Declaration Relating To Use Of Life-Sustaining Procedures
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4DIVISION OF PUBLIC HEALTH
1 W EST W ILSON STREET
P O BOX 2659
Scott Walker
MADISON W I 53701-2659
Governor
State of Wisconsin
608-266-1251
Kitty Rhoades
FAX: 608-267-2832
Secretary
TTY: 888-701-1253
Department of Health Services
dhs.wisconsin.gov
To Whom It May Concern:
Enclosed is the Declaration to Physicians (Living Will) form you requested. This form makes it possible
for adults in Wisconsin to state their preferences for life-sustaining procedures and feeding tubes in the event the
person is in a terminal condition or persistent vegetative state.
Be sure to read both sides of the form carefully and understand it before you complete and sign it.
The withholding or withdrawal of any medication, life-sustaining procedure or feeding tube may not be
made if the attending physician advises that doing so will cause pain or reduce comfort, and the pain or
discomfort cannot be alleviated through pain relief measures.
Two witnesses are required. Witnesses must be at least 18 years of age, not related to you by blood,
marriage or adoption, and not directly financially responsible for your health care. Witnesses may not be persons
who know they are entitled to or have a claim on any portion of your estate. A witness cannot be a health care
provider who is serving you at the time the document is signed, an employee of the health care provider, other
than a chaplain or a social worker, or an employee other than a chaplain or social worker of an inpatient health
care facility in which you are a patient. Valid witnesses acting in good faith are immune from civil or criminal
liability.
You should make relatives and friends aware that you have signed the document and the location where it
is kept. A signed form may be kept in a safe, easily accessible place until needed. The document may be filed for
safekeeping for a fee with the Register in Probate of your county of residence, but it is not required that it be filed.
The fee for filing with the Register in Probate has been set by State Statute at $8.00.
You are responsible for notifying your attending physician of the existence of the Declaration. An
attending physician who is notified shall make the Declaration part of your medical records. A Declaration that is
in its original form or is a legible photocopy or electronic facsimile copy is presumed to be valid.
If you have both a Declaration to Physicians and a Power of Attorney for Health Care, the provisions of a
valid Power of Attorney for Health Care supersede any directly conflicting provisions of a valid Declaration to
Physicians.
Up to four copies of the Declaration to Physicians are available free to anyone who sends a stamped, self-
addressed, business-size envelope to: Living Will, Division of Public Health, P.O. Box 2659, Madison, Wisconsin
53701-2659. You may make additional copies of the enclosed blank form. The form is also available on the
Department of Health Services Web page
.
If you have questions about the availability of the Declaration to Physicians (Living Will) form or
obtaining larger quantities of the form, you may contact the Division of Public Health at (608) 266-1251.
INSTRUCTIONS FOR DECLARATION TO PHYSICIANS FORM
Definitions
“Declaration” means a written, witnessed document voluntarily executed by the declarant under State Statute
154.03 (1), but is not limited in form or substance to that provided in State Statute 154.03 (2).
“Department” means the Department of Health Services.
“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.
Wisconsin.gov
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