Declaration Relating To Use Of Life-Sustaining Procedures Page 3
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4DEPARTMENT OF HEALTH SERVICES
STATE OF WISCONSIN
Division of Public Health
Effective Date April 6, 1996
F-00060 (Rev. 09/13) Page 1 of 2
S. 154.03(1),(2)
PLEASE BE SURE YOU READ THE FORM CAREFULLY AND UNDERSTAND IT
BEFORE YOU COMPLETE AND SIGN IT
DECLARATION TO PHYSICIANS
(WISCONSIN LIVING WILL)
I,
being of sound mind, voluntarily 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 give
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 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-sustaining 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 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
personally 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 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 determined 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.
NO, 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 significant terms used in this document, see section
154.01 of the Wisconsin Statutes or the information accompanying this document.
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