therapist, or occupational therapy assistant licensed under ch. 448, a person practicility under s. 45.365, 51.05, 51.06, 233.40, 233.41, 233.42 or 252.10. (7) "Health care provider" means a nurse licensed or permitted under ch. 441, a chiropractor licensed under ch. 446, a dentist lnty home, county infirmary, county hospital, county mental health center or other place licensed or approved by the department under s. 49.70, 49.71, 49.72, 50.02, 50.03, 50.35, 51.08 or 51.09 or a fa accept, maintain, discontinue or refuse health care. (6) "Health care facility" means a facility, as defined in s. 647.01 (4), or any hospital, nursing home, community-based residential facility, coudual is unable or unwilling to make those decisions, an alternate individual designated by the principal to do so. (5) "Health care decision" means an informed decision in the exercise of the right toor treat an individual's physical or mental condition. (4) "Health care agent" means an individual designated by a principal to make health care decisions on behalf of the principal or, if that indiviutrition or hydration is administered into the vein, stomach, nose, mouth or other body opening of a declarant. (3) "Health care" means any care, treatment, service or procedure to maintain, diagnose wer Of Attorney For Health Care Form. 155.01 Definitions. In this chapter: (1) "Department" means the department of health and family services. (2) "Feeding tube" means a medical tube through which n. This Wisconsin Power Of Attorney For Health Care is based on the Wisconsin Statutes Chapter 154. For your convenience, we have included useful excerpts from the Wisconsin Statutes relating to the Po Wisconsin Power Of Attorney For Health Care This package contains (1) Information and Instruction for Wisconsin Power Of Attorney For Health Care; (2) Wisconsin Power Of Attorney For Health Care Forms document should be discussed with a tax professional. [_] The purchase and use of these forms is subject to the Disclaimers and Terms of Use found at findlegalforms.com Information and Instructionsney first to make sure it fits your particular situation. Advice from a local attorney is always recommended when dealing with estate planning matters. Any possible tax consequences arising out of thiitute for legal and/or tax advice. Laws vary from time to time and from state to state. These forms should only be a starting point for you and should not be used or signed without consulting an attord or express warranties have been made or are provided as to their suitability for any specific purpose or as to their legal effect or completeness. [_]These forms are not intended and are not a substsometimes known as an Advance Health Care Directive. The first form is the Power of Attorney for Health Care and the second form is the Living Will. [_] These forms are provided "as is" and no implieWisconsin Advance Health Care Directive This package contains both a Wisconsin Power of Attorney for Health Care and a Wisconsin Declaration to Physician (Living Will). Together these forms are also Wisconsin