WISCONSIN ADVANCE DIRECTIVE
(“Declaration to Physicians” / Living Will)
[// GUIDANCE: This template integrates Wisconsin-specific statutory requirements (Wis. Stat. ch. 154) and the custom metadata supplied by the user. Practitioners should review Chapter 155 if they also wish to grant a Power of Attorney for Health Care.]
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TABLE OF CONTENTS
- Document Header
- Definitions
- Directive Provisions
- Optional Nomination of Health-Care Agent
- Anatomical Gifts (Optional)
- Indemnification & Limitation of Liability
- Enforcement; Injunctive Relief
- Revocation Procedures
- General Provisions
- Execution & Witness Attestation
1. DOCUMENT HEADER
This Wisconsin Advance Directive (“Directive”) is executed on [EFFECTIVE DATE] by [DECLARANT FULL LEGAL NAME], date of birth [MM/DD/YYYY], residing at [FULL RESIDENTIAL ADDRESS] (“Declarant”), pursuant to Wis. Stat. § 154.03 (2023) and other applicable Wisconsin health-care laws (“State Health-Care Law”).
Declarant is of sound mind and at least eighteen (18) years of age and issues this Directive to communicate instructions regarding life-sustaining procedures, feeding tubes, and other medical interventions if Declarant is in a terminal condition or persistent vegetative state as certified by two (2) physicians, one of whom is the attending physician.
2. DEFINITIONS
For purposes of this Directive, capitalized terms have the meanings set forth below. Undefined capitalized terms shall be construed according to State Health-Care Law.
“Artificially Administered Nutrition and/or Hydration” means invasive provision of nutrients or fluids through medical technology, including but not limited to gastrostomy, jejunostomy, or intravenous infusion.
“Declarant” has the meaning provided in Section 1.
“Health-Care Provider” means any individual or entity licensed, certified, or otherwise authorized to provide health-care services to Declarant.
“Life-Sustaining Procedure” means any medical treatment that serves only to prolong the process of dying or to maintain Declarant in a persistent vegetative state and does not include comfort care or pain alleviation.
“Persistent Vegetative State” means an irreversible condition in which Declarant is not aware of self or surroundings and cannot interact meaningfully with the environment as determined by the attending physician and one (1) consulting physician.
“Terminal Condition” means an incurable condition caused by injury, disease, or illness that, to a reasonable degree of medical certainty, will result in death imminently or within a relatively short time without application of Life-Sustaining Procedures.
3. DIRECTIVE PROVISIONS
3.1 Declaration Regarding Life-Sustaining Procedures.
If I am diagnosed, in writing, by two (2) physicians as being in a Terminal Condition or Persistent Vegetative State, and if Life-Sustaining Procedures would serve only to prolong the dying process or maintain me in such state, I DIRECT that such procedures be withheld or withdrawn so that I may be permitted to die naturally with only the administration of medication or medical procedures necessary to provide me with comfort care or to relieve pain.
3.2 Artificially Administered Nutrition and/or Hydration.
[CHOOSE ONE – strike or delete the non-selected option]
- Option A (Withhold): I direct that Artificially Administered Nutrition and/or Hydration be withheld or withdrawn in accordance with Section 3.1.
- Option B (Provide): I direct that Artificially Administered Nutrition and/or Hydration be continued even if all other Life-Sustaining Procedures are withheld.
[// GUIDANCE: Wisconsin’s statutory form defaults to withholding feeding tubes unless declarant specifically requests them. Practitioners should confirm client intent.]
3.3 Pregnancy Exception.
If I am known to be pregnant and my attending physician believes that Life-Sustaining Procedures will allow the fetus a reasonable chance to develop to the point of live birth, I direct that this Directive shall / shall not [SELECT ONE] be honored during such pregnancy.
3.4 Palliative & Comfort Care.
Nothing herein prohibits or restricts the provision of pain medication, comfort care, or any other measure required for my comfort or to alleviate suffering, even if such measure may hasten my death.
4. OPTIONAL NOMINATION OF HEALTH-CARE AGENT
[// GUIDANCE: This is not required for a Chapter 154 living will, but many clients prefer to include an agent designation. Remove entire Section 4 if a separate Chapter 155 POA-HC will be executed.]
4.1 Nomination.
I nominate [AGENT NAME], currently residing at [AGENT ADDRESS], as my Health-Care Agent (“Agent”) to make health-care decisions on my behalf if I am incapacitated. If the Agent is unable or unwilling to serve, I nominate [ALTERNATE AGENT NAME] as alternate.
4.2 Scope of Authority.
Agent’s authority is limited to implementing the instructions expressed in this Directive and any additional instructions I have communicated orally or in writing.
4.3 Agent Standards.
Agent shall act in good faith, consistent with my known wishes, religious or moral beliefs, and best interests, and shall consult relevant health-care professionals when making decisions.
5. ANATOMICAL GIFTS (OPTIONAL)
[ ] I elect to make an anatomical gift under Wis. Stat. ch. 157. Details/specify organs or purposes: [INSERT].
[ ] I decline to make any anatomical gift.
6. INDEMNIFICATION & LIMITATION OF LIABILITY
6.1 Provider Protection.
Declarant agrees that any Health-Care Provider, facility, or individual who, in good-faith reliance on this Directive, withholds or withdraws Life-Sustaining Procedures or otherwise acts in accordance with its terms shall be indemnified and held harmless from any civil or criminal liability arising out of such actions, except in cases of gross negligence or willful misconduct, consistent with Wis. Stat. § 154.11 (2023).
6.2 Good-Faith Standard.
Liability, if any, of a Health-Care Provider acting pursuant to this Directive shall not exceed damages directly resulting from acts or omissions taken in bad faith or in knowing violation of State Health-Care Law.
7. ENFORCEMENT; INJUNCTIVE RELIEF
7.1 Right to Seek Enforcement.
Any person statutorily authorized to enforce Declarant’s rights, including the Agent and immediate family members, may seek injunctive relief in any court of competent jurisdiction to compel compliance with this Directive.
7.2 Emergency Relief.
Because noncompliance with Declarant’s wishes may cause irreparable harm not compensable by money damages, the parties agree that injunctive or other equitable relief is an appropriate and necessary remedy.
8. REVOCATION PROCEDURES
8.1 Revocation by Declarant.
Pursuant to Wis. Stat. § 154.07 (2023), Declarant may revoke this Directive at any time by:
a. Executing a written revocation signed and dated by Declarant;
b. Physically destroying this Directive or directing another to do so in Declarant’s presence;
c. An oral statement of intent to revoke made in the presence of two (2) witnesses; or
d. Executing a subsequent Directive.
8.2 Notification Obligation.
Upon revocation, Declarant (or a person acting on Declarant’s behalf) should promptly notify all known Health-Care Providers and Agents and retrieve or destroy all known copies.
9. GENERAL PROVISIONS
9.1 Governing Law.
This Directive shall be construed in accordance with the laws of the State of Wisconsin.
9.2 Copies.
A photocopy or electronically transmitted copy of this Directive shall have the same force and effect as the original.
9.3 Severability.
If any provision of this Directive is held invalid, the remaining provisions shall remain in full force and effect consistent with Declarant’s intent.
9.4 Reliance.
Health-Care Providers may rely on the most recent dated Directive in their possession and are under no duty to inquire into its validity beyond reasonable authentication of Declarant’s signature.
10. EXECUTION & WITNESS ATTESTATION
I have read this Directive or had it read to me, understand its meaning, and sign it voluntarily.
Declarant’s Signature: _____ Date: _ / _ / ___
Declarant’s Printed Name: _____
Witness Statement (required by Wis. Stat. § 154.03(1))
We declare under penalty of perjury that we are at least 18 years of age; are not related to the Declarant by blood, marriage, or adoption; are not entitled to any portion of Declarant’s estate; are not directly financially responsible for Declarant’s medical care; are not Health-Care Providers serving Declarant; and are not employees of such providers (unless serving as chaplain or social worker). We witnessed the Declarant sign this Directive (or the Declarant’s acknowledgment of signature) on the date indicated.
| Witness No. | Signature | Printed Name & Address | Date |
|---|---|---|---|
| 1 | ____ | ____ ____ |
//______ |
| 2 | ____ | ____ ____ |
//______ |
[// GUIDANCE: Wisconsin does not require notarization for a living will, but nothing prohibits adding a notary block if preferred by client or facility policy.]
END OF DOCUMENT
[// GUIDANCE: Provide copies to primary physician, hospital, and Agent. Encourage client to discuss wishes openly with family and medical professionals.]
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