ARC 0621D

ARC 0621D

PUBLIC HEALTH DEPARTMENT[641]

Notice of Intended Action

Proposing rulemaking related to out-of-hospital do-not-resuscitate orders
and providing an opportunity for public comment

    The Department of Health and Human Services hereby proposes to amend Chapter 142, “Out-of-Hospital Do-Not-Resuscitate Orders,” Iowa Administrative Code.

Legal Authority for Rulemaking

    This rulemaking is proposed under the authority provided in Iowa Code chapter 147A and section 144A.7A.

State or Federal Law Implemented

    This rulemaking implements, in whole or in part, Iowa Code chapter 147A and section 144A.7A and 2026 Iowa Acts, House File 2305.

Purpose and Summary

     This proposed rulemaking implements 2026 Iowa Acts, House File 2305, by updating the definition of who can serve as an attending provider for the purposes of an out-of-hospital do-not-resuscitate (OOH DNR) order.

Regulatory Analysis

    A Regulatory Analysis for this rulemaking was published in the Iowa Administrative Bulletin on August 19, 2026. A public hearing was held on the following date(s):

     ?   September 8, 2026

Fiscal Impact

     This rulemaking has no fiscal impact to the State of Iowa.

Jobs Impact

    After analysis and review of this rulemaking, no impact on jobs has been found.

Waivers

    Any person who believes that the application of the discretionary provisions of this rulemaking would result in hardship or injustice to that person may petition the Department for a waiver of the discretionary provisions, if any, pursuant to 441—Chapter 2504.

Public Comment

     Any interested person may submit written or oral comments concerning this proposed rulemaking, which must be received by the Department no later than 4:30 p.m. on October 20, 2026. Comments should be directed to:

Public Hearing

     A public hearing at which persons may present their views orally or in writing will be held as follows:

    Persons who wish to make oral comments at the public hearing may be asked to state their names for the record and to confine their remarks to the subject of this proposed rulemaking.

     Any persons who intend to attend the public hearing and have special requirements, such as those related to hearing or mobility impairments, should contact the Department and advise of specific needs.

Review by Administrative Rules Review Committee

    The Administrative Rules Review Committee, a bipartisan legislative committee which oversees rulemaking by executive branch agencies, may, on its own motion or on written request by any individual or group, review this rulemaking at its regular monthly meeting or at a special meeting. The Committee’s meetings are open to the public, and interested persons may be heard as provided in Iowa Code section 17A.8(6).

    The following rulemaking action is proposed:

    ITEM 1.  Amend rule 641—142.1(144A), definitions of “Attending physician,” “Health care provider,” “Life-sustaining procedure,” “Out-of-hospital do-not-resuscitate order,” “Resuscitation” and “Terminal condition,” as follows:

    “Attending physician provider” means a physician selected by, or assigned to, the patient who has primary responsibility for the treatment and care of the patient the same as defined in Iowa Code section 135J.1.

    “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 the same as defined in Iowa Code section 144A.2.

    “Life-sustaining procedure” means any medical procedure, treatment, or intervention, including resuscitation, which utilizes mechanical or artificial means to sustain, restore or supplant a spontaneous vital function, and when applied to a patient in a terminal condition, would serve only to prolong the dying process. “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 the same as defined in Iowa Code section 144A.2.

    “Out-of-hospital do-not-resuscitate order” or “OOH DNR order” means a written order on a form approved by the department, signed by an attending physician, executed in accordance with the requirements of Iowa Code section 144A.7A and issued consistent with Iowa Code section 144A.2, that directs the withholding or withdrawal of resuscitation when an adult patient in a terminal condition is outside the hospital the same as defined in Iowa Code section 144A.2.

    “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 the same as defined in Iowa Code section 144A.2.

    “Terminal condition” means an incurable or irreversible condition that, without the administration of life-sustaining procedures, will, in the opinion of the attending physician, 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 the same as defined in Iowa Code section 144A.2.

    ITEM 2.  Rescind the definition of “Attending physician associate” in rule 641—142.1(144A).

    ITEM 3.  Amend subrule 142.2(1) as follows:

    142.2(1) OOH DNR physician or physician associate Attending provider order. The department designates the OOH DNR order form contained in Appendix A as the uniform OOH DNR order form to be used statewide. If an attending physician or attending physician associate provider issues an OOH DNR order for a qualified patient, the physician or physician associate attending provider must use the form contained in Appendix A.

    ITEM 4.  Amend subrule 142.4(1) as follows:

    142.4(1) Attending physicians or attending physician associates providers who issue OOH DNR orders. The attending physician or attending physician associate provider should ensure that the following are accomplished:

    a. and b. No change.

    c.  If the qualified patient or individual legally authorized to act on the patient’s behalf decides that the patient should not be resuscitated, the attending physician or attending physician associate provider may issue the OOH DNR order on the prescribed uniform order form. The order will direct health care providers to withhold or withdraw resuscitation.

    d. to f. No change.

    ITEM 5.  Amend rule 641—142.7(144A) as follows:

641—142.7(144A) Transfer of patients. Attending providers shall comply with the provisions of Iowa Code section 144A.8.

    142.7(1) An attending physician or attending physician associate who is unwilling to comply with an OOH DNR order or who is unwilling to comply with the provisions of Iowa Code section 144A.7A shall take all reasonable steps to effect the transfer of the patient to another physician or physician associate.

    142.7(2) If the policies of a hospital, nursing home, home health care agency, hospice or other health care organization preclude compliance with the OOH DNR order of a qualified patient, the provider shall take all reasonable steps to effect the transfer of the patient to an organization in which the provisions of Iowa Code section 144A.7A can be carried out.

ITEM 6.  Amend 641—Chapter 142, Appendix A, as follows:

APPENDIX A

Iowa Department of Health and Human Services

OUT-OF-HOSPITAL DO-NOT-RESUSCITATE ORDER

(Please type or print)

Date of Order: _____/_____/_____

Patient Information:

Name: (Last)____________________(First)____________________(Middle)__________________

Address: _____________________________(City)___________________(Zip)____________

Date of Birth: _____/_____/_____ Sex (Circle): M or F

Name of Hospice or Care Facility (if applicable):

Attending Physician or Physician Associate Provider Order

As the attending physician or attending physician associate provider for the above-named patient, I certify that this individual is over 18 years of age and has a terminal diagnosis. After consultation with this patient (or the patient’s legal representative), I hereby direct any and all health care providers, including qualified emergency medical services (EMS) personnel, to withhold or withdraw the following life-sustaining procedures in accordance with Iowa law (Iowa Code chapter 142A):

     ?   Cardiopulmonary Resuscitation/Cardiac Compression (Chest Compressions).

     ?   Endotracheal Intubation/Artificial or Mechanical Ventilation (Advance Airway Management).

     ?   Defibrillation and Related Procedures.

     ?   Use of Resuscitation Drugs.

This directive does NOT apply to other medical interventions for comfort care.

To the extent that it is possible, a person designated by the patient may revoke this order on the patient’s behalf. If the patient wishes to authorize any other person(s) to revoke this order, the patient MUST list those persons’ names below:

Name:

Name:

Name:

Name:

Patients, please note: Directions for obtaining a uniform identifier are listed on the back of this form. The uniform identifier is the key way the health care provider and/or EMS personnel can quickly recognize that you have an Out-of-Hospital Do-Not-Resuscitate order. If you are not wearing an identifier, the health care provider and/or EMS personnel may not realize that you do not want to be resuscitated.

Physicians or physician associates Attending providers, please note: Information regarding the completion of an Out-of-Hospital Do-Not-Resuscitate order is on the back of this form.

APPENDIX A

Directions for obtaining a uniform identifier:

The uniform identifier may be obtained through MedicAlert®¹, which requires:

    1.   A completed MedicAlert® application, which is available in physician, or physician associate, or ARNP offices or through MedicAlert® by phoning (800)432-5378 or by visiting the website www.medicalert.org, and submitting the fee.

    2.   A copy of this completed OOH DNR order, which must accompany the MedicAlert® application or be sent to MedicAlert® prior to the identifier’s being mailed.

¹MedicAlert® is a nonprofit 501C membership organization.

Suggested guidelines for physicians or physician associates attending providers:

    1.   Please review the Iowa Out-of-Hospital Do-Not-Resuscitate order and related protocol with the patient/patient’s legal representative(s). The following points may be helpful:

     ?   Patient/patient’s legal representative(s) listed on this order must understand the significance of this order, that in the event the patient’s heart or breathing stops or malfunctions, the anticipated result of this order is death.

     ?   Patient/patient’s legal representative(s) listed on this order may revoke this directive at any time. However, the desire to revoke must be communicated to the EMS or other health care professionals at the scene.

     ?   It is important to emphasize that this order does not apply to medical interventions to make the patient more comfortable.

     ?   The importance of wearing the uniform identifier for those qualified patients who would benefit from the mobility this offers should be stressed. It is also helpful to walk patients through the process they must follow to acquire the identifier.

    2.   Provide a copy of this order to the patient/patient’s legal representative(s) listed on this order and place the original in the patient’s medical records.

The OOH DNR Order form is available through the department’s website.

    ITEM 7.  Amend 641—Chapter 142, Appendix B, as follows:

APPENDIX B

EMS OUT-OF-HOSPITAL DO-NOT-RESUSCITATE PROTOCOL

Purpose: This protocol is intended to avoid unwarranted resuscitation by emergency care providers in the out-of-hospital setting for a qualified patient.¹ There must be a valid Out-of-Hospital Do-Not-Resuscitate (OOH DNR) order signed by the qualified patient’s attending physician or physician associate provider or the presence of the OOH DNR identifier indicating the existence of a valid OOH DNR order.

No resuscitation: Means withholding any medical intervention that utilizes mechanical or artificial means to sustain, restore, or supplant a spontaneous vital function, including but not limited to:

    1.   Chest compressions,

    2.   Defibrillation,

    3.   Esophageal/tracheal/double-lumen airway; endotracheal intubation, or

    4.   Emergency drugs to alter cardiac or respiratory function or otherwise sustain life.

Patient criteria: The following patients are recognized as qualified patients to receive no resuscitation:

    1.   The presence of the uniform OOH DNR order or uniform OOH DNR identifier, or

    2.   The presence of the attending physician or attending physician associate provider to provide direct verbal orders for care of the patient.

The presence of a signed physician or physician associate attending provider order on a form other than the uniform OOH DNR order form approved by the department may be honored if approved by the service program EMS medical director. However, the immunities provided by law apply only in the presence of the uniform OOH DNR order or uniform OOH DNR identifier. When the uniform OOH DNR order or uniform OOH DNR identifier is not present, contact must be made with on-line medical control and on-line medical control must concur that no resuscitation is appropriate.

Revocation: An OOH DNR order is deemed revoked at any time that a patient, or an individual authorized to act on the patient’s behalf as listed on the OOH DNR order, is able to communicate in any manner the intent that the order be revoked. The personal wishes of family members or other individuals who are not authorized in the order to act on the patient’s behalf shall not supersede a valid OOH DNR order.

Comfort Care (?): When a patient has met the criteria for no resuscitation under the foregoing information, the emergency care provider should continue to provide that care which is intended to make the patient comfortable (a.k.a. ?Comfort Care). Whether other types of care are indicated will depend upon individual circumstances for which medical control may be contacted by or through the responding ambulance service personnel.

?Comfort Care may include but is not limited to:

    1.   Pain medication.

    2.   Fluid therapy.

    3.   Respiratory assistance (oxygen and suctioning).

¹Qualified patient means an adult patient determined by an attending physician or attending physician associate provider to be in a terminal condition for which the attending physician or attending physician associate provider has issued an Out-of-Hospital DNR order in accordance with the law. (Rule 641—142.1(144A), definitions)