S.F. _____ Section 1. Section 144A.2, Code 2014, is amended by adding 1 the following new subsections: 2 NEW SUBSECTION . 1A. “Advanced registered nurse practitioner” 3 means an advanced registered nurse practitioner licensed 4 pursuant to chapter 152 or 152E. 5 NEW SUBSECTION . 1B. “Attending advanced registered nurse 6 practitioner” means the advanced registered nurse practitioner 7 selected by, or assigned to, the patient who has primary 8 responsibility for the treatment and care of the patient. 9 NEW SUBSECTION . 2A. “Attending physician assistant” means 10 the physician assistant selected by, or assigned to, the 11 patient who has primary responsibility for the treatment and 12 care of the patient. 13 NEW SUBSECTION . 10A. “Physician assistant” means a person 14 licensed under chapter 148C. 15 Sec. 2. Section 144A.2, subsections 9, 11, and 13, Code 16 2014, are amended to read as follows: 17 9. “Out-of-hospital do-not-resuscitate order” means a written 18 order signed by a physician , physician assistant, or advanced 19 registered nurse practitioner , executed in accordance with the 20 requirements of section 144A.7A and issued consistent with 21 this chapter , that directs the withholding or withdrawal of 22 resuscitation when an adult patient in a terminal condition is 23 outside the hospital. 24 11. “Qualified patient” means a patient who has executed 25 a declaration or an out-of-hospital do-not-resuscitate order 26 in accordance with this chapter and who has been determined 27 by the attending physician , attending physician assistant, or 28 attending advanced registered nurse practitioner to be in a 29 terminal condition. 30 13. “Terminal condition” means an incurable or irreversible 31 condition that, without the administration of life-sustaining 32 procedures, will, in the opinion of the attending physician , 33 attending physician assistant, or attending advanced registered 34 nurse practitioner , result in death within a relatively short 35 -1- LSB 5328XC (3) 85 ad/nh 1/ 7

S.F. _____ period of time or a state of permanent unconsciousness from 1 which, to a reasonable degree of medical certainty, there can 2 be no recovery. 3 Sec. 3. Section 144A.3, subsections 3 and 5, Code 2014, are 4 amended to read as follows: 5 3. It is the responsibility of the declarant to provide the 6 declarant’s attending physician , attending physician assistant, 7 attending advanced registered nurse practitioner, or health 8 care provider with the declaration. An attending physician , 9 attending physician assistant, attending advanced registered 10 nurse practitioner, or health care provider may presume, in the 11 absence of actual notice to the contrary, that the declaration 12 complies with this chapter and is valid. 13 5. A declaration executed pursuant to this chapter may, but 14 need not, be in the following form: 15 DECLARATION 16 If I should have an incurable or irreversible condition that 17 will result either in death within a relatively short period 18 of time or a state of permanent unconsciousness from which, 19 to a reasonable degree of medical certainty, there can be no 20 recovery, it is my desire that my life not be prolonged by 21 the administration of life-sustaining procedures. If I am 22 unable to participate in my health care decisions, I direct 23 my attending physician , attending physician assistant, or 24 attending advanced registered nurse practitioner to withhold 25 or withdraw life-sustaining procedures that merely prolong the 26 dying process and are not necessary to my comfort or freedom 27 from pain. 28 Sec. 4. Section 144A.4, Code 2014, is amended to read as 29 follows: 30 144A.4 Revocation of declaration. 31 1. A declaration may be revoked at any time and in any 32 manner by which the declarant is able to communicate the 33 declarant’s intent to revoke, without regard to mental or 34 physical condition. A revocation is only effective as to 35 -2- LSB 5328XC (3) 85 ad/nh 2/ 7

S.F. _____ the attending physician , attending physician assistant, 1 or attending advanced registered nurse practitioner upon 2 communication to such physician , physician assistant, or 3 advanced registered nurse practitioner by the declarant or by 4 another to whom the revocation was communicated. 5 2. The attending physician , attending physician assistant, 6 or attending advanced registered nurse practitioner shall make 7 the revocation a part of the declarant’s medical record. 8 Sec. 5. Section 144A.5, Code 2014, is amended to read as 9 follows: 10 144A.5 Determination of terminal condition. 11 When an attending physician , an attending physician 12 assistant, or attending advanced registered nurse practitioner 13 who has been provided with a declaration determines that 14 the declarant is in a terminal condition, this decision 15 must be confirmed by another physician , physician assistant, 16 or advanced registered nurse practitioner . The attending 17 physician , attending physician assistant, or attending advanced 18 registered nurse practitioner must record that determination in 19 the declarant’s medical record. 20 Sec. 6. Section 144A.6, subsection 2, Code 2014, is amended 21 to read as follows: 22 2. The declaration of a qualified patient known to 23 the attending physician , attending physician assistant, 24 or attending advanced registered nurse practitioner to be 25 pregnant shall not be in effect as long as the fetus could 26 develop to the point of live birth with continued application 27 of life-sustaining procedures. However, the provisions 28 of this subsection do not impair any existing rights or 29 responsibilities that any person may have in regard to the 30 withholding or withdrawal of life-sustaining procedures. 31 Sec. 7. Section 144A.7, subsection 1, unnumbered paragraph 32 1, Code 2014, is amended to read as follows: 33 Life-sustaining procedures may be withheld or withdrawn from 34 a patient who is in a terminal condition and who is comatose, 35 -3- LSB 5328XC (3) 85 ad/nh 3/ 7

S.F. _____ incompetent, or otherwise physically or mentally incapable of 1 communication and has not made a declaration in accordance with 2 this chapter if there is consultation and written agreement for 3 the withholding or the withdrawal of life-sustaining procedures 4 between the attending physician , attending physician assistant, 5 or attending advanced registered nurse practitioner and any of 6 the following individuals, who shall be guided by the express 7 or implied intentions of the patient, in the following order 8 of priority if no individual in a prior class is reasonably 9 available, willing, and competent to act: 10 Sec. 8. Section 144A.7, subsection 3, Code 2014, is amended 11 to read as follows: 12 3. Subsections 1 and 2 shall not be in effect for a patient 13 who is known to the attending physician , attending physician 14 assistant, or attending advanced registered nurse practitioner 15 to be pregnant with a fetus that could develop to the point 16 of live birth with continued application of life-sustaining 17 procedures. However, the provisions of this subsection do 18 not impair any existing rights or responsibilities that any 19 person may have in regard to the withholding or withdrawal of 20 life-sustaining procedures. 21 Sec. 9. Section 144A.7A, subsection 1, Code 2014, is amended 22 to read as follows: 23 1. If an attending physician , attending physician 24 assistant, or attending advanced registered nurse practitioner 25 issues an out-of-hospital do-not-resuscitate order for an adult 26 patient under this section , the physician , physician assistant, 27 or advanced registered nurse practitioner shall use the form 28 prescribed pursuant to subsection 2 , include a copy of the 29 order in the patient’s medical record, and provide a copy to 30 the patient or an individual authorized to act on the patient’s 31 behalf. 32 Sec. 10. Section 144A.7A, subsection 3, paragraph e, Code 33 2014, is amended to read as follows: 34 e. The physician’s , physician assistant’s, or advanced 35 -4- LSB 5328XC (3) 85 ad/nh 4/ 7

S.F. _____ registered nurse practitioner’s signature. 1 Sec. 11. Section 144A.8, subsection 1, Code 2014, is amended 2 to read as follows: 3 1. An attending physician , attending physician assistant, 4 or attending advanced registered nurse practitioner who is 5 unwilling to comply with the requirements of section 144A.5 , or 6 who is unwilling to comply with the declaration of a qualified 7 patient in accordance with section 144A.6 or an out-of-hospital 8 do-not-resuscitate order pursuant to section 144A.7A , or who is 9 unwilling to comply with the provisions of section 144A.7 or 10 144A.7A shall take all reasonable steps to effect the transfer 11 of the patient to another physician , physician assistant, or 12 advanced registered nurse practitioner . 13 Sec. 12. Section 144A.9, subsection 1, paragraphs a and c, 14 Code 2014, are amended to read as follows: 15 a. A physician , physician assistant, or advanced registered 16 nurse practitioner who causes the withholding or withdrawal of 17 life-sustaining procedures from a qualified patient. 18 c. A person who participates in the withholding or 19 withdrawal of life-sustaining procedures under the direction of 20 or with the authorization of a physician , physician assistant, 21 or advanced registered nurse practitioner . 22 Sec. 13. Section 144A.9, subsection 2, Code 2014, is amended 23 to read as follows: 24 2. A physician , physician assistant, or advanced registered 25 nurse practitioner is not subject to civil or criminal 26 liability for actions under this chapter which are in accord 27 with reasonable medical standards. 28 Sec. 14. Section 144A.11, subsection 3, Code 2014, is 29 amended to read as follows: 30 3. A physician, physician assistant, advanced registered 31 nurse practitioner, health care provider, health care service 32 plan, insurer issuing disability insurance, self-insured 33 employee welfare benefit plan, or nonprofit hospital plan 34 shall not require any person to execute a declaration or an 35 -5- LSB 5328XC (3) 85 ad/nh 5/ 7

S.F. _____ out-of-hospital do-not-resuscitate order as a condition for 1 being insured for, or receiving, health care services. 2 Sec. 15. Section 144D.4, subsection 3, Code 2014, is amended 3 to read as follows: 4 3. If the individual’s physician , physician assistant, 5 or advanced registered nurse practitioner has issued an 6 out-of-hospital do-not-resuscitate order pursuant to section 7 144A.7A , the POST form shall not supersede the out-of-hospital 8 do-not-resuscitate order. 9 Sec. 16. Section 235B.2, subsection 5, paragraph b, 10 subparagraph (3), Code 2014, is amended to read as follows: 11 (3) The withholding or withdrawing of health care from 12 a dependent adult who is terminally ill in the opinion of a 13 licensed physician , physician assistant, or advanced registered 14 nurse practitioner , when the withholding or withdrawing of 15 health care is done at the request of the dependent adult or at 16 the request of the dependent adult’s next of kin, attorney in 17 fact, or guardian pursuant to the applicable procedures under 18 chapter 125 , 144A , 144B , 222 , 229 , or 633 . 19 Sec. 17. Section 235E.1, subsection 5, paragraph b, 20 subparagraph (3), Code 2014, is amended to read as follows: 21 (3) The withholding or withdrawing of health care from 22 a dependent adult who is terminally ill in the opinion of a 23 licensed physician , physician assistant, or advanced registered 24 nurse practitioner , when the withholding or withdrawing of 25 health care is done at the request of the dependent adult or at 26 the request of the dependent adult’s next of kin, attorney in 27 fact, or guardian pursuant to the applicable procedures under 28 chapter 125 , 144A , 144B , 222 , 229 , or 633 . 29 EXPLANATION 30 The inclusion of this explanation does not constitute agreement with 31 the explanation’s substance by the members of the general assembly. 32 This bill relates to a physician assistant’s or advanced 33 registered nurse practitioner’s authority in regard to 34 life-sustaining procedures. The bill grants a physician 35 -6- LSB 5328XC (3) 85 ad/nh 6/ 7

S.F. _____ assistant and an advanced registered nurse practitioner the 1 same authority as a physician to issue an out-of-hospital 2 do-not-resuscitate order for an adult patient pursuant to 3 Code chapter 144A, to withhold life-sustaining procedures in 4 accordance with the Code chapter, to consult and be party to a 5 written agreement for withholding life-sustaining procedures 6 pursuant to the Code chapter, and to determine that a patient 7 has a terminal condition. 8 The bill makes conforming changes. 9 -7- LSB 5328XC (3) 85 ad/nh 7/ 7