Wisconsin Living Will Declaration
This Living Will Declaration is made in accordance with the Wisconsin Statutes Chapter 155 - Power of Attorney for Health Care and Living Will. This document allows you to express your wishes concerning life-sustaining procedures if you are diagnosed with a terminal condition or are in a persistent vegetative state. By completing this Living Will, you direct healthcare providers on how to proceed with treatments that may only prolong the dying process.
Please complete the following information to ensure this Living Will accurately reflects your healthcare preferences.
Your Information:
- Full Name: _____________________________________________________________________
- Date of Birth: __________________________________________________________________
- Address: ________________________________________________________________________
- City, State, Zip Code: ___________________________________________________________
- Phone Number: __________________________________________________________________
Declaration Statement:
I, ____________________________, being of sound mind, willfully, and voluntarily make known my desire that my dying shall not be artificially prolonged under the circumstances set forth below. I understand the full import of this declaration.
Life-Sustaining Treatment:
If at any time I am unable to communicate my healthcare decisions and I have been diagnosed by two or more physicians to be either in a terminal condition or in a persistent vegetative state with no reasonable expectation of recovery, I direct that:
- Life-sustaining procedures be withheld or withdrawn when the burdens of treatment outweigh the benefits I expect to gain, and my condition is deemed irreversible.
- Artificially provided nutrition and hydration be withheld or withdrawn, except when needed for comfort care, unless I have indicated otherwise in this document.
Additional Instructions:
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
Appointment of Health Care Agent: (Optional)
I designate ______________________________________ as my Health Care Agent to make health care decisions for me, consistent with my desires, if I am unable to make such decisions myself.
Agent's Information:
- Full Name: _____________________________________________________________________
- Relationship: __________________________________________________________________
- Phone Number: __________________________________________________________________
- Alternate Phone Number: _________________________________________________________
This Living Will is executed on the _____ day of ____________, 20____.
Signature: ___________________________________________________
Witness Declaration:
Two witnesses must sign this document. Witnesses must be over the age of 18 and should not be the appointed health care agent or related to you by blood, marriage, or adoption. They cannot be heirs, devisees, or have any claim against your estate.
- Witness 1 Signature: __________________________________ Date: ____________________
- Witness 1 Print Name: ___________________________________________________________
- Witness 2 Signature: __________________________________ Date: ____________________
- Witness 2 Print Name: ___________________________________________________________