House File 2305 - Enrolled House File 2305 AN ACT RELATING TO HEALTH CARE DECISIONS RELATED TO PALLIATIVE CARE, HOSPICE PROGRAMS, LIFE-SUSTAINING PROCEDURES, OUT-OF-HOSPITAL DO-NOT-RESUSCITATE ORDERS, DURABLE POWER OF ATTORNEY FOR HEALTH CARE, AND PROBATE COURT GUARDIANSHIP REPORTS. BE IT ENACTED BY THE GENERAL ASSEMBLY OF THE STATE OF IOWA: Section 1. Section 135J.1, Code 2026, is amended to read as follows: 135J.1 Definitions. For the purposes of this chapter unless otherwise defined: 1. “Attending physician provider ” means a physician licensed pursuant to chapter 148 or a physician assistant licensed pursuant to chapter 148C , physician assistant, or an advanced registered nurse practitioner who is licensed in this state . 2. “Attorney in fact” means the same as defined in section 144B.1. 2. 3. “Core services” means physician services, nursing services, medical social services, counseling services, and volunteer services provided by volunteers . These core services, as well as others deemed necessary by the hospice in delivering safe and appropriate care to its case load the hospice’s hospice patients , can be provided through either direct or indirect arrangement by the hospice. 3. 4. “Department” means the department of inspections, appeals, and licensing.

House File 2305, p. 2 5. “Guardian” means the same as defined in section 633.3. 4. 6. “Hospice patient” or “patient” means a diagnosed terminally ill person an individual with an anticipated life expectancy of six months or less, as certified by the attending physician provider , who , alone or in conjunction with a unit of care as defined in subsection 9, has voluntarily requested and received admission into the a hospice program. If the patient is unable to request admission, a family member may voluntarily request and receive admission on the patient’s behalf. An individual may make this request in conjunction with a unit of care, the individual’s attorney in fact, the individual’s guardian, or the majority of the guardians if the individual has more than one guardian with equal responsibilities appointed. 5. 7. “Hospice patient’s family” means the immediate kin of the a hospice patient, including a spouse, parent, stepparent, brother, sister, stepbrother, stepsister, child, or stepchild. Additional relatives or individuals with significant personal ties to the hospice patient may be included in the hospice patient’s family. 6. 8. “Hospice program” means a centrally coordinated program of home and inpatient care provided directly or through an agreement under the direction of an identifiable hospice administration providing palliative care directed at symptom management and supportive medical and other health services to terminally ill hospice patients and their families. A licensed hospice program shall utilize a medically directed interdisciplinary team and provide care to meet the physical, emotional, social, spiritual, and other special needs which are experienced during the final stages of illness, dying, and bereavement. Hospice care shall be available twenty-four hours a day, seven days a week. 7. 9. “Interdisciplinary team” means the hospice patient and the hospice patient’s family, the attending physician provider , and all of the following individuals trained to serve with a licensed hospice program: a. A licensed physician pursuant to chapter 148 . b. A licensed registered nurse pursuant to chapter 152 . c. An individual with at least a baccalaureate degree in the

House File 2305, p. 3 field of social work providing medical-social services. d. Trained hospice volunteers Volunteers . e. As deemed appropriate by the hospice, physician assistants, providers of special services including but not limited to a spiritual counselor, a pharmacist pharmacists , or professionals in the fields of mental health may be included on the interdisciplinary team. 8. 10. “Palliative care” means specialized medical care directed at managing symptoms experienced by the hospice provided to a patient , as well as addressing related needs of the patient and family as they experience the stress of the dying process who has been diagnosed by the patient’s attending provider with a serious illness. Palliative care is stress and symptom management care, based on the needs of the patient rather than the patient’s diagnosis, provided by an interdisciplinary team . The intent of palliative care is to enhance the quality of life for the hospice patient and family unit , and is not treatment directed at cure of the terminal illness . Palliative care may be provided at any stage of a patient’s serious illness, regardless of the patient’s age, and may be provided in conjunction with curative treatment for the serious illness. 11. “Serious illness” means a health condition that carries a high risk of mortality and either negatively impacts an individual’s daily functioning or quality of life, or excessively strains the individual’s caregivers. 12. “Terminal condition” means the same as defined in section 144A.2. 9. 13. “Unit of care” means the a hospice patient and the a hospice patient’s family within a hospice program. 10. 14. “Volunteer services” “Volunteer” means the services provided by individuals an individual who have has successfully completed a training program developed by a licensed hospice program and who provides services . Sec. 2. Section 135J.3, Code 2026, is amended to read as follows: 135J.3 Basic requirements. A licensed hospice program shall include: 1. A planned program of hospice care, the medical components

House File 2305, p. 4 of which shall be under the direction of an attending physician provider . 2. Centrally administered, coordinated hospice core services provided in home, outpatient, or institutional settings. 3. A mechanism that assures the rights of the patient and family a unit of care . 4. Palliative care Symptom management provided to a hospice patient and family unit of care under the direction of an attending physician provider . 5. An interdisciplinary team which develops, implements, and evaluates the hospice plan of care for the patient and family a unit of care . 6. Bereavement services. 7. Accessible hospice care twenty-four hours a day, seven days a week in all settings. 8. An ongoing system of quality assurance and utilization review. Sec. 3. NEW SECTION . 135J.3A Patient incapable of making a treatment decision. 1. a. A request for admission and placement in a hospice program for a patient who has a terminal condition, and who is comatose, incompetent, or otherwise physically or mentally incapable of communication, and who has not expressed their desire for palliative care or a hospice program, may be made by the patient’s attorney in fact or the patient’s guardian. If the patient has more than one guardian with equal responsibilities appointed, the decision agreed to by a majority of guardians. If a majority consensus is not achieved by the guardians, a court order shall be required. b. If a patient does not have an attorney in fact or a guardian, the request may be made by an individual, in the same order of priority prescribed in section 144A.7, subsection 1, paragraph “b” , who shall be guided by the express or implied intentions of the patient and who is reasonably available, willing, and competent to make a request. 2. This section shall not apply to a guardian appointed under chapter 232D. Sec. 4. Section 144A.2, Code 2026, is amended to read as

House File 2305, p. 5 follows: 144A.2 Definitions. Except as otherwise provided, as used in this chapter : 1. “Adult” means an individual eighteen years of age or older. 2. “Advanced registered nurse practitioner” means the same as defined in section 152.1. 2. 3. “Attending physician provider ” means the physician selected by, or assigned to, the patient who has primary responsibility for the treatment and care of the patient same as defined in section 135J.1 . 3. 4. “Attending physician assistant” means the physician assistant selected by, or assigned to, the patient who has primary responsibility for the treatment and care of the patient “Attorney in fact” means the same as defined in section 144B.1 . 5. “Close adult friend” means a friend of a patient to whom all of the following apply: a. The individual is at least eighteen years of age. b. The individual has shown special care and concern for the patient. c. The individual maintains regular contact with the patient and is familiar with the patient’s health, activities, and beliefs. d. The individual has provided an affidavit to the patient’s attending provider that states that the individual is willing and able to be involved in the patient’s care. 4. 6. “Declaration” means a document executed in accordance with the requirements of section 144A.3 . 5. 7. “Department” means the department of health and human services. 6. 8. “Emergency medical care provider” means emergency medical care provider as defined in section 147A.1 . 7. 9. “Health care provider” means a person, including an emergency medical care provider, who is licensed, certified, or otherwise authorized or permitted by the law of this state to administer health care in the ordinary course of business or in the practice of a profession. 8. 10. “Hospital” means hospital as defined in section

House File 2305, p. 6 135B.1 . 9. 11. a. “Life-sustaining procedure” means any medical procedure, treatment, or intervention, including resuscitation, which meets both of the following requirements: (1) Utilizes mechanical or artificial means to sustain, restore, or supplant a spontaneous vital function. (2) When applied to a patient in a terminal condition, would serve only to prolong the dying process. b. “Life-sustaining procedure” does not include the provision of nutrition or hydration except when required to be provided parenterally or through intubation, or the administration of medication or performance of any medical procedure deemed necessary to provide comfort care or to alleviate pain. 10. 12. “Out-of-hospital do-not-resuscitate order” means a written order signed by a physician an attending provider , executed in accordance with the requirements of section 144A.7A and issued consistent with this chapter , that directs the withholding or withdrawal of resuscitation when an adult patient in a terminal condition is outside the hospital. 11. 13. “Physician” means a person licensed to practice medicine and surgery or osteopathic medicine and surgery in this state. 12. 14. “Physician assistant” means a person licensed to practice as a physician assistant in this state. 13. 15. “Qualified patient” means a patient who has executed a declaration or an out-of-hospital do-not-resuscitate order in accordance with this chapter and who has been determined by the patient’s attending physician provider to be in a terminal condition. 14. 16. “Resuscitation” means any medical intervention that utilizes mechanical or artificial means to sustain, restore, or supplant a spontaneous vital function, including but not limited to chest compression, defibrillation, intubation, and emergency drugs intended to alter cardiac function or otherwise to sustain life. 15. 17. “Terminal condition” means an incurable or irreversible condition that, without the administration of life-sustaining procedures, will, in the opinion of

House File 2305, p. 7 the attending physician provider , result 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. Sec. 5. Section 144A.3, subsections 3 and 5, Code 2026, are amended to read as follows: 3. It is the responsibility of the declarant to provide the declarant’s attending physician or health care provider with the declaration. An attending physician or health care provider may presume, in the absence of actual notice to the contrary, that the declaration complies with this chapter and is valid. 5. A declaration executed pursuant to this chapter may, but need not, be in the following form: 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 provider to withhold or withdraw life-sustaining procedures that merely prolong the dying process and are not necessary to my comfort or freedom from pain. Sec. 6. Section 144A.4, Code 2026, is amended to read as follows: 144A.4 Revocation of declaration. 1. A declaration may be revoked at any time and in any manner by which the declarant is able to communicate the declarant’s intent to revoke, without regard to mental or physical condition. A revocation is only effective as to the attending physician or attending physician assistant provider upon communication to such physician or physician assistant attending provider by the declarant or by another to whom the revocation was communicated. 2. The attending physician or attending physician assistant provider shall make the revocation a part of the declarant’s

House File 2305, p. 8 medical record. Sec. 7. Section 144A.5, Code 2026, is amended to read as follows: 144A.5 Determination of terminal condition. When an attending physician provider who has been provided with a declaration determines that the declarant is in a terminal condition, this decision must be confirmed by another physician , advanced registered nurse practitioner, or physician assistant . The attending physician provider must record that the determination in the declarant’s medical record. Sec. 8. Section 144A.6, subsection 2, Code 2026, is amended to read as follows: 2. The declaration of a qualified patient known to the attending physician provider to be pregnant shall not be in effect as long as the fetus could develop to the point of live birth with continued application of life-sustaining procedures. However, the provisions of this subsection do not impair any existing rights or responsibilities that any person may have in regard to the withholding or withdrawal of life-sustaining procedures. Sec. 9. Section 144A.7, subsections 1 and 2, Code 2026, are amended to read as follows: 1. a. Life-sustaining procedures may be withheld or withdrawn from a patient who is in a terminal condition and who is comatose, incompetent, or otherwise physically or mentally incapable of communication , and who has not made a declaration in accordance with this chapter section 144A.3 if there is consultation and written agreement for the withholding or the withdrawal of life-sustaining procedures between the attending physician provider, another physician, advanced registered nurse practitioner, or physician assistant, and the patient’s attorney in fact, the patient’s guardian appointed pursuant to chapter 633, or the patient’s guardian who has obtained court approval in accordance with section 232D.401, subsection 4, paragraph “a” . If the patient has more than one guardian with equal responsibilities appointed, the decision agreed to by a majority of the guardians. If a majority consensus is not achieved by the guardians, a court order shall be required. b. If a patient does not have an attorney in fact, a

House File 2305, p. 9 guardian appointed pursuant to chapter 633, or a guardian who has obtained court approval in accordance with section 232D.401, subsection 4, paragraph “a” , the decision may be made by any of the following individuals, who shall be guided by the express or implied intentions of the patient, in the following order of priority if no individual in a prior class the previous priority is reasonably available, willing, and competent to act make the decision : a. The attorney in fact designated to make treatment decisions for the patient should such person be diagnosed as suffering from a terminal condition, if the designation is in writing and complies with chapter 144B. b. The guardian of the person of the patient if one has been appointed, provided court approval is obtained in accordance with section 232D.401, subsection 4, paragraph “a” , or section 633.635, subsection 3, paragraph “b” , subparagraph (1). This paragraph does not require the appointment of a guardian in order for a treatment decision to be made under this section. c. (1) The patient’s spouse. d. (2) An adult child of the patient or, if the patient has more than one adult child, the decision agreed to by a majority of the adult children who are reasonably available for consultation with the patient’s attending provider . e. (3) A parent of the patient , or parents if the patient has more than one parent, the decision agreed to by both parents if both are reasonably available for consultation with the patient’s attending provider . f. (4) An adult sibling of the patient or, if the patient has more than one adult sibling, the decision agreed to by a majority of the adult siblings who are reasonably available for consultation with the patient’s attending provider . (5) The decision agreed to by a majority of the patient’s adult relatives, including but not limited to grandchildren, grandparents, aunts, uncles, nieces, nephews, stepchildren, stepparents, and stepsiblings who are reasonably available for consultation with the patient’s attending provider. (6) A close adult friend. 2. When a decision is made pursuant to this section to withhold or withdraw life-sustaining procedures, there shall

House File 2305, p. 10 be a witness present at the time of the consultation with the patient’s attending provider when that the decision is made. Sec. 10. Section 144A.7A, subsections 1 and 3, Code 2026, are amended to read as follows: 1. If an attending physician or attending physician assistant provider issues an out-of-hospital do-not-resuscitate order for an adult patient under this section , the physician attending provider shall use the form prescribed pursuant to subsection 2 , include a copy of the order in the patient’s medical record, and provide a copy to the patient or an individual authorized to act on the patient’s behalf. 3. The out-of-hospital do-not-resuscitate order form shall include all of the following: a. The patient’s name. b. The patient’s date of birth. c. The name of the individual authorized to act on the patient’s behalf, if applicable. d. A statement that the patient is in a terminal condition. e. The physician’s or physician assistant’s attending provider’s signature. f. The date the form is signed. g. A concise statement of the nature and scope of the order. h. Any other information necessary to provide clear and reliable instructions to a health care provider. Sec. 11. NEW SECTION . 144A.7B Procedure in absence of out-of-hospital do-not-resuscitate order. 1. a. Resuscitation may be withheld or withdrawn from a patient who has a terminal condition, and who is comatose, incompetent, or otherwise physically or mentally incapable of communication, and who has not executed an out-of-hospital do-not-resuscitate order, if there is consultation and written agreement for the withholding or the withdrawal of resuscitation between the attending provider and another physician, advanced registered nurse practitioner, or physician assistant, and the patient’s attorney in fact, the patient’s guardian appointed pursuant to chapter 633, or the patient’s guardian who has obtained court approval in accordance with section 232D.401, subsection 4, paragraph “a” . If the patient has more than one guardian appointed with equal

House File 2305, p. 11 responsibilities, the decision agreed to by a majority of the guardians. If a majority consensus is not achieved by the guardians, a court order shall be required. b. If a patient does not have an attorney in fact, a guardian appointed pursuant to chapter 633, or a guardian who has obtained a court approval in accordance with section 232D.401, subsection 4, paragraph “a” , the decision may be made by an individual, in the same order of priority prescribed in section 144A.7, subsection 1, paragraph “b” , who shall be guided by the express or implied intentions of the patient and who is reasonably available, willing, and competent to make the decision. 2. When a decision is made pursuant to this section to withhold or withdraw resuscitation, a witness shall be present at the time of the consultation with the patient’s attending provider when the decision is made. 3. This section shall only apply to a patient located in a health care facility as that term is defined in section 135C.1, a health facility as that term is defined in section 135P.1, or a hospice facility certified by the centers for Medicare and Medicaid services of the United States department of health and human services. Sec. 12. Section 144A.8, subsection 1, Code 2026, is amended to read as follows: 1. An attending physician provider who is unwilling to comply with the requirements of section 144A.5 , or who is unwilling to comply with the declaration of a qualified patient in accordance with section 144A.6 or an out-of-hospital do-not-resuscitate order pursuant to section 144A.7A , or who is unwilling to comply with the provisions of section 144A.7 or 144A.7A shall take all reasonable steps to effect the transfer of the patient to another physician provider . Sec. 13. Section 144B.1, Code 2026, is amended to read as follows: 144B.1 Definitions. For purposes of this chapter , unless the context otherwise requires: 1. “Attending provider” means the same as defined in section 135J.1.

House File 2305, p. 12 1. 2. “Attorney in fact” means an individual who is designated by a durable power of attorney for health care as an agent to make health care decisions on behalf of a principal and has consented to act in that capacity. 2. 3. “Designee” means a person named in a declaration under chapter 144C . 3. 4. “Durable power of attorney for health care” means a document authorizing an attorney in fact to make health care decisions for the principal if the principal is unable, in the judgment of the attending physician or attending physician assistant provider , to make health care decisions. 4. 5. “Health care” means any care, treatment, service, or procedure to maintain, diagnose, or treat an individual’s physical or mental condition. “Health care” does not include the provision of nutrition or hydration except when they are required to be provided parenterally or through intubation. 5. 6. “Health care decision” means the consent, refusal of consent, or withdrawal of consent to health care. 6. 7. “Health care provider” means a person who is licensed, certified, or otherwise authorized or permitted by the law laws of this state to administer health care in the ordinary course of business or in the practice of a profession. 7. 8. “Principal” means a person age eighteen or older who has executed a durable power of attorney for health care. Sec. 14. Section 144B.5, subsection 1, Code 2026, is amended to read as follows: 1. A durable power of attorney for health care executed pursuant to this chapter may, but need not, be in the following form: I hereby designate ........ 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 or attending physician assistant provider , 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. Except as otherwise specified in this document, this document gives my agent the power, where otherwise consistent with the law laws of this state, to consent to my physician or physician

House File 2305, p. 13 assistant attending provider 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. Sec. 15. Section 144B.6, subsection 1, Code 2026, is amended to read as follows: 1. Unless the district court sitting in equity specifically finds that the attorney in fact is acting in a manner contrary to the wishes of the principal or the durable power of attorney for health care provides otherwise, an attorney in fact who is known to the health care provider to be available and willing to make health care decisions has priority over any other person, including a guardian appointed pursuant to chapter 633 , to act for the principal in all matters of health care decisions. The attorney in fact has authority to make a particular health care decision only if the principal is unable, in the judgment of the attending physician or attending physician assistant provider , to make the health care decision. If the principal objects to a decision to withhold or withdraw health care, the principal shall be presumed to be able to make a decision. Sec. 16. Section 144C.2, subsection 16, Code 2026, is amended to read as follows: 16. “Licensed hospice program” means a licensed hospice program as defined described in section 135J.1 . Sec. 17. Section 633.635, Code 2026, is amended by adding the following new subsection: NEW SUBSECTION . 6. Notwithstanding subsections 2 and 3, a guardian may make a decision for a protected person pursuant to sections 135J.3A, 144A.7, and 144A.7B without court approval. Sec. 18. Section 633.669, subsection 1, paragraph b, Code 2026, is amended by adding the following new subparagraphs:

House File 2305, p. 14 NEW SUBPARAGRAPH . (11) The protected person’s wishes related to withholding or withdrawal of life-sustaining procedures pursuant to chapter 144A or 144D. NEW SUBPARAGRAPH . (12) The protected person’s wishes related to placement in a hospice program in the event of a terminal condition. Sec. 19. Section 633.669, subsection 1, paragraph c, Code 2026, is amended by adding the following new subparagraphs: NEW SUBPARAGRAPH . (9) The protected person’s wishes related to withholding or withdrawal of life-sustaining procedures pursuant to chapter 144A or 144D. NEW SUBPARAGRAPH . (10) The protected person’s wishes related to placement in a hospice program in the event of a terminal condition. ______________________________ PAT GRASSLEY Speaker of the House ______________________________ AMY SINCLAIR President of the Senate I hereby certify that this bill originated in the House and is known as House File 2305, Ninety-first General Assembly. ______________________________ MEGHAN NELSON Chief Clerk of the House Approved _______________, 2026 ______________________________ KIM REYNOLDS Governor