Iowa Medical Society
www.iowamedical.org

Advance Directives

An "advance directive" allows adult individuals to direct their medical care in the event they become incompetent and are unable to make medical decisions for themselves. Advance directive statutes define those medical situations in which individuals can direct their future care and steps they need to take to best assure legal recognition of their advance directives.

Iowa statutory law provides for three types of advance directives:

  1. Life-Sustaining Procedures Act (living will);
  2. Durable Power for Health Care Decision Making; and
  3. Out-of-Hospital Do-Not-Resuscitate Orders (OOH-DNR).

There are similarities and distinctions among these three types of directives. To enjoy the statutory immunities afforded to physicians under Iowa's advance directive laws, physicians must be aware of and adhere to the particulars of each statute.

Schiavo case raises awareness [+/-]

The plight of all persons involved in the Terri Schiavo case once again brings to the forefront the desirability of advance directives and the right of individuals to execute them under state law.

Iowa's Life Sustaining Procedures Act, Iowa Code chapter 144A, gives competent adults the legal right to execute a living will declaration stating the patient's desire that life-sustaining treatment be withheld or withdrawn in the event the patient is in a terminal medical condition and unable to direct his or her own care. "Life-sustaining procedure" is medical treatment that uses mechanical or artificial means to sustain a spontaneous vital function and that, when applied to a patient in a terminal condition, serves only to prolong the dying process. "Life-sustaining procedure" includes nutrition and hydration provided intravenously but, again, only if this form of nutritional support serves to prolong the dying process for a terminal patient. Upon withdrawal of life sustaining care from a terminal patient, comfort care and treatment to alleviate pain must continue. "Terminal" includes patients deemed by their attending physicians to be in a state of permanent unconsciousness from which to a reasonable degree of medical certainty, there can be no recovery.

The Life-Sustaining Procedures Act also provides a legally-sanctioned process for withholding or withdrawing life-sustaining care from a terminal patient who cannot speak for himself or herself and who does not have a living will. That decision ultimately is made by a substitute decision maker in the order of priority set forth in the Act.

Iowa's Durable Power of Attorney for Health Care, Iowa Code chapter 144B, gives individual competent adults the legal right to name an agent or "attorney in fact" to make medical decisions on the individual's behalf in the event the individual is unable to direct his or her own medical care. The named attorney in fact has precedence in decision making over any other person that might otherwise stand in the shoes of the patient who cannot speak for himself or herself. The attorney in fact is to make decisions consistent with the patient's wishes or, if unknown, the patient's best interests in light of the patient's medical condition and prognosis.

Information regarding the requirements of both of these laws is set forth in a pamphlet developed jointly by the Iowa Medical Society, the Iowa Hospital Association, and the Iowa State Bar Association. The pamphlet, "Advance Directives for Health Care - Deciding Today About Your Care in the Future," may be ordered on line (link) for a cost of 17 cents per pamphlet plus and mailing costs. Many hospitals and medical practices purchase these pamphlets in bulk for distribution to their patients. Medical practices and their patients also may be directed to the Iowa State Bar Association's web site to obtain basic information about advance directives under Iowa law and forms for executing a life-sustaining procedures living will declaration and a durable power of attorney for health care.

Life-Sustaining Procedures (Living Will) Act [+/-]

Iowa Code chapter 144A

A living will declaration under Iowa's Life Sustaining Procedures Act allows an adult individual to direct future decisions regarding the withholding or withdrawal of life-sustaining procedures in the event the individual is in a terminal medical condition and is not competent. The definitions of the law are critical. The statute specifies processes for executing a living will declaration and for withholding or withdrawing life sustaining procedures consistent with a patient's declaration. A process also is provided for withholding or withdrawing life-sustaining procedures from a patient in a terminal condition where the patient does not have a living will. Immunities for acting consistent with the statute are provided.

Go to http://www.legis.state.ia.us/ and click on "Iowa Law."

Durable Power for Health Care Decision Making [+/-]

Iowa Code chapter 144B

A durable power of attorney for health care is executed by an adult individual for purposes of authorizing another individual, called the "attorney in fact," to make health care decisions on the individual's behalf in the event the individual, called "the principal," is unable, in the judgment of the attending physician, to make health care decisions. Processes and procedures for executing and relying upon a durable power for health care decisions are set forth in the statute. Immunities for acting consistent with the statute are provided.

Go to http://www.legis.state.ia.us/ and click on "Iowa Law."

Out-of-Hospital Do-Not-Resuscitate Order [+/-]

Iowa Code chapter 144A, particularly section 144A.7A
Iowa Administrative Code chapter 641-142

This chapter allows emergency care providers and others in settings outside the hospital to rely upon a physician-issued do-not-resuscitate (DNR) order for an adult individual in a terminal condition. Rules of the Iowa Department of Public Health further detail the out-of-hospital do-not-resuscitate (OOH-DNR) process. Immunities for acting consistent with the statute and rules are provided.

Go to http://www.legis.state.ia.us/ and click on "Iowa Law" and search the Iowa Code for the statute and the Iowa Administrative Code for the rules.

Advance Directives - Pamphlet [+/-]

In response to the federal Patient Self-Determination Act of 1990, which seeks to inform individuals of their rights under state law to execute advance directives, the Iowa Hospital Association, the Iowa Medical Society and the Iowa State Bar Association jointly developed an informational pamphlet entitled "Advance Directives for Health Care - Deciding Today About Your Care in the Future."

Contact at the Iowa Medical Society to receive the pamphlet. There is a small charge to cover printing costs.

Forms [+/-]

The Iowa State Bar Association has developed forms that individuals may use to execute a living will or a durable power of attorney for health care.

Go to http://www.iowabar.org/ and click on "Public Resources - Forms."