Senate Amendment to House File 2305 H-8377 Amend House File 2305, as amended, passed, and reprinted by 1 the House, as follows: 2 1. By striking everything after the enacting clause and 3 inserting: 4 < Section 1. Section 135J.1, Code 2026, is amended to read 5 as follows: 6 135J.1 Definitions. 7 For the purposes of this chapter unless otherwise defined: 8 1. “Attending physician provider ” means a physician licensed 9 pursuant to chapter 148 or a physician assistant licensed 10 pursuant to chapter 148C , physician assistant, or an advanced 11 registered nurse practitioner who is licensed in this state . 12 2. “Attorney in fact” means the same as defined in section 13 144B.1. 14 2. 3. “Core services” means physician services, nursing 15 services, medical social services, counseling services, 16 and volunteer services provided by volunteers . These core 17 services, as well as others deemed necessary by the hospice 18 in delivering safe and appropriate care to its case load the 19 hospice’s hospice patients , can be provided through either 20 direct or indirect arrangement by the hospice. 21 3. 4. “Department” means the department of inspections, 22 appeals, and licensing. 23 5. “Guardian” means the same as defined in section 633.3. 24 4. 6. “Hospice patient” or “patient” means a diagnosed 25 terminally ill person an individual with an anticipated life 26 expectancy of six months or less, as certified by the attending 27 physician provider , who , alone or in conjunction with a unit 28 of care as defined in subsection 9, has voluntarily requested 29 and received admission into the a hospice program. If the 30 patient is unable to request admission, a family member the 31 may voluntarily request and receive admission on the patient’s 32 behalf. An individual may make this request in conjunction 33 with a unit of care, the individual’s attorney in fact, 34 the individual’s guardian, or the majority of the guardians 35 -1- HF 2305.4069.S (1) 91 mb 1/ 15 #1.

if the individual has more than one guardian with equal 1 responsibilities appointed. 2 5. 7. “Hospice patient’s family” means the immediate kin of 3 the a hospice patient, including a spouse, parent, stepparent, 4 brother, sister, stepbrother, stepsister, child, or stepchild. 5 Additional relatives or individuals with significant personal 6 ties to the hospice patient may be included in the hospice 7 patient’s family. 8 6. 8. “Hospice program” means a centrally coordinated 9 program of home and inpatient care provided directly or through 10 an agreement under the direction of an identifiable hospice 11 administration providing palliative care directed at symptom 12 management and supportive medical and other health services 13 to terminally ill hospice patients and their families. A 14 licensed hospice program shall utilize a medically directed 15 interdisciplinary team and provide care to meet the physical, 16 emotional, social, spiritual, and other special needs which 17 are experienced during the final stages of illness, dying, and 18 bereavement. Hospice care shall be available twenty-four hours 19 a day, seven days a week. 20 7. 9. “Interdisciplinary team” means the hospice patient 21 and the hospice patient’s family, the attending physician 22 provider , and all of the following individuals trained to serve 23 with a licensed hospice program: 24 a. A licensed physician pursuant to chapter 148 . 25 b. A licensed registered nurse pursuant to chapter 152 . 26 c. An individual with at least a baccalaureate degree in the 27 field of social work providing medical-social services. 28 d. Trained hospice volunteers Volunteers . 29 e. As deemed appropriate by the hospice, physician 30 assistants, providers of special services including but not 31 limited to a spiritual counselor, a pharmacist pharmacists , or 32 professionals in the fields of mental health may be included 33 on the interdisciplinary team. 34 8. 10. “Palliative care” means specialized medical care 35 -2- HF 2305.4069.S (1) 91 mb 2/ 15

directed at managing symptoms experienced by the hospice 1 provided to a patient , as well as addressing related needs 2 of the patient and family as they experience the stress of 3 the dying process who has been diagnosed by the patient’s 4 attending provider with a serious illness. Palliative care is 5 stress and symptom management care, based on the needs of the 6 patient rather than the patient’s diagnosis, provided by an 7 interdisciplinary team . The intent of palliative care is to 8 enhance the quality of life for the hospice patient and family 9 unit , and is not treatment directed at cure of the terminal 10 illness . Palliative care may be provided at any stage of a 11 patient’s serious illness, regardless of the patient’s age, and 12 may be provided in conjunction with curative treatment for the 13 serious illness. 14 11. “Serious illness” means a health condition that 15 carries a high risk of mortality and either negatively impacts 16 an individual’s daily functioning or quality of life, or 17 excessively strains the individual’s caregivers. 18 12. “Terminal condition” means the same as defined in 19 section 144A.2. 20 9. 13. “Unit of care” means the a hospice patient and the a 21 hospice patient’s family within a hospice program. 22 10. 14. “Volunteer services” “Volunteer” means the services 23 provided by individuals an individual who have has successfully 24 completed a training program developed by a licensed hospice 25 program and who provides services . 26 Sec. 2. Section 135J.3, Code 2026, is amended to read as 27 follows: 28 135J.3 Basic requirements. 29 A licensed hospice program shall include: 30 1. A planned program of hospice care, the medical components 31 of which shall be under the direction of an attending physician 32 provider . 33 2. Centrally administered, coordinated hospice core 34 services provided in home, outpatient, or institutional 35 -3- HF 2305.4069.S (1) 91 mb 3/ 15

settings. 1 3. A mechanism that assures the rights of the patient and 2 family a unit of care . 3 4. Palliative care Symptom management provided to a hospice 4 patient and family unit of care under the direction of an 5 attending physician provider . 6 5. An interdisciplinary team which develops, implements, 7 and evaluates the hospice plan of care for the patient and 8 family a unit of care . 9 6. Bereavement services. 10 7. Accessible hospice care twenty-four hours a day, seven 11 days a week in all settings. 12 8. An ongoing system of quality assurance and utilization 13 review. 14 Sec. 3. NEW SECTION . 135J.3A Patient incapable of making a 15 treatment decision. 16 1. a. A request for admission and placement in a hospice 17 program for a patient who has a terminal condition, and 18 who is comatose, incompetent, or otherwise physically or 19 mentally incapable of communication, and who has not expressed 20 their desire for palliative care or a hospice program, may 21 be made by the patient’s attorney in fact or the patient’s 22 guardian. If the patient has more than one guardian with 23 equal responsibilities appointed, the decision agreed to by a 24 majority of guardians. If a majority consensus is not achieved 25 by the guardians, a court order shall be required. 26 b. If a patient does not have an attorney in fact or a 27 guardian, the request may be made by an individual, in the same 28 order of priority prescribed in section 144A.7, subsection 1, 29 paragraph “b” , who shall be guided by the express or implied 30 intentions of the patient and who is reasonably available, 31 willing, and competent to make a request. 32 2. This section shall not apply to a guardian appointed 33 under chapter 232D. 34 Sec. 4. Section 144A.2, Code 2026, is amended to read as 35 -4- HF 2305.4069.S (1) 91 mb 4/ 15

follows: 1 144A.2 Definitions. 2 Except as otherwise provided, as used in this chapter : 3 1. “Adult” means an individual eighteen years of age or 4 older. 5 2. “Advanced registered nurse practitioner” means the same as 6 defined in section 152.1. 7 2. 3. “Attending physician provider ” means the physician 8 selected by, or assigned to, the patient who has primary 9 responsibility for the treatment and care of the patient same 10 as defined in section 135J.1 . 11 3. 4. “Attending physician assistant” means the physician 12 assistant selected by, or assigned to, the patient who has 13 primary responsibility for the treatment and care of the 14 patient “Attorney in fact” means the same as defined in section 15 144B.1 . 16 5. “Close adult friend” means a friend of a patient to whom 17 all of the following apply: 18 a. The individual is at least eighteen years of age. 19 b. The individual has shown special care and concern for the 20 patient. 21 c. The individual maintains regular contact with the patient 22 and is familiar with the patient’s health, activities, and 23 beliefs. 24 d. The individual has provided an affidavit to the patient’s 25 attending provider that states that the individual is willing 26 and able to be involved in the patient’s care. 27 4. 6. “Declaration” means a document executed in accordance 28 with the requirements of section 144A.3 . 29 5. 7. “Department” means the department of health and human 30 services. 31 6. 8. “Emergency medical care provider” means emergency 32 medical care provider as defined in section 147A.1 . 33 7. 9. “Health care provider” means a person, including an 34 emergency medical care provider, who is licensed, certified, or 35 -5- HF 2305.4069.S (1) 91 mb 5/ 15

otherwise authorized or permitted by the law of this state to 1 administer health care in the ordinary course of business or in 2 the practice of a profession. 3 8. 10. “Hospital” means hospital as defined in section 4 135B.1 . 5 9. 11. a. “Life-sustaining procedure” means any medical 6 procedure, treatment, or intervention, including resuscitation, 7 which meets both of the following requirements: 8 (1) Utilizes mechanical or artificial means to sustain, 9 restore, or supplant a spontaneous vital function. 10 (2) When applied to a patient in a terminal condition, would 11 serve only to prolong the dying process. 12 b. “Life-sustaining procedure” does not include the 13 provision of nutrition or hydration except when required 14 to be provided parenterally or through intubation, or the 15 administration of medication or performance of any medical 16 procedure deemed necessary to provide comfort care or to 17 alleviate pain. 18 10. 12. “Out-of-hospital do-not-resuscitate order” means 19 a written order signed by a physician an attending provider , 20 executed in accordance with the requirements of section 21 144A.7A and issued consistent with this chapter , that directs 22 the withholding or withdrawal of resuscitation when an adult 23 patient in a terminal condition is outside the hospital. 24 11. 13. “Physician” means a person licensed to practice 25 medicine and surgery or osteopathic medicine and surgery in 26 this state. 27 12. 14. “Physician assistant” means a person licensed to 28 practice as a physician assistant in this state. 29 13. 15. “Qualified patient” means a patient who has 30 executed a declaration or an out-of-hospital do-not-resuscitate 31 order in accordance with this chapter and who has been 32 determined by the patient’s attending physician provider to be 33 in a terminal condition. 34 14. 16. “Resuscitation” means any medical intervention that 35 -6- HF 2305.4069.S (1) 91 mb 6/ 15

utilizes mechanical or artificial means to sustain, restore, 1 or supplant a spontaneous vital function, including but not 2 limited to chest compression, defibrillation, intubation, and 3 emergency drugs intended to alter cardiac function or otherwise 4 to sustain life. 5 15. 17. “Terminal condition” means an incurable or 6 irreversible condition that, without the administration 7 of life-sustaining procedures, will, in the opinion of 8 the attending physician provider , result in death within 9 a relatively short period of time or a state of permanent 10 unconsciousness from which, to a reasonable degree of medical 11 certainty, there can be no recovery. 12 Sec. 5. Section 144A.3, subsections 3 and 5, Code 2026, are 13 amended to read as follows: 14 3. It is the responsibility of the declarant to provide 15 the declarant’s attending physician or health care provider 16 with the declaration. An attending physician or health care 17 provider may presume, in the absence of actual notice to the 18 contrary, that the declaration complies with this chapter and 19 is valid. 20 5. A declaration executed pursuant to this chapter may, but 21 need not, be in the following form: 22 DECLARATION 23 If I should have an incurable or irreversible condition that 24 will result either in death within a relatively short period 25 of time or a state of permanent unconsciousness from which, 26 to a reasonable degree of medical certainty, there can be no 27 recovery, it is my desire that my life not be prolonged by 28 the administration of life-sustaining procedures. If I am 29 unable to participate in my health care decisions, I direct 30 my attending physician provider to withhold or withdraw 31 life-sustaining procedures that merely prolong the dying 32 process and are not necessary to my comfort or freedom from 33 pain. 34 Sec. 6. Section 144A.4, Code 2026, is amended to read as 35 -7- HF 2305.4069.S (1) 91 mb 7/ 15

follows: 1 144A.4 Revocation of declaration. 2 1. A declaration may be revoked at any time and in any 3 manner by which the declarant is able to communicate the 4 declarant’s intent to revoke, without regard to mental or 5 physical condition. A revocation is only effective as to the 6 attending physician or attending physician assistant provider 7 upon communication to such physician or physician assistant 8 attending provider by the declarant or by another to whom the 9 revocation was communicated. 10 2. The attending physician or attending physician assistant 11 provider shall make the revocation a part of the declarant’s 12 medical record. 13 Sec. 7. Section 144A.5, Code 2026, is amended to read as 14 follows: 15 144A.5 Determination of terminal condition. 16 When an attending physician provider who has been provided 17 with a declaration determines that the declarant is in a 18 terminal condition, this decision must be confirmed by another 19 physician , advanced registered nurse practitioner, or physician 20 assistant . The attending physician provider must record that 21 the determination in the declarant’s medical record. 22 Sec. 8. Section 144A.6, subsection 2, Code 2026, is amended 23 to read as follows: 24 2. The declaration of a qualified patient known to the 25 attending physician provider to be pregnant shall not be in 26 effect as long as the fetus could develop to the point of live 27 birth with continued application of life-sustaining procedures. 28 However, the provisions of this subsection do not impair any 29 existing rights or responsibilities that any person may have 30 in regard to the withholding or withdrawal of life-sustaining 31 procedures. 32 Sec. 9. Section 144A.7, subsections 1 and 2, Code 2026, are 33 amended to read as follows: 34 1. a. Life-sustaining procedures may be withheld or 35 -8- HF 2305.4069.S (1) 91 mb 8/ 15

withdrawn from a patient who is in a terminal condition and who 1 is comatose, incompetent, or otherwise physically or mentally 2 incapable of communication , and who has not made a declaration 3 in accordance with this chapter section 144A.3 if there is 4 consultation and written agreement for the withholding or the 5 withdrawal of life-sustaining procedures between the attending 6 physician provider, another physician, advanced registered 7 nurse practitioner, or physician assistant, and the patient’s 8 attorney in fact, the patient’s guardian appointed pursuant to 9 chapter 633, or the patient’s guardian who has obtained court 10 approval in accordance with section 232D.401, subsection 4, 11 paragraph “a” . If the patient has more than one guardian with 12 equal responsibilities appointed, the decision agreed to by 13 a majority of the guardians. If a majority consensus is not 14 achieved by the guardians, a court order shall be required. 15 b. If a patient does not have an attorney in fact, a 16 guardian appointed pursuant to chapter 633, or a guardian 17 who has obtained court approval in accordance with section 18 232D.401, subsection 4, paragraph “a” , the decision may be 19 made by any of the following individuals, who shall be guided 20 by the express or implied intentions of the patient, in the 21 following order of priority if no individual in a prior class 22 the previous priority is reasonably available, willing, and 23 competent to act make the decision : 24 a. The attorney in fact designated to make treatment 25 decisions for the patient should such person be diagnosed as 26 suffering from a terminal condition, if the designation is in 27 writing and complies with chapter 144B. 28 b. The guardian of the person of the patient if one has been 29 appointed, provided court approval is obtained in accordance 30 with section 232D.401, subsection 4, paragraph “a”, or section 31 633.635, subsection 3, paragraph “b” , subparagraph (1). This 32 paragraph does not require the appointment of a guardian in 33 order for a treatment decision to be made under this section. 34 c. (1) The patient’s spouse. 35 -9- HF 2305.4069.S (1) 91 mb 9/ 15

d. (2) An adult child of the patient or, if the patient 1 has more than one adult child, the decision agreed to by a 2 majority of the adult children who are reasonably available for 3 consultation with the patient’s attending provider . 4 e. (3) A parent of the patient , or parents if the patient 5 has more than one parent, the decision agreed to by both 6 parents if both are reasonably available for consultation with 7 the patient’s attending provider . 8 f. (4) An adult sibling of the patient or, if the patient 9 has more than one adult sibling, the decision agreed to by a 10 majority of the adult siblings who are reasonably available for 11 consultation with the patient’s attending provider . 12 (5) The decision agreed to by a majority of the patient’s 13 adult relatives, including but not limited to grandchildren, 14 grandparents, aunts, uncles, nieces, nephews, stepchildren, 15 stepparents, and stepsiblings who are reasonably available for 16 consultation with the patient’s attending provider. 17 (6) A close adult friend. 18 2. When a decision is made pursuant to this section to 19 withhold or withdraw life-sustaining procedures, there shall 20 be a witness present at the time of the consultation with the 21 patient’s attending provider when that the decision is made. 22 Sec. 10. Section 144A.7A, subsections 1 and 3, Code 2026, 23 are amended to read as follows: 24 1. If an attending physician or attending physician 25 assistant provider issues an out-of-hospital do-not-resuscitate 26 order for an adult patient under this section , the physician 27 attending provider shall use the form prescribed pursuant to 28 subsection 2 , include a copy of the order in the patient’s 29 medical record, and provide a copy to the patient or an 30 individual authorized to act on the patient’s behalf. 31 3. The out-of-hospital do-not-resuscitate order form shall 32 include all of the following: 33 a. The patient’s name. 34 b. The patient’s date of birth. 35 -10- HF 2305.4069.S (1) 91 mb 10/ 15

c. The name of the individual authorized to act on the 1 patient’s behalf, if applicable. 2 d. A statement that the patient is in a terminal condition. 3 e. The physician’s or physician assistant’s attending 4 provider’s signature. 5 f. The date the form is signed. 6 g. A concise statement of the nature and scope of the order. 7 h. Any other information necessary to provide clear and 8 reliable instructions to a health care provider. 9 Sec. 11. NEW SECTION . 144A.7B Procedure in absence of 10 out-of-hospital do-not-resuscitate order. 11 1. a. Resuscitation may be withheld or withdrawn from a 12 patient who has a terminal condition, and who is comatose, 13 incompetent, or otherwise physically or mentally incapable of 14 communication, and who has not executed an out-of-hospital 15 do-not-resuscitate order, if there is consultation and 16 written agreement for the withholding or the withdrawal of 17 resuscitation between the attending provider and another 18 physician, advanced registered nurse practitioner, or physician 19 assistant, and the patient’s attorney in fact, the patient’s 20 guardian appointed pursuant to chapter 633, or the patient’s 21 guardian who has obtained court approval in accordance 22 with section 232D.401, subsection 4, paragraph “a” . If the 23 patient has more than one guardian appointed with equal 24 responsibilities, the decision agreed to by a majority of the 25 guardians. If a majority consensus is not achieved by the 26 guardians, a court order shall be required. 27 b. If a patient does not have an attorney in fact, a 28 guardian appointed pursuant to chapter 633, or a guardian 29 who has obtained a court approval in accordance with section 30 232D.401, subsection 4, paragraph “a” , the decision may be made 31 by an individual, in the same order of priority prescribed in 32 section 144A.7, subsection 1, paragraph “b” , who shall be guided 33 by the express or implied intentions of the patient and who 34 is reasonably available, willing, and competent to make the 35 -11- HF 2305.4069.S (1) 91 mb 11/ 15

decision. 1 2. When a decision is made pursuant to this section to 2 withhold or withdraw resuscitation, a witness shall be present 3 at the time of the consultation with the patient’s attending 4 provider when the decision is made. 5 3. This section shall only apply to a patient located in a 6 health care facility as that term is defined in section 135C.1, 7 a health facility as that term is defined in section 135P.1, or 8 a hospice facility certified by the centers for Medicare and 9 Medicaid services of the United States department of health and 10 human services. 11 Sec. 12. Section 144A.8, subsection 1, Code 2026, is amended 12 to read as follows: 13 1. An attending physician provider who is unwilling to 14 comply with the requirements of section 144A.5 , or who is 15 unwilling to comply with the declaration of a qualified 16 patient in accordance with section 144A.6 or an out-of-hospital 17 do-not-resuscitate order pursuant to section 144A.7A , or who is 18 unwilling to comply with the provisions of section 144A.7 or 19 144A.7A shall take all reasonable steps to effect the transfer 20 of the patient to another physician provider . 21 Sec. 13. Section 144B.1, Code 2026, is amended to read as 22 follows: 23 144B.1 Definitions. 24 For purposes of this chapter , unless the context otherwise 25 requires: 26 1. “Attending provider” means the same as defined in section 27 135J.1. 28 1. 2. “Attorney in fact” means an individual who is 29 designated by a durable power of attorney for health care as an 30 agent to make health care decisions on behalf of a principal 31 and has consented to act in that capacity. 32 2. 3. “Designee” means a person named in a declaration 33 under chapter 144C . 34 3. 4. “Durable power of attorney for health care” means a 35 -12- HF 2305.4069.S (1) 91 mb 12/ 15

document authorizing an attorney in fact to make health care 1 decisions for the principal if the principal is unable, in the 2 judgment of the attending physician or attending physician 3 assistant provider , to make health care decisions. 4 4. 5. “Health care” means any care, treatment, service, 5 or procedure to maintain, diagnose, or treat an individual’s 6 physical or mental condition. “Health care” does not include 7 the provision of nutrition or hydration except when they are 8 required to be provided parenterally or through intubation. 9 5. 6. “Health care decision” means the consent, refusal of 10 consent, or withdrawal of consent to health care. 11 6. 7. “Health care provider” means a person who is 12 licensed, certified, or otherwise authorized or permitted by 13 the law laws of this state to administer health care in the 14 ordinary course of business or in the practice of a profession. 15 7. 8. “Principal” means a person age eighteen or older who 16 has executed a durable power of attorney for health care. 17 Sec. 14. Section 144B.5, subsection 1, Code 2026, is amended 18 to read as follows: 19 1. A durable power of attorney for health care executed 20 pursuant to this chapter may, but need not, be in the following 21 form: 22 I hereby designate ........ as my attorney in fact (my 23 agent) and give to my agent the power to make health care 24 decisions for me. This power exists only when I am unable, in 25 the judgment of my attending physician or attending physician 26 assistant provider , to make those health care decisions. The 27 attorney in fact must act consistently with my desires as 28 stated in this document or otherwise made known. 29 Except as otherwise specified in this document, this document 30 gives my agent the power, where otherwise consistent with the 31 law laws of this state, to consent to my physician or physician 32 assistant attending provider not giving health care or stopping 33 health care which is necessary to keep me alive. 34 This document gives my agent power to make health care 35 -13- HF 2305.4069.S (1) 91 mb 13/ 15

decisions on my behalf, including to consent, to refuse to 1 consent, or to withdraw consent to the provision of any care, 2 treatment, service, or procedure to maintain, diagnose, or 3 treat a physical or mental condition. This power is subject 4 to any statement of my desires and any limitations included in 5 this document. 6 My agent has the right to examine my medical records and to 7 consent to disclosure of such records. 8 Sec. 15. Section 144B.6, subsection 1, Code 2026, is amended 9 to read as follows: 10 1. Unless the district court sitting in equity specifically 11 finds that the attorney in fact is acting in a manner contrary 12 to the wishes of the principal or the durable power of attorney 13 for health care provides otherwise, an attorney in fact who 14 is known to the health care provider to be available and 15 willing to make health care decisions has priority over any 16 other person, including a guardian appointed pursuant to 17 chapter 633 , to act for the principal in all matters of health 18 care decisions. The attorney in fact has authority to make 19 a particular health care decision only if the principal is 20 unable, in the judgment of the attending physician or attending 21 physician assistant provider , to make the health care decision. 22 If the principal objects to a decision to withhold or withdraw 23 health care, the principal shall be presumed to be able to make 24 a decision. 25 Sec. 16. Section 144C.2, subsection 16, Code 2026, is 26 amended to read as follows: 27 16. “Licensed hospice program” means a licensed hospice 28 program as defined described in section 135J.1 . 29 Sec. 17. Section 633.635, Code 2026, is amended by adding 30 the following new subsection: 31 NEW SUBSECTION . 6. Notwithstanding subsections 2 and 3, a 32 guardian may make a decision for a protected person pursuant to 33 sections 135J.3A, 144A.7, and 144A.7B without court approval. 34 Sec. 18. Section 633.669, subsection 1, paragraph b, Code 35 -14- HF 2305.4069.S (1) 91 mb 14/ 15

2026, is amended by adding the following new subparagraphs: 1 NEW SUBPARAGRAPH . (11) The protected person’s wishes 2 related to withholding or withdrawal of life-sustaining 3 procedures pursuant to chapter 144A or 144D. 4 NEW SUBPARAGRAPH . (12) The protected person’s wishes 5 related to placement in a hospice program in the event of a 6 terminal condition. 7 Sec. 19. Section 633.669, subsection 1, paragraph c, Code 8 2026, is amended by adding the following new subparagraphs: 9 NEW SUBPARAGRAPH . (9) The protected person’s wishes 10 related to withholding or withdrawal of life-sustaining 11 procedures pursuant to chapter 144A or 144D. 12 NEW SUBPARAGRAPH . (10) The protected person’s wishes 13 related to placement in a hospice program in the event of a 14 terminal condition. > 15 2. Title page, line 3, by striking < and > 16 3. Title page, line 4, by striking < care > and inserting 17 < care, and probate court guardianship reports > 18 -15- HF 2305.4069.S (1) 91 mb 15/ 15 #2.