[Health Care Directive] Iowa

Using these Materials

BEFORE YOU BEGIN

1. Check to be sure that you have the materials for each state in which you may receive health care.

2. These materials include:
   • Instructions for preparing your advance directive, please read all the instructions.
   • Your state-specific advance directive forms, which are the pages with the gray instruction bar on the left side.

ACTION STEPS

1. You may want to photocopy or print a second set of these forms before you start so you will have a clean copy if you need to start over.

2. When you begin to fill out the forms, refer to the gray instruction bars — they will guide you through the process.

3. Talk with your family, friends, and physicians about your advance Be sure the person you appoint to make decisions on your behalf understands your wishes.

4. Once the form is completed and signed, photocopy the form and give it to the person you have appointed to make decisions on your behalf, your family, friends, health care providers and/or faith leaders so that the form is available in the event of an emergency.

5. You may also want to save a copy of your form in an online personal health records application, program, or service that allows you to share your medical documents with your physicians, family, and others who you want to take an active role in your advance care planning.

Introduction to Your Iowa Advance Directive

This packet contains a legal document that protects your right to refuse medical treatment you do not want, or to request treatment you do want, in the event you lose the ability to make decisions yourself. You may complete Part One, Part Two, or both, depending on your advance planning needs.

Part One. The IowaDurablePowerof Attorney for Health Care lets you name someone to make decisions about your medical care — including decisions about life- sustaining procedures — if you can no longer speak for yourself. The Durable Power of Attorney for Health Care is especially useful because it appoints someone to speak for you any time you are unable to make your own medical decisions, not only at the end of life. The person you choose is called your “agent.” You may also hear the term “attorney-in-fact.”

Your Iowa Durable Power of Attorney goes into effect when your doctor determines that you are no longer able to make or communicate your health-care decisions.

You may also appoint a designee to make choices regarding the final disposition of your remains.

Part Two. The IowaDeclaration is your state’s living will. It lets you state your wish to have life-sustaining procedures withheld or withdrawn in the event that you develop a terminal condition and can no longer make your own medical decisions. If this is not your wish, you should not fill out part two.

Your Iowa Declaration goes into effect when your doctor determines that you have a terminal condition and can no longer make your own health-care decisions or that you are permanently unconscious.

Part Three contains the signature and witness provisions so that your document will be effective.

Following the advance directive form is an Iowa Organ Donation Form.

These forms do not expressly address mental illness. If you would like to make advance care plans involving mental illness, you should talk to your physician and an attorney about a durable power of attorney tailored to your needs.

Note: These documents will be legally binding only if the person completing them is a competent adult (at least 18 years old).

Completing Your Iowa Advance Directive Form How do I make my Iowa Advance Directive legal?

The law requires that you sign and date your advance directive. You must also have it witnessed in one of two ways:

1. Have your signature witnessed by a notary public, OR

2. Sign your document, or direct another to sign it, in the presence of two These witnesses cannot be:
   • your doctor or other treating health-care provider,
   • an employee of your treating health-care provider,
   • the person you appointed as your agent, or
   • an individual who is less than 18 years of age.

At least one of your witnesses must be a person who is not related to you by blood, marriage, or adoption within the third degree of consanguinity. This means that your agent must be more distantly related to you by blood or adoption than your uncles, aunts, nephews, nieces, great-grandparents, and great-grandchildren or by marriage than your step uncles, step aunts, step nephews, step nieces, step great grandparents, and step great-grandchildren.

Whom should I appoint as my agent?

Your agent is the person you appoint to make decisions about your medical care if you become unable to make those decisions yourself. Your agent may be a family member or a close friend whom you trust to make serious decisions. The person you name as your agent should clearly understand your wishes and be willing to accept the responsibility of making medical decisions for you.

The person you appoint as your agent cannot be:

• your doctor or other treating health-care provider, or
• an employee of your treating health-care provider, unless he or she is related to you by blood, marriage, or adoption within the third degree of consanguinity.

You can appoint a second person as your alternate agent. The alternate will step in if the first person you name as an agent is unable, unwilling, or unavailable to act for you.

Should I add personal instructions to my Iowa Advance Directive?

One of the strongest reasons for naming an agent is to have someone who can respond flexibly as your medical situation changes and deal with situations that you did not foresee. If you add instructions to this document it may help your agent carry out your wishes, but be careful that you do not unintentionally restrict your agent’s power to act in your best interest. In any event, be sure to talk with your agent about your future medical care and describe what you consider to be an acceptable “quality of life.”

What if I change my mind?

You may revoke your Durable Power of Attorney for Health Care or Declaration at any time and in any manner, regardless of your mental or physical condition. Your revocation becomes effective when you, or someone else, communicate this revocation to your attending physician.

If you appoint your spouse as your agent and your marriage ends, your agent’s power is automatically revoked.

If you decide to declare a designee to make choices regarding the final disposition of your remains, you may only revoke that power in a signed writing.

IOWA ADVANCE DIRECTIVE – PAGE 1 OF 5

Part One: Durable Power of Attorney for Health Care

as my attorney-in-fact (my “agent”) and give to my agent the power to make health-care decisions for me. This power exists only when I am unable, in the judgment of my attending physician, to make those health-care decisions. The attorney in fact must act consistently with my desires as stated in this document or otherwise made known.

In the event the person I designate above is unable, unwilling or unavailable to act as my agent, I hereby designate

IOWA ADVANCE DIRECTIVE – PAGE 2 OF 5

Part One: Durable Power of Attorney for Health Care (continued)

Except as otherwise specified in this document, this document gives my agent the power, where otherwise consistent with the law of this state, to consent to my physician not giving health care or stopping health care which is necessary to keep me alive.

This document gives my agent power to make health-care decisions on my behalf, including to consent, to refuse to consent, or to withdraw consent to the provision of any care, treatment, service, or procedure to maintain, diagnose, or treat a physical or mental condition. This power is subject to any statement of my desires and any limitations included in this document.

My agent has the right to examine my medical records and to consent to disclosure of such records.

Final Disposition Declaration (optional)

as my designee under the Iowa Final Disposition Act. My designee shall have the sole responsibility for making decisions concerning the final disposition of my remains and the ceremonies to be performed after my death. This final disposition declaration hereby revokes all prior final disposition declarations. This designation becomes effective upon my death.

My designee shall act in a manner that is reasonable under the circumstances.

I may revoke or amend this final disposition declaration at any time. I agree that a third party (such as a funeral or cremation establishment, funeral director, or cemetery) who receives a copy of this final disposition declaration may act in reliance on it. Revocation of this final disposition declaration is not effective as to a third party until the third party receives notice of the revocation. My estate shall indemnify my designee and any third party for costs incurred by them or claims arising against them as a result of their good faith reliance on this declaration.

IOWA ADVANCE DIRECTIVE — PAGE 3 OF 5

Part One: Durable Power of Attorney for Health Care (continued)

Optional instructions:

IOWA ADVANCE DIRECTIVE — PAGE 4 OF 5

Part Two: Declaration

If I should have an incurable or irreversible condition that will result either in death within a relatively short period of time or a state of permanent unconsciousness from which, to a reasonable degree of medical certainty, there can be no recovery, it is my desire that my life not be prolonged by the administration of life-sustaining procedures. If I am unable to participate in my health-care decisions, I direct my attending physician to withhold or withdraw life-sustaining procedures that merely prolong the dying process and are not necessary to my comfort or freedom from pain.

Additional, specific directions (if any):

IOWA ADVANCE DIRECTIVE — PAGE 5 OF 5

Part Three: Execution

The declarant is known to me and voluntarily signed this document in my presence.

– OR –

Alternative No. 2, Acknowledgment by Notary Public:

IOWA ORGAN DONATION FORM – PAGE 1 OF 1

Initial the line next to the statement below that best reflects your wishes. You do not have to initial any of the statements. If you do not initial any of the statements, your attorney-in-fact, guardian, or other agent, or your family may have the authority to make a gift of all or part of your body under Iowa law.

You Have Filled Out Your Health Care Directive, Now What?

1. Your Iowa Advance Directive is an important legal document. Keep the original signed document in a secure but accessible Do not put the original document in a safe deposit box or any other security box that would keep others from having access to it.

2. Give photocopies of the signed original to your agent and alternate agent, doctor(s), family, close friends, clergy, and anyone else who might become involved in your health If you enter a nursing home or hospital, have photocopies of your document placed in your medical records.

3. Be sure to talk to your agent(s), doctor(s), clergy, family, and friends about your wishes concerning medical treatment. Discuss your wishes with them often, particularly if your medical condition changes.

4. You may also want to save a copy of your form in an online personal health records application, program, or service that allows you to share your medical documents with your physicians, family, and others who you want to take an active role in your advance care planning.

5. If you want to make changes to your documents after they have been signed and witnessed, you must complete a new document.

6. Remember, you can always revoke your Iowa document.

7. Be aware that your Iowa document will not be effective in the event of a medical Ambulance and hospital emergency department personnel are required to provide cardiopulmonary resuscitation (CPR) unless they are given a separate directive that states otherwise. These directives called “prehospital medical care directives” or “do not resuscitate orders” are designed for people whose poor health gives them little chance of benefiting from CPR. These directives instruct ambulance and hospital emergency personnel not to attempt CPR if your heart or breathing should stop.

Iowa authorizes an “Out-of-Hospital Do-Not-Resuscitate Order.” We suggest you speak to your physician if you are interested in obtaining one.