Iowa Living Will Declaration

DECLARATION RELATING TO USE OF LIFE-SUSTAINING PROCEDURES 

IOWA LIVING WILL 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 to withhold or withdraw life-sustaining procedures that merely prolong the dying process and are not necessary to my comfort or freedom from pain.

Signed this ______ day of _________________, 20_____.

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Signature of Person Making Declaration (Declarant)

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(Type or Print Name of Declarant)

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Street Address

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City, State, Zip Code

This Declaration must be witnessed by two persons or be notarized.

STATE OF IOWA, _____________________ COUNTY, ss:

On this ______ day of _________________, 20_____, before me, the undersigned, a Notary Public in and for the State of Iowa, personally appeared ______________________________ to me known to be the person named in and who executed the foregoing instrument as Declarant, and acknowledged that (he) (she) executed the same as (his) (her) voluntary act and deed.

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Notary Public in and for said State

By signing this form I declare that I signed this form in the presence of the other witness and the Declarant and I witnessed the signing by the Declarant or by another person acting on behalf of and at the Declarant's direction.

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Signature of Witness #1

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(Type or Print Name of Witness #1)

__________________________________________
Street Address

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City, State, Zip Code

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Signature of Witness #2

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(Type or Print Name of Witness #2)

__________________________________________
Street Address

__________________________________________
City, State, Zip Code

(IMPORTANT: PLEASE SEE NOTES AS TO USE ON REVERSE SIDE OR THE FOLLOWING PAGE)

General Information on Declaration Relating to Use of Life-Sustaining Procedures

By Iowa Law:

1.     This Declaration will be given effect only when the Declarant's condition is determined to be terminal or Declarant is in a state of permanent unconsciousness and the Declarant is not able to make treatment decisions.

2.     "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. If you do not wish to have nutrition or hydration withdrawn under any circumstances, please consult an attorney for appropriate modification of this Declaration.

3.     It is the responsibility of the Declarant to provide the Declarant's attending physician or health care provider with this Declaration.

4.     This Declaration may be revoked 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 upon communication to such physician by the Declarant, or by another to whom the revocation was communicated by the Declarant.

5.     If this form is witnessed rather than notarized, at least one witness shall be an individual who is not a relative of the Declarant by blood, marriage or adoption within the third degree of consanguinity. The following individuals shall not serve as witness to a Declaration:

a.     A health care provider attending the Declarant on the date of execution.

b.     An employee of a health care provider attending the Declarant on the date of execution.

c.     An individual who is less than eighteen years of age.