$13.95

Add to cart

Wisconsin ___________ _________________________________________________ Date Signed _________________ Date Signed _________________ -2- roviders to whom he or she has given copies of this document: _________________________________________________ _________________________________________________ ______________________________________hat 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 health care pst 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. If you know teasures. 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 document, you mue 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 pain relief merminal 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 unless you believng 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 patient has a t_________ Witness Signature: ______________________________________ Print Name: ____________________________________________ DIRECTIVES TO ATTENDING PHYSICIAN 1. This document authorizes the withholdiny portion of the person's estate and am not otherwise restricted by law from being a witness. Witness Signature: ______________________________________ Print Name: ___________________________________he person signing this document is of sound mind. I am 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 aame time. Signed ________________________________________________ Address _______________________________________________ Date Signed _________________ Date of Birth ________________ I believe that tficant terms used in this document, see section 154.01 of the Wisconsin Statutes or the information accompanying this document. -1- ATTENTION: You and the 2 witnesses must sign the document at the sNO, I do not want feeding tubes used if I am in a persistent vegetative state. If you have not checked either box, feeding tubes will be used. If you are interested in more information about the signietermined by 2 physicians who have personally examined me, the following are my directions regarding the use of feeding tubes: YES, I want feeding tubes used if I am in a persistent vegetative state. life-sustaining procedures used if I am in a persistent vegetative state. If you have not checked either box, life-sustaining procedures will be used. 3. If I am in a PERSISTENT VEGETATIVE STATE, as dy examined me, the following are my directions regarding the use of life-sustaining procedures: YES, I want life-sustaining procedures used if I am in a persistent vegetative state. NO, I do not want tubes used if I have a terminal condition. If you have not checked either box, feeding tubes will be used. 2. If I am in a PERSISTENT VEGETATIVE STATE, as determined by 2 physicians who have personallaining procedures to be used. In addition, the following are my directions regarding the use of feeding tubes: YES, I want feeding tubes used if I have a terminal condition. NO, I do not want feeding or surgical treatment. 1. If I have a TERMINAL CONDITION, as determined by 2 physicians who have personally examined me, I do not want my dying to be artificially prolonged and I do not want life-sustgive directions regarding the use of life-sustaining procedures or feeding tubes, I intend that my family and physician honor this document as the final expression of my legal right to refuse medical untarily state my desire that my dying not be prolonged under the circumstances specified in this document. Under those circumstances, I direct that I be permitted to die naturally. If I am unable to ct to the Disclaimers and Terms of Use found at findlegalforms.com Declaration to Physicians (Living Will) I,________________________________________________________________, being of sound mind, vol matters. Any possible tax consequences arising out of this document should be discussed with a tax professional. Information & Instructions ­ Page 4 [_] The purchase and use of these forms is subjed should not be used or signed without consulting an attorney first to make sure it fits your particular situation. Advice from a local attorney is always recommended when dealing with estate planningeness. [_]These forms are not intended and are not a substitute 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 ancation. [_] These forms are provided "as is" and no implied or express warranties have been made or are provided as to their suitability for any specific purpose or as to their legal effect or completion. The attending physician shall record in the patient's medical record the time, date and place of the revocation and the time, date and place, if different, that he or she was notified of the revotive only if the declarant or a person who is acting on behalf of the declarant notifies the attending physician of the revocation. (d) By executing a subsequent declaration. (2) Recording the revocat declarant expressing the intent to revoke, signed and dated by the declarant. (c) By a verbal expression by the declarant of his or her intent to revoke the declaration. This revocation becomes effec, obliterated, burned, torn or otherwise destroyed by the declarant or by some person who is directed by the declarant and who acts in the presence of the declarant. (b) By a written revocation of therant is a patient. 154.05 Revocation of declaration. (1) Method of revocation. A declaration may be revoked at any time by the declarant by any of the following methods: (a) By being canceled, defacedon, an employee, other than a chaplain or a social worker, of the health care provider or an employee, other than a chaplain or a social worker, of an inpatient health care facility in which the decla (c) Directly financially responsible for the declarant's health care. (d) An individual who is a health care provider, as defined in s. 155.01 (7), who is serving the declarant at the time of executiRelated to the declarant by blood, marriage or adoption. Information & Instructions ­ Page 3 (b) Have knowledge that he or she is entitled to or has a claim on any portion of the declarant's estate.who is so notified shall make the declaration a part of the declarant's medical records. No witness to the execution of the declaration may, at the time of the execution, be any of the following: (a) be acknowledged by the declarant in the presence of 2 witnesses. The declarant is responsible for notifying his or her attending physician of the existence of the declaration. An attending physician ion must be signed in the declarant's name by one of the witnesses or some other person at the declarant's express direction and in his or her presence; such a proxy signing shall either take place orthe administration is medically contraindicated. A declaration must be signed by the declarant in the presence of 2 witnesses. If the declarant is physically unable to sign a declaration, the declaratation that is administered or otherwise received by the declarant through means other than a feeding tube unless the declarant's attending physician advises that, in his or her professional judgment, nt pain or reduce the declarant's comfort and the pain or discomfort cannot be alleviated through pain relief measures. A declarant may not authorize the withholding or withdrawal of nutrition or hydrany medication, life-sustaining procedure or feeding tube if the declarant's attending physician advises that, in his or her professional judgment, the withholding or withdrawal will cause the declarawal of life-sustaining procedures or of feeding tubes when the person is in a terminal condition or is in a persistent vegetative state. A declarant may not authorize the withholding or withdrawal of s. (1) Any person of sound mind and 18 years of age or older may at any time voluntarily execute a declaration, which shall take effect on the date of execution, authorizing the withholding or withdrawith a terminal condition or to be in a persistent vegetative state by 2 physicians, one of whom is the attending physician, who have personally examined the declarant. 154.03 Declaration to physiciandministered into the vein, stomach, nose, mouth or other body opening of a qualified patient. (3) "Qualified patient" means a declarant who has been diagnosed and certified in writing to be afflicted cuted by the declarant under s. 154.03 (1), but is not limited in form or substance to that provided in s. 154.03 (2). (2) "Feeding tube" means a medical tube through which nutrition or hydration is athe application of life-sustaining procedures serves only to postpone the moment of death. 154.02 Definitions. In this subchapter: (1) "Declaration" means a written, witnessed document voluntarily exee. Information & Instructions ­ Page 2 (8) "Terminal condition" means an incurable condition caused by injury or illness that reasonable medical judgment finds would cause death imminently, so that chronic and irreversible cessation of all cognitive functioning and consciousness and a complete lack of behavioral responses that indicate cognitive functioning, although autonomic functions continursistent vegetative state" means a condition that reasonable medical judgment finds constitutes complete and irreversible loss of all of the functions of the cerebral cortex and results in a complete,nd other similar procedures, but does not include: (a) The alleviation of pain by administering medication or by performing any medical procedure. (b) The provision of nutrition or hydration. (5m) "Pedeath when applied to a qualified patient. "Life-sustaining procedure" includes assistance in respiration, artificial maintenance of blood pressure and heart rate, blood transfusion, kidney dialysis a. 50.01 (1g). (5) "Life-sustaining procedure" means any medical procedure or intervention that, in the judgment of the attending physician, would serve only to prolong the dying process but not avert ertified or registered under ch. 441, 448 or 455. (4) "Inpatient health care facility" has the meaning provided under s. 50.135 (1) and includes community-based residential facilities, as defined in sho has primary responsibility for the treatment and care of the patient. (2g) "Department" means the department of health and family services. (3) "Health care professional" means a person licensed, cnience, we have included useful excerpts from the Wisconsin Statutes relating to Living Wills. 154.01 Definitions. In this chapter: (1) "Attending physician" means a physician licensed under ch. 448 w Will); (2) Wisconsin Declaration to Physicians (Wisconsin Living Will). This Wisconsin Declaration to Physicians (Wisconsin Living Will) is based on the Wisconsin Statutes Chapter 154. For your conveInformation and Instructions Wisconsin Declaration to Physicians (Wisconsin Living Will) This package contains (1) Information and Instruction for Wisconsin Declaration to Physicians (Wisconsin Living Wisconsin