Iowa Durable Power of Attorney for Health Care

IOWA DURABLE POWER OF ATTORNEY FOR HEALTH CARE

Suggested Form Based on Iowa Code § 144B.5

IMPORTANT INFORMATION

This is a suggested form based on the optional language in Iowa Code § 144B.5. Iowa does not require the exact wording of § 144B.5. A durable power of attorney for health care must substantially comply with chapter 144B.

Your agent (attorney in fact) may make a health care decision for you only when you are unable, in the judgment of your attending physician or attending physician assistant, to make that decision. If you object to a decision to withhold or withdraw health care, you are presumed able to make the decision.

Under Iowa Code chapter 144B, nutrition or hydration is included in “health care” only when required to be provided parenterally or through intubation. The general authority granted below includes decisions concerning nutrition or hydration provided in that manner unless you expressly limit your agent’s authority. This form does not give your agent authority over ordinary oral food or drink.

Your agent’s authority is subject to the limitations in this document and applicable Iowa law. Discuss this document with the person you name and with your clinician. Give signed copies to your agent, alternates, and health care providers. It is your responsibility to notify providers of the terms of this document.

You may revoke this durable power of attorney at any time and in any manner by which you are able to communicate your intent to revoke. A revocation is effective as to a health care provider when it is communicated to that provider. Unless this document provides otherwise, a valid new durable power of attorney for health care revokes any prior durable power of attorney for health care.

If you designate your spouse and the marriage is later dissolved, Iowa Code § 144B.12(3) provides that “the power is thereby revoked.” Remarriage to each other reinstates the power unless you have otherwise revoked it.

To make this document effective, date and sign it (or have another person sign it at your direction), then either (1) have at least two qualified adult witnesses, present with each other and with you, witness the signing, with at least one witness not related to you by blood, marriage, or adoption within the third degree of consanguinity, or (2) acknowledge it before a notarial officer within Iowa under chapter 9B. Complete one execution path.

1. PRINCIPAL

My full legal name: ________________________________________________

Date of birth: ____________________________

Address: _______________________________________________________

City, State, ZIP: ________________________________________________

Telephone: ____________________________

2. DESIGNATION OF ATTORNEY IN FACT (AGENT)

Do not designate as attorney in fact a health care provider attending you on the date of execution, or an employee of that provider unless the employee is related to you by blood, marriage, or adoption within the third degree of consanguinity. (Iowa Code § 144B.4.)

Attorney in fact full legal name: ________________________________________

Relationship to me (optional): ____________________________________

Address: _______________________________________________________

City, State, ZIP: ________________________________________________

Telephone: ____________________________

Email (optional): ________________________________________

3. STATUTORY GRANT OF AUTHORITY (IOWA CODE § 144B.5)

The following language is the optional form set out in Iowa Code § 144B.5(1). The person named above is the attorney in fact designated in this section.

I hereby designate the person named in Section 2 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, 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 of this state, to consent to my physician or physician assistant 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.

4. OPTIONAL INSTRUCTION CONCERNING NUTRITION OR HYDRATION

Iowa Code chapter 144B includes nutrition or hydration within “health care” only when required to be provided parenterally or through intubation. Initial ONE choice only if you wish to address this authority specifically. If neither choice is initialed, the general authority granted above remains unchanged. Do not initial both choices. This section does not address ordinary oral food or drink.

(___) I CONFIRM that my agent may consent to, refuse consent to, or withdraw consent to nutrition or hydration required to be provided parenterally or through intubation, including decisions to start, continue, withhold, or withdraw it, subject to my other instructions.

(___) I LIMIT my agent’s authority: my agent shall not consent to withholding or withdrawing nutrition or hydration required to be provided parenterally or through intubation.

5. STATEMENT OF DESIRES, SPECIAL PROVISIONS, AND LIMITATIONS

Optional. State any treatment you want or do not want, limits on your agent’s authority, or other instructions consistent with chapter 144B.

______________________________________________________________

______________________________________________________________

______________________________________________________________

______________________________________________________________

______________________________________________________________

6. OPTIONAL ATTORNEY-IN-FACT CONSENT CONFIRMATION

Optional written confirmation. Under Iowa Code § 144B.1(1), an attorney in fact is a person who has consented to act.

I have been notified of this designation and consent to act as attorney in fact for the principal named in this document.

Attorney in fact signature: ________________________________________

Printed name: ________________________________________

Date: ______________________

7. ALTERNATE ATTORNEYS IN FACT

Optional. If the primary attorney in fact is unable, unwilling, unavailable, or ineligible to act, I designate the following alternatives to serve individually in the order listed, with the same authority.

First alternate attorney in fact

Full legal name: __________________________________________

Address: _______________________________________________________

Telephone: ____________________________

Second alternate attorney in fact

Full legal name: __________________________________________

Address: _______________________________________________________

Telephone: ____________________________

8. FINAL DISPOSITION DESIGNEE (CHAPTER 144C)

This instrument does not itself designate a person under Iowa Code chapter 144C. A separate chapter 144C declaration may be completed or attached, but it must independently satisfy that chapter’s requirements.

9. PRIOR DESIGNATIONS

Unless I provide otherwise in Section 5, this durable power of attorney for health care revokes any prior durable power of attorney for health care. (Iowa Code § 144B.8(3).)

10. DATE AND SIGNATURE OF PRINCIPAL

I am at least eighteen years of age. I understand this document and sign it voluntarily.

Date of execution: ____________________________

City and State where signed: ________________________________________

Principal signature: __________________________________________

Principal printed name: ________________________________________

If another person signs at the principal’s direction:

Directed signer’s signature: ______________________________________

Directed signer’s printed name: ____________________________________

COMPLETE EITHER SECTION 11 (TWO WITNESSES) OR SECTION 12 (IOWA NOTARY). You need only one path.

11. ALTERNATIVE A: STATEMENT OF TWO QUALIFIED WITNESSES

Two individuals must sign. In the presence of each other and the principal, each witness must witness the principal sign this instrument, or witness another person sign it on the principal’s behalf at the principal’s direction. At least one witness must not be a relative of the principal by blood, marriage, or adoption within the third degree of consanguinity. (Iowa Code § 144B.3.)

Witness 1

By signing, I declare that I am at least eighteen years old; I am not a health care provider attending the principal on the date of execution; I am not an employee of such a provider; and I am not a person designated in this instrument as an attorney in fact or alternative attorney in fact. In the presence of the other witness and the principal, I witnessed the principal sign this instrument, or witnessed another person sign it on the principal’s behalf at the principal’s direction.

Initial if true (at least one of the two witnesses must initial):

(___) I am not a relative of the principal by blood, marriage, or adoption within the third degree of consanguinity.

Witness signature: ________________________________________

Printed name: ________________________________________

Date: ______________________

Residence address: ________________________________________________

Witness 2

By signing, I declare that I am at least eighteen years old; I am not a health care provider attending the principal on the date of execution; I am not an employee of such a provider; and I am not a person designated in this instrument as an attorney in fact or alternative attorney in fact. In the presence of the other witness and the principal, I witnessed the principal sign this instrument, or witnessed another person sign it on the principal’s behalf at the principal’s direction.

Initial if true (at least one of the two witnesses must initial):

(___) I am not a relative of the principal by blood, marriage, or adoption within the third degree of consanguinity.

Witness signature: ________________________________________

Printed name: ________________________________________

Date: ______________________

Residence address: ________________________________________________

12. ALTERNATIVE B: IOWA NOTARIAL ACKNOWLEDGMENT (CHAPTER 9B)

Use this path instead of the two-witness path. Acknowledgment must be before a notarial officer within Iowa as provided in chapter 9B.

State of Iowa, County of: ______________________________

This record was acknowledged before me on ____________________ by ____________________________.

Signature of notarial officer: ______________________________________

Printed name: ________________________________________

Title of office: ____________________________________

My commission expires: ____________________________