H.F. 708 Section 1. Section 135J.1, Code 2025, is amended by adding 1 the following new subsections: 2 NEW SUBSECTION . 1A. “Attorney in fact” means an individual 3 who is designated by a durable power of attorney for health 4 care as an agent to make health care decisions on behalf of a 5 patient and has consented to act in that capacity. 6 NEW SUBSECTION . 1B. “Close adult friend” means a friend of 7 the patient to whom all of the following apply: 8 a. The individual is at least eighteen years of age. 9 b. The individual has shown special care and concern for the 10 patient. 11 c. The individual maintains regular contact with the patient 12 and is familiar with the patient’s health, activities, and 13 beliefs. 14 d. The individual has signed an affidavit with the patient’s 15 attending physician that states that the close adult friend is 16 willing and able to be involved in the patient’s care. 17 NEW SUBSECTION . 3A. “Durable power of attorney for health 18 care” means a document authorizing an attorney in fact to 19 make health care decisions for the patient if the patient is 20 unable, in the judgment of the patient’s attending physician or 21 attending physician assistant, to make health care decisions. 22 NEW SUBSECTION . 8A. “Serious illness” means a health 23 condition that carries a high risk of mortality and either 24 negatively impacts a person’s daily functioning or quality of 25 life, or excessively strains the person’s caregivers. 26 NEW SUBSECTION . 8B. “Terminal condition” means the same as 27 defined in section 144A.2. 28 Sec. 2. Section 135J.1, subsections 4, 6, 8, and 9, Code 29 2025, are amended to read as follows: 30 4. “Hospice patient” or “patient” means a person diagnosed 31 terminally ill person with a terminal illness by an attending 32 physician, with an anticipated life expectancy of six months or 33 less, as certified by the attending physician, who, alone or in 34 conjunction with a unit of care as defined in subsection 9 , has 35 -1- LSB 1139YH (8) 91 lh/ko 1/ 9

H.F. 708 voluntarily requested and received admission into the a hospice 1 program. If the patient is unable to request admission, a 2 family member may voluntarily request and receive admission on 3 the patient’s behalf. 4 6. “Hospice program” means a centrally coordinated program 5 of home and inpatient care provided directly or through an 6 agreement under the direction of an identifiable hospice 7 administration providing palliative care directed at symptom 8 management and supportive medical and other health services 9 to terminally ill hospice patients and their families. A 10 licensed hospice program shall utilize a medically directed 11 interdisciplinary team and provide care to meet the physical, 12 emotional, social, spiritual, and other special needs which 13 are experienced during the final stages of illness, dying, and 14 bereavement. Hospice care shall be available twenty-four hours 15 a day, seven days a week. 16 8. “Palliative care” means specialized medical care directed 17 at managing symptoms experienced by the hospice patient, as 18 well as addressing related needs of the patient and family 19 as they experience the stress of the dying process a patient 20 diagnosed by an attending physician with a serious illness . 21 Palliative care is provided by a trained team of health 22 care providers who work together with a patient’s health 23 care providers to provide support through stress and symptom 24 management based on the needs of the patient, not the patient’s 25 prognosis. The intent of palliative care is to enhance the 26 quality of life for the hospice patient and family unit , and 27 is not treatment directed at cure of the terminal illness . 28 Palliative care is appropriate for a patient at any age and 29 at any stage of a serious illness and can be utilized with 30 curative treatment for the serious illness. 31 9. “Unit of care” means the a hospice patient and the 32 hospice patient’s family within a hospice program. 33 Sec. 3. Section 135J.3, subsections 3, 4, and 5, Code 2025, 34 are amended to read as follows: 35 -2- LSB 1139YH (8) 91 lh/ko 2/ 9

H.F. 708 3. A mechanism that assures the rights of the patient and 1 family unit of care . 2 4. Palliative Symptom management care provided to a hospice 3 patient and family unit of care under the direction of an 4 attending physician. 5 5. An interdisciplinary team which develops, implements, 6 and evaluates the hospice plan of care for the patient and 7 family unit of care . 8 Sec. 4. NEW SECTION . 135J.3A Patient incapable of making a 9 treatment decision. 10 A patient who has a terminal condition, and who is comatose, 11 incompetent, or otherwise physically or mentally incapable 12 of communication, and who has not expressed their desire 13 for palliative care or a hospice program, may be placed in 14 a hospice program by any of the following individuals, who 15 shall be guided by the express or implied intentions of the 16 patient, in the following order of priority if no individual 17 in the previous priority is reasonably available, willing, and 18 competent to make the decision. 19 1. The attorney in fact of a durable power of attorney for 20 health care executed by the patient pursuant to chapter 144B. 21 2. The guardian of the patient appointed pursuant to chapter 22 633. 23 3. The patient’s spouse. 24 4. An adult child or stepchild of the patient or, if 25 the patient has more than one adult child or stepchild, the 26 decision agreed to by a majority of the adult children and 27 stepchildren who are reasonably available for consultation with 28 the patient’s attending physician. 29 5. A parent or stepparent of the patient, or if the patient 30 has more than one parent or stepparent, the decision agreed to 31 by a majority of the parents and stepparents who are reasonably 32 available for consultation with the patient’s attending 33 physician. 34 6. An adult sibling or stepsibling of the patient, or if 35 -3- LSB 1139YH (8) 91 lh/ko 3/ 9

H.F. 708 the patient has more than one sibling or stepsibling, the 1 decision agreed to by a majority of the adult siblings and 2 stepsiblings who are reasonably available for consultation with 3 the patient’s attending physician. 4 7. The decision agreed to by a majority of the patient’s 5 relatives, including but not limited to grandchildren, 6 grandparents, aunts, uncles, nieces, and nephews, who are 7 reasonably available for consultation with the patient’s 8 attending physician. 9 8. A close adult friend. 10 Sec. 5. Section 144A.2, Code 2025, is amended by adding the 11 following new subsections: 12 NEW SUBSECTION . 3A. “Attorney in fact” means an individual 13 who is designated by a durable power of attorney for health 14 care as an agent to make health care decisions on behalf of a 15 patient and has consented to act in that capacity. 16 NEW SUBSECTION . 3B. “Close adult friend” means a friend of 17 the patient to whom 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 signed an affidavit with the patient’s 25 attending physician that states that the close adult friend is 26 willing and able to be involved in the patient’s care. 27 NEW SUBSECTION . 5A. “Durable power of attorney for health 28 care” means a document authorizing an attorney in fact to 29 make health care decisions for the patient if the patient is 30 unable, in the judgment of the patient’s attending physician or 31 attending physician assistant, to make health care decisions. 32 Sec. 6. Section 144A.7, subsections 1 and 2, Code 2025, are 33 amended to read as follows: 34 1. Life-sustaining procedures may be withheld or withdrawn 35 -4- LSB 1139YH (8) 91 lh/ko 4/ 9

H.F. 708 from a patient who is in a terminal condition , and who is 1 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 and any of the following individuals, who shall be 7 guided by the express or implied intentions of the patient, in 8 the following order of priority if no individual in a prior 9 class the previous priority is reasonably available, willing, 10 and competent to act: make a decision. 11 a. The attorney in fact designated to make treatment 12 decisions for the patient should such person be diagnosed as 13 suffering from a terminal condition, if the designation is in 14 writing and complies with chapter 144B . 15 b. The guardian of the person of the patient if one has been 16 appointed , provided pursuant to chapter 633, or the guardian 17 of the patient who has obtained court approval is obtained in 18 accordance with section 232D.401, subsection 4 , paragraph “a” , 19 or section 633.635, subsection 3 , paragraph “b” , subparagraph 20 (1) . This paragraph does not require the appointment of a 21 guardian in order for a treatment decision to be made under 22 this section . 23 c. The patient’s spouse. 24 d. An adult child or stepchild of the patient or, if 25 the patient has more than one adult child or stepchild , the 26 decision agreed to by a majority of the adult children and 27 stepchildren who are reasonably available for consultation with 28 the patient’s attending physician . 29 e. A parent or stepparent of the patient, or parents if 30 both the patient has more than one parent or stepparent, the 31 decision agreed to by a majority of the parents and stepparents 32 who are reasonably available for consultation with the 33 patient’s attending physician . 34 f. An adult sibling or stepsibling of the patient or, if 35 -5- LSB 1139YH (8) 91 lh/ko 5/ 9

H.F. 708 the patient has more than one adult sibling or stepsibling, 1 the decision agreed to by a majority of the adult siblings and 2 stepsiblings who are reasonably available for consultation with 3 the patient’s attending physician . 4 g. The decision agreed to by a majority of the patient’s 5 relatives, including but not limited to grandchildren, 6 grandparents, aunts, uncles, nieces, and nephews, who are 7 reasonably available for consultation with the patient’s 8 attending physician. 9 h. A close adult friend. 10 2. When a decision is made pursuant to this section to 11 withhold or withdraw life-sustaining procedures, there shall 12 be a witness present at the time of the consultation with 13 the patient’s attending physician when that the decision is 14 made. The witness shall be an adult who is not related to the 15 patient by blood, marriage, or adoption within the third degree 16 of consanguinity and who is not an attending physician or an 17 employee of an attending physician involved in the patient’s 18 care. 19 Sec. 7. NEW SECTION . 144A.7B Procedure in absence of 20 out-of-hospital do-not-resuscitate order. 21 1. Resuscitation may be withheld or withdrawn from a patient 22 who has a terminal illness, and who is comatose, incompetent, 23 or otherwise physically or mentally incapable of communication, 24 and who has not executed an out-of-hospital do-not-resuscitate 25 order, if there is consultation and written agreement for the 26 withholding or the withdrawal of resuscitation between the 27 attending physician and any of the following individuals, who 28 shall be guided by the express or implied intentions of the 29 patient, in the following order of priority if no individual 30 in the previous priority is reasonably available, willing, and 31 competent to make a decision. 32 a. The attorney in fact of a durable power of attorney for 33 health care executed by the patient pursuant to chapter 144B. 34 b. The guardian of the patient appointed pursuant to chapter 35 -6- LSB 1139YH (8) 91 lh/ko 6/ 9

H.F. 708 633. 1 c. The patient’s spouse. 2 d. An adult child or stepchild of the patient or, if 3 the patient has more than one adult child or stepchild, the 4 decision agreed to by a majority of the adult children and 5 stepchildren who are reasonably available for consultation with 6 the patient’s attending physician. 7 e. A parent or stepparent of the patient, or if the patient 8 has more than one parent or stepparent, the decision agreed to 9 by a majority of the parents and stepparents who are reasonably 10 available for consultation with the patient’s attending 11 physician. 12 f. An adult sibling or stepsibling of the patient, or if 13 the patient has more than one adult sibling or stepsibling, 14 the decision agreed to by a majority of the adult siblings and 15 stepsiblings who are reasonably available for consultation with 16 the patient’s attending physician. 17 g. The decision agreed to by a majority of the relatives, 18 including but not limited to grandchildren, grandparents, 19 aunts, uncles, nieces, and nephews, who are reasonably 20 available for consultation with the patient’s attending 21 physician. 22 h. A close adult friend. 23 2. When a decision is made pursuant to this section to 24 withhold or withdraw resuscitation, a witness shall be present 25 at the time of the consultation with the patient’s attending 26 physician when the decision is made. The witness shall be an 27 adult who is not related to the patient by blood, marriage, or 28 adoption within the third degree of consanguinity and who is 29 not the attending physician or an employee of the attending 30 physician involved in the patient’s care. 31 Sec. 8. Section 144C.2, subsection 16, Code 2025, is amended 32 to read as follows: 33 16. “Licensed hospice program” means a licensed hospice 34 program as defined described in section 135J.1 . 35 -7- LSB 1139YH (8) 91 lh/ko 7/ 9

H.F. 708 Sec. 9. Section 633.635, Code 2025, is amended by adding the 1 following new subsection: 2 NEW SUBSECTION . 6. Notwithstanding subsection 2 or 3, a 3 guardian may make a decision for a protected person pursuant to 4 sections 135J.3A, 144A.7, and 144A.7B without court approval. 5 EXPLANATION 6 The inclusion of this explanation does not constitute agreement with 7 the explanation’s substance by the members of the general assembly. 8 This bill relates to health care decisions related to 9 palliative care, hospice programs, life-sustaining procedures, 10 and out-of-hospital do-not-resuscitate orders. 11 Current law requires a hospice program to provide palliative 12 care in order to be eligible for a license. The bill removes 13 this requirement and requires a hospice program to provide 14 care directed at symptom management to be eligible to receive 15 a license. 16 Under the bill, if a patient who has a terminal condition, 17 and is comatose, incompetent, or incapable of communication, 18 and has not expressed their desire regarding palliative care 19 or a hospice program, certain individuals in order of priority 20 have the authority to make the decision to place the patient in 21 a hospice program. The individuals who have the authority to 22 make such a decision include an attorney in fact, a guardian, 23 the patient’s spouse, an adult child or stepchild, a parent 24 or stepparent, adult sibling or adult stepsibling, a relative 25 of the patient, and a close adult friend. The bill defines 26 close adult friend. An individual making a decision for such a 27 patient shall be guided by the express or implied intention of 28 the patient in making the decision. 29 Current law provides that certain individuals in order 30 of priority, including an attorney in fact, a guardian, 31 the patient’s spouse, an adult child, a parent, and an 32 adult sibling, have the authority to withhold or withdraw 33 life-sustaining procedures from a patient who has a terminal 34 condition, and who is comatose, incompetent, or incapable 35 -8- LSB 1139YH (8) 91 lh/ko 8/ 9

H.F. 708 of communication, and who has not made a declaration for 1 life-sustaining procedures. The bill broadens these categories 2 to include stepchildren, stepparents, and stepsiblings, 3 relatives of the patient, and a close adult friend of the 4 patient. The bill provides restrictions on who may act as a 5 witness to the consultation when the decision is made with the 6 patient’s attending physician. 7 The bill provides that resuscitation may be withheld or 8 withdrawn from a patient who has a terminal condition, and who 9 is comatose, incompetent, or incapable of communication, and 10 who has not executed an out-of-hospital do-not-resuscitate 11 order if there is consultation and written agreement between 12 the patient’s attending physician and certain individuals, in 13 order of priority, making the decision. The individuals who 14 are authorized to make such a decision include an attorney 15 in fact, a guardian, the patient’s spouse, an adult child or 16 stepchild, a parent or stepparent, adult sibling or adult 17 stepsibling, a relative of the patient, and a close adult 18 friend. An individual making a health care decision for such a 19 patient shall be guided by the express or implied intention of 20 the patient in making the decision. A witness, as specified 21 in the bill, shall be present at the time of consultation with 22 the patient’s attending physician when a decision is made to 23 withdraw or withhold resuscitation. 24 Current law requires a guardian to obtain court approval 25 before the guardian may consent to the withholding or 26 withdrawal of life-sustaining procedures for a protected 27 person. The bill makes an exception to this requirement and 28 allows a guardian to make a decision for the protected person 29 relating to hospice care, life-sustaining procedures, and 30 resuscitation without court approval in circumstances detailed 31 in the bill. 32 -9- LSB 1139YH (8) 91 lh/ko 9/ 9