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5820.ARM
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1991-06-27
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/* Wisconsin Living Will Form Para. 4420 */
DECLARATION TO PHYSICIANS AS PROVIDED BY WISCONSIN
STATUTES SECTION 154.01
DECLARATION TO PHYSICIANS
Declaration made this _________________ day of _________.
I #NAME#, being of sound mind, willfully and voluntarily state my
desire that my life shall not be artificially prolonged if I have
an incurable injury or illness certified to be a terminal
condition by two physicians who have personally examined me, one
of whom is my attending physician, and if the physicians have
determined that my death is imminent so that the application of
life sustaining procedures serve only to artificially prolong
artificially the dying process. Under these circumstances, I
direct that such procedures be withheld or withdrawn, and that
I be permitted to die naturally, with only:
a. The continuation of nutritional support and fluid maintenance;
and,
b. The alleviation of pain by administering medication or other
medical procedure.
2. If I am unable to give directions regarding the use of such
life-sustaining procedures, I intend that my family and
physician(s) honor this declaration as the final expression of my
legal right to refuse medical or surgical treatment and accept
the consequences from such refusal.
3. If I have been diagnosed as pregnant and my physician knows of
this diagnosis this declaration has no force during the course of
my pregnancy.
4. This declaration takes effect immediately.
I understand the full import of this declaration
and I am emotionally and mentally competent to make this
directive.
Signed _________________________________________________
@001
Address: @002
@003
I know the declarant personally and I believe him or her
to be of sound mind. I am not related to the declarant by blood
or marriage, and am not entitled to any portion of the
declarant's estate under any will of the declarant. I am neither
the declarant's attending physician, the attending nurse, the
attending medical staff nor an employee of the attending
physician or the inpatient health care facility in which the
declarant may be a patient and I have no claim against the
declarant's estate at this time, except that if I am not a health
care provider who is involved in the medical care of the
declarant, I may be an employee of the inpatient health care
facility regardless of whether or not the facility may have a
claim against the estate of the declarant.
Witness:
________________________________________________________________
Witness:
________________________________________________________________
This declaration is executed as provided in chapter 154,
Wisconsin Statutes