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Release: April 30, 2002

UI project helps secure new health care rights for terminally ill

Investigators in the University of Iowa College of Public Health were instrumental in the development of a new state law that provides expanded rights for terminally ill Iowans. Under the legislation, terminally ill patients who are not in the hospital will no longer have to worry about receiving unwanted and painful resuscitation while they are dying.

The law signed by Iowa Gov. Tom Vilsack on April 4 allows new out-of-hospital do not resuscitate (DNR) orders to be authorized by licensed physicians, ensuring that a terminally ill patient's wish not to be resuscitated will be honored. On the form, a physician will document that a patient has an incurable disease from which they are not expected to survive or is in a persistent vegetative state, and that the patient expressly desires to refuse resuscitation care.

The legislation was initiated by the Iowa Partnership for Quality Care in Dying with Dignity: Advancing Comfort, Choice and Control, a community-state coalition housed in the UI College of Public Health. Throughout 2001, the partnership worked in conjunction with the Iowa Medical Society to facilitate a consensus-building process with representatives from more than 40 organizations with differing opinions on implementing a statewide out-of-hospital DNR order process. At least 43 states have statutory or regulatory out-of-hospital DNR processes.

"This law is important because it not only provides emergency services personnel with legal protection to honor the end-of-life care wishes of those patients unable to speak for themselves, but also includes provisions for comfort care," said Douglas Wakefield, Ph.D., UI professor of health management and policy and lead investigator of the Iowa Partnership for Quality Care in Dying with Dignity.

Prior to the new law's enactment, terminally ill Iowans who chose not to spend their last days in a hospital could not be certain their wishes would be honored because there was no uniform or consistent way for emergency medical service (EMS) providers or other health care providers, such as long-term care personnel, to verify a patient's wishes. EMS/health care providers are obligated to provide life-sustaining care until it has been made clear that the patient wants to refuse resuscitation. In a hospital setting, a DNR order in a patient's chart is generally followed.

A DNR is a physician's order authorizing other health care providers to let a patient die when their body gives out -- without subjecting them to unwanted medical intervention. This physician-directed order adds the protection of physician involvement and extends many of the same rights existing in Iowa's living will statute beyond the hospital in-patient environment. Patients and their families can still expect excellent medical care, including comfort care, when resuscitation is not provided.

"The intent of the law is not to discourage resuscitation, which has great value for many patients. However, failure to honor a patient's refusal of resuscitation may add to the patient's suffering during the dying process. Resuscitation can be painful and often futile on patients weakened by end-stage illness. Honoring the patient's choice in this setting is the right thing to do," said Tim Peterson, M.D., chief and medical director of the Bureau of EMS, Iowa Department of Public Health.

The Iowa Partnership for Quality Care in Dying with Dignity is committed to improving quality of care for all Iowans who are near the end of life. The coalition is funded in part by a grant from The Robert Wood Johnson Foundation.