-Guide your health care in a way that fits with your beliefs, values and goals.
-Make sure your wishes are followed even if you are not able to speak for yourself.
-Support relationships between you, your family and your health care providers.
-Lift the stress of difficult decision making on family or friends.
Power of Attorney for Health Care is a document that allows you to pick one or more persons to make health care decisions for you if you are unable to make those decisions for yourself. This person is known as your health care agent. The document offers guidance to your health care agent(s) and health care providers(s) about your treatment preference so they can best honor your wishes.
Power of Attorney for Health Care (English)
Power of Attorney for Health Care (Spanish)
Power of Attorney for Health Care (Hmong)
Power of Attorney for Health Care (Russian)
We also recognize that it may be difficult to know what to discuss with your health care agent or whom to choose as a healthcare agent. Ministry offers a set of questionnaires that may be helpful for you. We hope that when you compare your answers to those of your agent, you will have a better idea of topics to discuss to aid in your decision-making.
Questionnaire – For Patient (English)
Questionnaire – For Patient (Spanish)
And your health care agent:
Questionnaire - Health Care Agent (English)
Questionnaire - Health Care Agent (Spanish)
Living Will/Declaration to Physicians is document that gives instructions to health care providers about the type of life sustaining care you would want only in the event of a terminal condition or persistent vegetative state.
If the Power of Attorney for Health Care document is not the preferred document for you, use the Wisconsin State Living Will (Declaration to Physicians). Please note: this form does not allow you to legally designate a person to make healthcare decisions for you if you are not able.
Community Do-Not-Resuscitate (DNR) Order and Bracelet is an order and legal document issued by a physician that communicates to emergency medical technicians (EMTs), first responders or emergency department staff that a qualified patient has decided he/she does not wish to be resuscitated. A qualified patient is an adult who has a terminal condition or would suffer pain or harm from resuscitation or for whom resuscitation would be unsuccessful. The form must be signed by the patient (or guardian or POAHC agent) and the physician AND a bracelet with must be worn by the patient to signify to emergency personnel they do not want resuscitation.
For more information, obtain a form by clicking on the link below:
Wisconsin Do Not Resuscitate Information
Wisconsin Do Not Resuscitate Order form (pdf)
Medic Alert Application Form
Per Wisconsin Statute ch. 154, Medic Alert® is the only State of Wisconsin authorized vendor for a permanent-type metal bracelet. The metal DNR bracelet is purchased, for a cost, through Medic Alert®. Any person who chooses to have a metal bracelet but is not able to afford the fees can apply for a sponsored membership and metal DNR bracelet. For additional information on cost and fee information for a metal bracelet, please visit the Medic Alert© website.
Demographic Change Form
If you or your agents move or change phone numbers, please use the Demographic Change Form to update the information. Once completed please give a copy to your providers and or your local hospital.
Wisconsin Catholic Conference Addendum to POAHC Form
In March of 2014, the Wisconsin Catholic Conference offered an addendum for a patient’s advance directive from the Catholic perspective. It is important to note that this addendum is merely that, an addendum. It is not an advance directive itself. This addendum is designed for use with a Power for Attorney Health Care document like the one found on this web page. We share in the Bishops’ reminder that vital conversations need to occur between loved ones and that no tool can replace that.
Catholic Health Association Advance Directives Booklet: A Guide to Help You Express your Health Care Wishes
Now and at the Hour of Our Death – Wisconsin Catholic Conference
UW Madison Body and Tissue Donation information
Medical College of Wisconsin Body Donation information
Heart Rhythm Society Position on Deactivation of Implantable Cardiac Devices
Ethical and Religious Directives for Catholic Health Care Services