Attorney-Approved Wisconsin Living Will Document

Wisconsin Living Will Template

This document serves as a Living Will, designed specifically for residents of Wisconsin, in accordance with the Wisconsin State Statutes Chapter 155 - Power of Attorney for Health Care and Declaration to Physicians (Living Will). This template is intended to guide you through the process of documenting your health care preferences in the event that you are unable to communicate these wishes due to a terminal illness or persistent vegetative state.

Please fill in the following information:

Full Name: ________________________________________________________

Date of Birth: ____________________________________________________

Address: __________________________________________________________

City: ___________________________ State: WI Zip Code: _______________

Primary Phone: ____________________________________________________

Alternate Phone: __________________________________________________

I, _______________[Full Name]__, being of sound mind, hereby direct the following:

1. Primary Directive: If I am diagnosed with a terminal condition, where the application of life-sustaining procedures would only serve to artificially prolong the dying process, I elect to have such procedures withdrawn or withheld, and to be permitted to die naturally.
2. Nutrition and Hydration: In the event I am unable to take food or water by mouth, I wish to receive artificially provided nutrition and hydration only if it is believed by my doctors that this would provide comfort or alleviate pain.
3. Pain Relief: I request that medication be administered to me for the purpose of alleviating pain, even if this medication may hasten the moment of my death.
4. Declaration to Physicians (Living Will): This living will is my declaration to my physicians. If two physicians certify in writing that I am in a terminal condition and unable to express my health care decisions, it is my express wish that my dying not be artificially prolonged and that I receive care which is necessary to relieve pain, even if it hastens my death.

Signature: _______________________________________ Date: ________________________

Witness:

Name: ________________________________________

Signature: ___________________________________ Date: ________________________

Alternate Witness:

Name: ________________________________________

Signature: ___________________________________ Date: ________________________

This Living Will shall remain in effect indefinitely unless it is revoked by me or by law. An executed copy of this document should be given to my physician and other health care providers.

By creating this Living Will, I affirm that I fully understand its contents and the implications of declaring such directives regarding my health care. This document is executed voluntarily and without any undue influence.