The Wisconsin F 00060 form, also known as the Declaration to Health Care Professionals (Living Will), is a crucial document for adults in Wisconsin who wish to express their medical treatment preferences in cases of terminal illness or persistent vegetative states. It outlines the conditions under which an individual prefers to withhold or withdraw life-sustaining treatments and feeding tubes. Understanding the specifications and completing this form with care is essential for its intended purpose to be effectively carried out.
In Wisconsin, adults have the power to make crucial decisions about their healthcare through the F 00060 form, otherwise known as the Declaration to Health Care Professionals or Living Will. This important document allows individuals to express their preferences regarding the use of life-sustaining procedures and feeding tubes if they find themselves in a terminal condition or persistent vegetative state. It emphasizes the importance of understanding every aspect of the form before completing and signing it, highlighting the conditions under which medical interventions may be withheld or withdrawn. With specific clauses addressing pain management, the necessity of two witnesses who meet defined criteria, and the procedural steps to follow post-signing, the form is comprehensive in scope. Moreover, the form outlines the responsibilities of the attending healthcare professionals upon notification of the Declaration, details on filing with the Register in Probate, and circumstances under which a Declaration might be superseded by a Power of Attorney for Health Care. Lastly, it discusses the accessibility of the form, instructions for declaration, its legal presumptions, revocation methods, and the liabilities related to compliance and non-compliance. By navigating these nuances, individuals can ensure their healthcare wishes are known and respected, granting them peace of mind and asserting their rights to decide about their medical treatment under dire circumstances.
State of Wisconsin
Department of Health Services
The Declaration to Health Care Professionals (Living Will) 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 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, physician assistant, or advanced practice registered nurse 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.
When you have completed and signed the form:
The original signed form should be kept in a safe, easily accessible place until needed.
You should make relatives and friends aware that you have signed the document and the location where it is kept.
A copy of the signed form may be kept on file with your physician, physician assistant, or advanced practice registered nurse. You are responsible for notifying your attending physician, physician assistant, or advanced practice registered nurse of the existence of the Declaration. An attending physician, physician assistant or advanced practice registered nurse who is notified shall make the Declaration part of your medical records.
The document may, but is not required to be, filed for safekeeping, for a fee, with the Register in Probate of your county of residence. The fee for filing with the Register in Probate has been set by State at $8.
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 Health Care Professionals 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 Health Care Professionals.
Up to four copies of the Declaration to Health Care Professionals are available free to anyone who sends a stamped, self-addressed, business-size envelope to Living Will, Division of Public Health, PO 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 https://www.dhs.wisconsin.gov/forms/advdirectives/index.htm.
INSTRUCTIONS FOR DECLARATION TO HEALTH CARE PROFESSIONALS FORM Definitions
“Declaration” means a written, witnessed document voluntarily executed by the declarant under State Statute (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.
“Terminal condition” means an incurable condition caused by injury or illness that reasonable medical judgment finds would cause death imminently, so that the application of life-sustaining procedures serves only to postpone the moment of death.
“Persistent vegetative state” means a condition that reasonable, medical judgment finds constitutes complete and irreversible loss of all the functions of the cerebral cortex and results in a complete, chronic and irreversible cessation of all cognitive functioning and consciousness and a complete lack of behavioral responses that indicate cognitive functioning, although autonomic functions continue.
“Qualified patient” means a declarant who has been diagnosed, and certified in writing to be afflicted with a terminal condition or to be in a persistent vegetative state by two health care professionals and one of whom is a physician, who have personally examined the declarant.
“Attending health care professional” means a health care professional who has primary responsibility for the treatment and care of the patient.
“Advanced practice registered nurse” means a nurse licensed under ch. 154 who is currently certified by a national certifying body approved by the board of nursing as a nurse practitioner, certified midwife, certified registered nurse anesthetist, or clinical nurse specialist.
“Health care professional” means any of the following: a physician licensed under ch. 154, a physician assistant licensed under ch. 154, or an advanced practice registered nurse.
“Inpatient health care facility” has the meaning provided under State Statute 50.135(1) and includes community-based residential facilities as defined in State Statute 50.01(1g).
“Life-sustaining procedure” means any medical procedure or intervention that, in the judgment of the attending health care professional, would serve only to prolong the dying process but not avert death when applied to a qualified patient.
“Life-sustaining procedure” includes assistance in respiration, artificial maintenance of blood pressure and heart rate, blood transfusion, kidney dialysis and other similar procedures, but does not include (a) the alleviation of pain by administering medication or by performing a medical procedure; or (b) the provision of nutrition or hydration.
Procedures for Signing Declarations
A Declaration must be signed by the declarant in the presence of two witnesses. If the declarant is physically unable to sign a Declaration, the Declaration must be signed in the declarant’s name by one of the witnesses or some other person at the declarant’s express direction and in his or her presence; such a proxy signing shall either take place or be acknowledged by the declarant in the presence of two witnesses.
Effect of Declaration
The desires of a qualified patient who is competent supersede the effect of the Declaration at all times. If a qualified patient is incompetent at the time of the decision to withhold or withdraw life- sustaining procedures or feeding tubes, a Declaration executed under this chapter is presumed to be valid.
Revocation of Declaration
A Declaration may be revoked at any time by the declarant by any of the following methods:
1)By being canceled, defaced, obliterated, burned, torn or otherwise destroyed by the declarant or by some person who is directed by the declarant and who acts in the presence of the declarant.
2)By a written revocation, signed and dated by the declarant expressing the intent to revoke.
3)By a verbal expression by the declarant of his or her intent to revoke the Declaration, but only if the declarant or a person acting on behalf of the declarant notifies the attending physician, physician assistant, or advanced practice registered nurse of the revocation.
4)By executing a subsequent Declaration.
The attending physician, physician assistant, or advanced practice registered nurse shall record in the declarant’s medical records the time, date and place of the revocation and time, date and place, if different, that he or she was notified of the revocation.
Liabilities
No physician, physician assistant, or advanced practice registered nurse, inpatient health
care facility or health care professional acting under direction of a physician, physician assistant, or advanced practice registered nurse may be held criminally or civilly liable, or charged with unprofessional conduct of any of the following:
1)Participating in the withholding or withdrawal of life-sustaining procedures or feeding tubes under Ch. 154, subchapter II.
2)Failing to act upon a revocation unless the person or facility has actual knowledge of therevocation.
3)Failing to comply with a Declaration, except that failure by a physician, physician assistant, or advanced practice registered nurse to comply with a Declaration of a qualified patient constitutes unprofessional conduct if the physician, physician assistant, or advanced practice registered nurse refuses or fails to make a good faith attempt to transfer the patient to another physician, physician assistant, or advanced practice registered nurse who will comply with the Declaration.
F-00060A (Rev. 02/2020)
DEPARTMENT OF HEALTH SERVICES
STATE OF WISCONSIN
Division of Public Health
Effective Date February 7, 2020
F-00060 (02/2020) Page 1 of 2
Wis. Stat. §154.03(1)(2)
PLEASE BE SURE YOU READ THE FORM CAREFULLY AND UNDERSTAND IT
BEFORE YOU COMPLETE AND SIGN IT
DECLARATION TO HEALTH CARE PROFESSIONALS (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, physician assistant or advanced practice registered nurse, 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 a physician, physician assistant, or advanced practice registered nurse, who have personally examined me, and if a physician who has also personally examined me agrees with that determination, 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 a physician, physician assistant, or advanced practice registered nurse who have personally examined me, and if a physician who has also personally examined me agrees with that determination, 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 a physician, physician assistant, or advanced practice registered nurse who has personally examined me, and if a physician who has also personally examined me agrees with that determination, 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.
F-00060 (02/2020) Page 2 of 2
ATTENTION: You and the 2 witnesses must sign the document at the same time.
Signed
Date
Address
Date of Birth
I believe that the person signing this document is of sound mind. I am an adult and am not related to the person signing this document by blood, marriage or adoption. I am not entitled to and do not have a claim on any portion of the person's estate and am not otherwise restricted by law from being a witness.
Witness Signature_______________________________________Date Signed
Print Name
Witness Signature
Date Signed
DIRECTIVES TO ATTENDING PHYSICIAN, PHYSICIAN ASSISTANT,
OR ADVANCED PRACTICE REGISTERED NURSE
1.This document authorizes the withholding or withdrawal of life-sustaining procedures or of feeding tubes when a physician and another physician, physician assistant, or advanced practice registered nurse, one of whom is the attending health care professional, have personally examined and certified in writing that the patient has a terminal condition or is in a persistent vegetative state.
2.The choices in this document were made by a competent adult. Under the law, the patient's stated desires must be followed unless you believe that withholding or withdrawing life- sustaining procedures or feeding tubes would cause the patient pain or reduced comfort and that the pain or discomfort cannot be alleviated through pain relief measures. If the patient's stated desires are that life-sustaining procedures or feeding tubes be used, this directive must be followed.
3.If you feel that you cannot comply with this document, you must make a good faith attempt to transfer the patient to another physician, physician assistant, or advanced practice registered nurse who will comply. Refusal or failure to make a good faith attempt to do so constitutes unprofessional conduct.
4.If you know that the patient is pregnant, this document has no effect during her pregnancy.
* * * * *
The person making this living will may use the following space to record the names of those individuals and health care providers to whom he or she has given copies of this document:
Filling out the Wisconsin F 00060 form, known as the Declaration to Health Care Professionals (Living Will), allows individuals in Wisconsin to express their preferences regarding life-sustaining procedures and feeding tubes under certain conditions. It's important to approach this document with clarity and thoughtfulness, as it outlines your wishes in scenarios where you might not be able to communicate them yourself. Witnesses are critical in this process, ensuring the document's validity and your desires are respected. Here's a step-by-step guide to help you through filling out the form.
After completing the form, it's your responsibility to communicate with your health care providers about your wishes and provide them with a copy of the document. This ensures that in challenging times, your preferences are known and respected, providing peace of mind to both you and your loved ones.
What is the Wisconsin F 00060 form?
The Wisconsin F 00060 form, also known as the Declaration to Health Care Professionals or Wisconsin Living Will, is a document that allows adults in Wisconsin to state their preferences regarding the use of life-sustaining procedures and feeding tubes if they are in a terminal condition or persistent vegetative state. It helps ensure that a person's healthcare choices are respected even if they are no longer able to communicate their wishes.
Who can sign the Wisconsin F 00060 form?
Any competent adult can sign the Wisconsin F 00060 form. To be considered competent, the individual must be of sound mind, understanding the nature and significance of the document and its implications regarding their medical treatment choices.
What are the requirements for witnesses on the Wisconsin F 00060 form?
The form requires the signature of two witnesses. These witnesses must be at least 18 years old and cannot be related to the signer by blood, marriage, or adoption. They also cannot be financially responsible for the signer's healthcare, have a claim on their estate, be healthcare providers to the signer at the time of signing, or be employees of a healthcare provider or facility where the signer is receiving care, except for chaplains or social workers.
Where should the original signed Wisconsin F 00060 form be kept?
The original signed document should be kept in a safe but easily accessible location. It's important that close relatives and friends are made aware of the document and its location. Additionally, a copy can be kept on file with the signer's physician, physician assistant, or advanced practice registered nurse, and it may also be filed with the Register in Probate in the signer's county of residence, though this is not required.
Can a signed Wisconsin F 00060 form be revoked?
Yes, the signer can revoke the form at any time through several methods: by physically destroying the document, by a written and dated revocation, verbally expressing the intent to revoke in the presence of a physician, physician assistant, or advanced practice registered nurse, or by creating a new declaration. The healthcare professional should be notified of the revocation and document it accordingly.
What happens if I have both a Wisconsin F 00060 form and a Power of Attorney for Health Care?
If you have both documents and there is a conflict between them, the provisions in the valid Power of Attorney for Health Care will take precedence over those in the Wisconsin F 00060 form. It's important to ensure that the instructions in both documents are consistent to avoid any confusion about your healthcare wishes.
How can I obtain a Wisconsin F 00060 form?
You can request up to four free copies of the Declaration to Health Care Professionals by sending a stamped, self-addressed, business-size envelope to the specified address. The form is also available on the Wisconsin Department of Health Services website. Additional copies can be made as needed.
Filling out the Wisconsin F 00060 form, or the Declaration to Health Care Professionals (Living Will), is a crucial step in planning for future health care decisions. However, individuals often make mistakes during this process, which can lead to confusion or unintended consequences. Understanding these common errors can help ensure that your living will reflects your true intentions regarding life-sustaining treatment.
Not reading the form thoroughly: One of the most common mistakes is not reading both sides of the form carefully before completing and signing it. The form includes important definitions and instructions that are essential for making informed decisions about your health care preferences.
Incorrectly handling the feeding tube and life-sustaining procedures sections: The form requires clear directions regarding the use of feeding tubes and life-sustaining procedures in cases of terminal condition or persistent vegetative state. A frequent error is failing to check the appropriate boxes to indicate your preferences, which could result in the automatic use of these interventions.
Choosing invalid witnesses: The form specifies that witnesses must be at least 18 years of age and cannot be related to you by blood, marriage, or adoption. Additionally, witnesses should not be financially responsible for your health care, have claims on any portion of your estate, be your health care provider, or an employee of a health care facility where you are a patient. Overlooking these restrictions can invalidate the witnesses and, by extension, the living will itself.
Not properly distributing copies of the signed form: After signing the form, it's crucial to keep the original in a safe, easily accessible place and inform close relatives and friends about its existence and location. Failing to file a copy with your physician, physician assistant, or advanced practice registered nurse means they might not be aware of your living will, which could prevent your wishes from being honored. Additionally, although not required, filing the document for safekeeping with the Register in Probate of your county of residence adds an extra layer of security.
By avoiding these mistakes, you can help ensure that your health care wishes are understood and respected in critical moments. The Wisconsin F 00060 form is a powerful tool for expressing your health care preferences and provides peace of mind knowing that decisions about your health care will align with your values and desires.
The State of Wisconsin Department of Health Services provides the essential Declaration to Health Care Professionals (Living Will) Form F 00060, allowing individuals to express their wishes concerning life-sustaining procedures and feeding tubes in terminal conditions or persistent vegetative states. This critical document is often accompanied by various other forms and documents to ensure that a person's health care and estate planning are comprehensive and clearly communicated. Below are nine other forms and documents frequently used alongside Form F 00060:
Ensuring that these forms are completed and accessible can provide peace of mind to individuals and their families, making it easier to honor their wishes during difficult times. Each form plays a vital role in a comprehensive approach to end-of-life planning, covering health care decisions, estate planning, and personal wishes concerning body disposition and organ donation.
The Power of Attorney for Health Care form shares similarities with the Wisconsin F 00060 form in its function to provide instructions for medical care in the event that the individual is unable to communicate their wishes directly. Like the Declaration to Health Care Professionals, the Power of Attorney for Health Care designates someone else to make decisions on behalf of the patient, focusing on a broader range of health decisions beyond the life-sustaining treatment addressed in the Living Will.
A Do Not Resuscitate (DNR) Order is another document with purposes that align closely with the Living Will. However, while the Living Will specifies preferences for a variety of life-sustaining procedures or feeding tubes, a DNR order specifically directs medical personnel not to perform CPR if the patient's breathing or heart stops. Both documents guide healthcare professionals on how to proceed in critical situations when the patient cannot make their wishes known.
The Health Insurance Portability and Accountability Act (HIPAA) Release Form also shares a key feature with the Living Will by involving the patient's healthcare information. Though its main purpose is to allow the sharing of an individual's health information with designated people or entities, it is similar to the Living Will in that it requires thoughtful consideration about who should have access to sensitive information and under what circumstances.
An Advance Healthcare Directive is a broader term that encompasses the Living Will but also includes elements found in other documents like a Power of Attorney for Health Care. It outlines a person’s healthcare preferences and may appoint a healthcare agent to make decisions. This similarity lies in its comprehensive approach to planning for medical care, reflecting the intent behind the F 00060 form to ensure respect for the patient's healthcare wishes.
The Five Wishes Document, although not legally recognized in all states, offers a more personal approach to living wills and healthcare directives. It addresses medical, personal, emotional, and spiritual wishes, making it akin to the Living Will in its attempt to cover all aspects of end-of-life care but going further by incorporating personal values and desires into the planning.
A Mental Health Advance Directive provides instructions regarding mental health care, in case the individual cannot make decisions due to a mental health crisis. While it specifically focuses on mental health treatment preferences, it shares the Living Will's goal of ensuring the individual’s healthcare preferences are known and considered, even when they cannot express these wishes themselves.
A POLST form (Physician Orders for Life-Sustaining Treatment) is a medical order that outlines specific wishes about certain medical treatments. Similar to a Living Will, the POLST is intended for seriously ill patients and addresses their preferences about life-sustaining treatments, but it is completed and signed by a healthcare professional based on the patient’s wishes.
The Organ Donor Registry Form signifies a person's wish to donate their organs upon death. While its focus is different, it relates to the Wisconsin F 00060 form in its purpose of recording a person’s healthcare-related wishes in advance. Both documents tackle scenarios where the individual is not able to communicate but has important directions about their body's treatment pre and post-death.
Finally, the Appointment of Health Care Agent form shares the purpose of designating someone to make health decisions on the individual's behalf, paralleling the section in the Declaration that could supersede in certain aspects if there's a Power of Attorney for Health Care in place. It’s similar in ensuring decisions are made according to the person's wishes when they're incapacitated.
Do read the entire Wisconsin F 00060 form and understand the provisions related to life-sustaining procedures and feeding tubes before signing. This helps ensure your decisions are accurately reflected.
Don't rush through the form without fully understanding the implications of your choices, especially regarding terminal conditions or persistent vegetative states.
Do ensure witnesses are at least 18 years old, not related to you by blood, marriage, or adoption, and not financially responsible for your healthcare. This step is crucial for the form's validity.
Don't choose witnesses who are healthcare providers currently serving you, employees of such providers (except chaplains or social workers), or anyone entitled to any part of your estate.
Do keep the original signed document in a safe, easily accessible place, and inform relatives and friends of its existence and location.
Don't fail to notify your attending physician, physician assistant, or advanced practice registered nurse about the declaration. Their awareness and inclusion of it in your medical records are vital.
Do consider filing the document with the Register in Probate in your county for safekeeping, though this is not a requirement. Remember, there is a small fee associated with this filing.
Don't disregard the necessity of making additional copies of the living will. Providing copies to key healthcare providers and loved ones ensures that your wishes are known and accessible when needed.
Do keep in mind that the desires of a competent qualified patient override the declaration at any time. Staying informed and current on the choices made in your living will allows for appropriate modifications as your circumstances or wishes change.
Discussing the Wisconsin F 00060 form, commonly known as the Declaration to Health Care Professionals or the Living Will, uncovers several misconceptions that might cloud its purpose and use. Below, four commonly held misunderstandings are explained to clarify how this important document functions within the realm of health care and patient rights in Wisconsin.
One major misconception is that the Wisconsin F 00060 form allows individuals to make broad health care decisions beyond refusing or requesting the withdrawal of life-sustaining procedures and feeding tubes in specific conditions. In truth, the scope of this document is more focused. It addresses life-sustaining measures and feeding tubes in instances where a person is in a terminal condition or persistent vegetative state. It's a critical tool for expressing one's wishes in these scenarios but doesn't cover all possible medical interventions or treatments.
Another often misunderstood aspect concerns the requirements for witnesses. The document must indeed be signed in the presence of two witnesses, but not just anyone can fulfill this role. Witnesses must be adults who are not related to the signer by blood, marriage, or adoption, do not stand to gain financially from the person's death, and are not directly financially responsible for the signer's healthcare. This stipulation ensures that the witnesses are objective and have no conflict of interest.
Some may mistakenly believe that once a Living Will is signed, its directives are set in stone. However, the document honors flexibility according to changing desires or circumstances. A declarant can revoke their Living Will at any time, using various methods such as destruction of the document, a written revocation, a verbal statement, or by completing a new Declaration. This adaptability ensures that individuals can align their end-of-life care with their current wishes.
There's a common belief that a Living Will negates the need for a Power of Attorney (POA) for Health Care. While both documents relate to medical decisions and treatments, they serve different purposes. A Living Will provides specific directives about life-sustaining treatment in terminal conditions or persistent vegetative states. In contrast, a POA for Health Care allows you to appoint an agent to make broader health care decisions on your behalf if you're unable to do so. Moreover, if there's a conflict between the two, the provisions in a valid Power of Attorney for Health Care supersede any directly conflicting provisions in a valid Declaration to Health Care Professionals. Thus, having both documents can provide a comprehensive approach to planning for future health care decisions.
Understanding these misconceptions clarifies the purpose, use, and flexibility of the Wisconsin F 00060 form, enabling individuals to make informed decisions about their end-of-life care preferences.
The Wisconsin F 00060 form, also known as the Declaration to Health Care Professionals or Living Will, is a vital document for adults in Wisconsin who wish to express their preferences regarding life-sustaining procedures and feeding tubes if they find themselves in a terminal condition or persistent vegetative state. Understanding the intricacies and implications of this form can provide peace of mind and ensure that one's healthcare wishes are known and considered. Here are five key takeaways about filling out and using the Wisconsin F 00060 form:
Understanding these key aspects of the Wisconsin F 00060 form empowers individuals to make informed decisions about their healthcare preferences and provides a clear directive to healthcare professionals in critical moments.
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