In Iowa, there are two methods for advance directives to allow planning for health care decisions.

Living Wills

A living will (called in the Iowa Code as a Declaration relating to use life-sustaining procedures) is covered in Iowa Code section 144A.3 (2009).

A Living Will informs medical personnel that you do not want certain life-sustaining procedures if you are in a terminal condition (which includes a persistent vegetative state and a coma) and unable to decide for yourself. It is important to inform your physician of your desire to deny any medical procedures, treatments, or interventions that use mechanical or artificial means to sustain, restore or supplant a spontaneous vital function, and would serve only to prolong the dying process.

Life Sustaining procedures refer to the utilization of mechanical or artificial means to sustain, restore, or supplement a spontaneous function that would serve only to prolong the dying process.  Life sustaining procedures include nutrition and hydration only when it is to be provided parenterally or through intubation (intravenously or by tube).

Terminal condition means an incurable or irreversible condition that without life-sustaining procedure will, in the opinion of the attending physician, result in death within a relatively short period of time or a state of permanent uncounsciousness from which, to a reasonable degree of medical certainty, there can be no recovery.

If there is no living will, the family can make the decision in accordance with the Family Consent Law. Decisions are made in the following order: Attorney-in-fact under a Durable Power of Attorney for Health Care, Guardian, Spouse, Adult child (if more than one child, then a majority of the children), parent or parents, adult sibling. If you do not believe that a spouse could make the decision at the crucial time, you might want to appoint an attorney-in-fact to make the decision.

Physicians determine whether the condition is a terminal condition. The attending physician makes the determination and must be confirmed by another physician. The conclusions must be noted in the written medical record. If the attending physician will not honor the Living Will, then by Iowa Code, the physician must transfer the patient. Iowa Code section 144A.8 (2009).  There is a presumption that the living will is valid unless the physician has actual notice to the contrary.  It is the declarant's responsibility to provide the attending physican with the declaration.

Requirements:

    1. Declarant must be competent- which is assumed in Iowa unless a guardian or conservator has been appointed.

    2. Capacity- over age 18

    3. Signed by Declarant or someone else at the direction of the declarant

    4. Signed in front of 2 witnesses or a notary (witnesses must be at least 18 years old and cannot be a health care provider or employee of a health care provider attending the declarant on the date of execution.

    5. Must be in writing- no verbal living wills

    6. Dated when signed

Revocation:

Revocation can be conducted by the declarant in writing or orally. This revocation needs to be conveyed to the attending physician, and other personnel who have knowledge of the living will.


Form:

A suggested form is listed in Iowa Code section 144A.3(5) (2009).

Emergency Personnel:

EMS personnel must attempt to resuscitate even if a living will has been signed. However, Iowa allows an Out of Hospital DNR which allows a health care provider to withhold or withdraw resuscitation outside a hospital. The attending physician issues the order (prescribed under Iowa Code section 144A.7A (2009)). The patient should then obtain a necklace or bracelet which identifies the order. However the Out of Hospital DNR only applies to a terminal condition. Information on bracelets can be obtained from Department of Public Health, Bureau of EMS, 800-728-3367, www.idph.state.ia.us/EMS .

Do Not Resuscitate (DNR):  (Iowa Code section 144A.7A)

A DNR can only be written by the doctor with permission of the patient, his/her attorney-in-fact under a Durable Power of Attorney for Health Care, or his/her family. A Guardian must obtain permission of the court to agree to a DNR.

Unless there is a DNR on file, medical personnel will attempt life saving procedures.  If there is any doubt about the validity of a DNR, the health care provider must provide necessary and appropriate resuscitation.  A health care provider must document compliance or noncompliance with the DNR and the reasons for not complying with the order.  Willful violation of a DNR can constitute a serious misdemeanor.  Iowa Code section 144A.10(1).  Falsification of a DNR or concealing revocation is also a serious misdemeanor.  Iowa Code section 144A.10(2).

A DNR is only effective in the same facility in which it is written. If the patient is moved to another facility, another DNR must be obtained. This may change soon in Iowa, as a test is being conducted which allows the DNR to follow the patient, and is expected to be written into Iowa law.

The personal wishes of family members or others who are not authorized to act on the patient's behalf shall not supersede a valid DNR. Compliance with a DNR does not constitute homicide or suicide, and does not affect life insurance.  DNRs cannot be required by insurance or medical personnel.

Durable Power of Attorney for Health Care

Durable Power of Attorney for Health Care procedures are covered under Iowa Code Chapter 144B (2009).

A Durable Power of Attorney for Health Care allows another person to make medical and health care decisions for you (the principal) when you are not capable of making your own decisions. The power of attorney must be signed when you still have the ability to make decisions (when you are competent). In Iowa, a person is considered competent by law, unless a guardian or conservator has been appointed on your behalf. If a power of attorney has been signed prior to a guardian or conservator being appointed, the attorney in fact (person who is granted the power to act) has priority over the guardian.

The Power of Attorney for Health Care only covers health care decisions, but can be combined with a Power of Attorney for financial decisions in a joint document.

Requirements for a Power of Attorney

    1. The Principal must have capacity (over 18 years old) and be competent (assumed in Iowa unless a guardian or conservator have been appointed for the ward (who would be the principal).

    2. Must be in writing. The writing can be handwritten, typed, or a form, but cannot be oral.

    3. Must contain:

            a. Name of person authorized to act as the attorney-in-fact (the person who has the authority to act on your behalf). It is advisable to talk to the attorney-in-fact in advance to ensure that he/she will actually serve. It is also advisable to designate numbered alternates in case the primary attorney-in-fact cannot serve. Otherwise, the document would be void if no one will serve. Alternates should be numbered otherwise all alternates would have to be unanimous in their decision as all would serve as the attorney-in-fact. The attorney-in-fact cannot be:

                    i. A health care provider attending the principal

                    ii. An employee of a health care provider unless the individual is related to the principal.

            b. Powers and responsibilities given to the attorney-in-fact

            c. Principal’s signature

            d. Date signed

            e. Signed in the presence of a notary or two witnesses.

                 i. Witnesses cannot be:

                        1. Health care provider who is attending the principal on the date of signing

                        2. An Employee of a health care provider

                        3. Attorney-in-fact (or one of the alternates in case, the primary cannot serve)

                        4. Under the age of 18

                        5. At least one should not be a relative

                ii. A notary may be one of the above however

4. Questions to be asked

    a. Time frame- effective immediately or only upon incapacity?

    b. Authority and responsibilities of the attorney-in-fact? (Be specific including the following)

            i. Authority to refuse or decline life-sustaining procedures?

            ii. Admit principal to long-term care facility?

            iii. Admit principal to hospice?

            iv. Order invasive diagnostic tests?

            v. Order dental surgery?

            vi. Withhold or withdraw life-sustaining procedures and under what conditions?

            vii. Consent to a DNR (Do Not Resuscitate) request

            viii. Consent to mechanical breathing

    c. Who will be the attorney-in-fact?

    d. Who will be the alternates for the primary attorney-in-fact?

5. Copies should be provided to:

    a. Family members and close friends. Should be discussed when providing copies

    b. The attorney-in-fact and all alternates

    c. The Principal’s doctor and health care facilities

    d. Principal should keep the original. The original should not be kept in a safety deposit box, and it should be well known as to its location.

6. Revocation- A Power of Attorney can be revoked at any time, regardless of capacity, orally or in writing. All persons given a copy should be notified, especially medical personnel. A Power of Attorney terminates upon disability or incapacity unless it is designated as a durable power which is terminated when revoked or upon death.

7. Copies of a form for a Durable Power of Attorney are available at:

    a. The Department of Elder Affairs www.aging.iowa.gov

    b. Iowa State Bar Association www.iowabar.org

    c.  A general form is provided under Iowa Code sction 144B.5 (1) (2009).

8.  Final Disposition Act.
A Durable Power of Attorney for Health Care may include a declaration that names a designee and alternates to make decisions concerning the principal's final disposition.  This may also be provided in a separate document. 

A declaration should be made, as the executor of a will may not be appointed immediately after death, and conservatorships and guardianships end at death of the ward.  Thus, it is possible that no one would be designated to determine final dispositions.  The Iowa Code Chapter 144C (2009) designates the order of persons to make the decision providing no one was declared to make the decision.  The order is:  Designee, surviving spouse, children, parents, grandchildren, siblings, grandparents, next degree of kinship, any person who knows the individual, and finally the county medical examiner.

The Final Disposition Act is covered in Iowa Code Chapter 144C (2009).

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