Legal briefing: The unbefriended: Making healthcare decisions for patients without surrogates (Part 2)

Journal of Clinical Ethics

Volumn 23, Issue 2, 2012, Pages 177-192

  Pope, Thaddeus Mason ^a   Sellers, Tanya ^b  

^a HAMLINE UNIVERSITY   (United States)

^b WIDENER UNIVERSITY   (United States)

Author keywords

[No Author keywords available]

Indexed keywords

ARTICLE; CUSTODY; DECISION MAKING; EMERGENCY; ETHICS; HUMAN; INFORMED CONSENT; LEGAL ASPECT; MEDICAL STAFF; ORGANIZATION AND MANAGEMENT; PATIENT CARE; PROFESSIONAL STANDARD; UNITED STATES; VOLUNTARY WORKER;

ADVANCE CARE PLANNING; DECISION MAKING; EMERGENCIES; ETHICS COMMITTEES; HUMANS; LEGAL GUARDIANS; MEDICAL STAFF, HOSPITAL; PUBLIC SECTOR; THIRD-PARTY CONSENT; UNITED STATES; VOLUNTARY WORKERS;

EID: 84865130369     PISSN: 10467890     EISSN: None     Source Type: Journal    
DOI: None     Document Type: Article

References (160)

1. I. Hyun et al., "When Patients Do Not Have a Proxy: A Procedure for Medical Decision Making When There Is No One to Speak for the Patient", The Journal of Clinical Ethics 17, no. 4(2006):323-30;
2. D. M. Bartels et al., "Dignity Matters: Advance Care Planning for People Experiencing Homelessness", The Journal of Clinical Ethics 19, no. 3(2008):214-22.
3. N. Karp and E. Wood, Incapacitated and Alone: Healthcare Decision Making for Unbefriended Older People (Washington, D. C.: American Bar Association, 2003);
4. When Others Must Choose: Deciding for Patients without Capacity, (Albany, N. Y.: New York State Task Force on Life and the Law, March 1992), chapter 10;
5. J. E. B. Ortiz, Advocating for the Unbefriended Elderly: An Informational Brief (Washington, D. C.: National Consumer Voice for Quality Long-Term Care, August 2010), http://www.ltcombudsman.org/sites/default/files/ombudsmen-support/ training/Informational-Brief-on-Unbefriended-Elders-0.pdf accessed 27 January 2012;
6. Center for Advocacy for the Rights and Interests of the Elderly (CARIE), White Paper: Meeting the Needs of Persons with Alzheimer's or Other Dementia When No Informal Support is Available, October 2010, http://www.carie.org/ alzheimers-white-paper/, accessed 27 January 2012.
7. The issue has also been described as "one of the most difficult problems in medical decision-making." Guidelines on the Termination of Life-Sustaining Treatment and the Care of the Dying (Briarcliff Manor, N. Y.: Hastings Center, 1987).
8. M. J. Quinn, Guardianships of Adults: Achieving Justice, Autonomy, and Safety (New York: Springer, 2005): 112.
9. "Only a few states specify a procedure [for a] patient without a surrogate." American Medical Directors Association, "White Paper on Surrogate Decision-Making and Advance Care Planning in Long-Term Care, 2003, http://www.amda.com/governance/whitepapers/surrogate/decisionmaking-hierarchy. cfm, accessed 27 January 2012;
10. J. Sacco, "Incapacitated, Alone, and Treated to Death", New York Times, 7 Oct. 2008.
11. M. B. Kapp, "The 'Voluntary' Status of Nursing Facility Admissions: Legal, Practical, and Public Policy Implications", Criminal and Civil Confinement 24, no. 1(1998):1-35;
12. M. B. Kapp, "Editorial-Surrogate Decision-Making for the Unbefriended: Social and Ethical Problem, Legal Solution?" Journal of Ethics, Law, and Aging 1, no. 2(1995):83-5.
13. This briefing does not address some related issues. First, it does not address decision-making mechanisms for special and extraordinary medical situations such as sterilization and the administration of psychotropic medication. Additional protections are usually required in such situations. E.g. Fla. Stat § 765.113. Second, this briefing does not address the situation in which the incapacitated unbefriended patient "objects" to treatment. Third, while this briefing focuses on healthcare decision making, such decisions are often intertwined with those concerning finances. For example, it might be necessary to authorize someone to sell a patient's property so that she or he can qualify for Medicaid and long-term care placement. Fourth, this briefing does not address the participation of the unbefriended in biomedical research.
14. T. M. Pope and T. Sellers, "Legal Briefing: The Unbefriended: Making Healthcare Decisions for Patients Without Surrogates", The Journal of Clinical Ethics 23, no. 1(Spring 2012):84-96.
15. A. K. Dayton, T. H. Guare, L. M. Mezzullo, and M. M. Wood, Advising the Elderly Client (St. Paul, Minn., West, 2011), § 34:10.
16. A. Meisel and K. L. Cerminara, The Right to Die: The Law of End of Life Decisionmaking, 3rd ed. (suppl.) (New York: Aspen, 2010), § 3.26 [A][2].
17. L. M. Beauregard, "Ethics in Electrophysiology: Who Speaks for this Man?" Pacing and Electrophysiology 35, no. 5(May 2012):564-6.
18. E. J. Larson and T. A. Eaton, "Limits of Advance Directives: A History and Assessment of the Patient Self Determination Act", Wake Forest Law Review 32, no. 2(1997):249-94.
19. Rains v. Belshe, 38 Cal. Rptr. 2d 185, 189 (App. 1995) (seven-month delay in obtaining judicial decision authorizing treatment).
20. P. B. Teaster et al., Public Guardianship: In the Best Interest of Incapacitated People? (Santa Barbara, Calif.: ABC-CLIO, 2010).
21. L. A. Frolik and R. L Kaplan, Elder Law in a Nutshell, 5th ed. (St. Paul, Minn.: West, 2010): 251-2.
22. Recently proposed legislation would provide a tax credit for legal expenses paid with respect to establishing guardianship. H. R. 878, 112th Cong., 1st Sess. (2011) (Deutch, D-Fla.).
23. The Boston Globe published an article discussing the dire guardianship situation in Massachusetts. The article notes that there are no prerequisite training requirements to become a guardian. The article discusses how "guardianship businesses" open up, but the compensation is so low that, in order to survive, the businesses take on too many wards to adequately monitor all of them. The wards become neglected and ignored, some receiving only two visits a year from their guardian. The article notes that courts are too overburdened to properly monitor the guardians and fail to demand the filing of required paperwork. For instance, guardians in Massachusetts are required to file an inventory of property and an annual accounting. But in one county, 262 of the 308 guardian cases in the probate court had no filing at all. J. Kelly, M. Kowalski, and C. Novak, "Courts Strip Elders of their Independence", Boston Globe, 13 January 2008.
24. See Mien Others Must Choose, note 2 above, p. 159.
25. Alternate Decision Makers, http://altdecisionmakers.com/, accessed 27 January 2012.
26. ABA Commission on Law and Aging, "State Guardianship Legislation: Directions for Reform 2011", http://www.americanbar.org/content/dam/aba/ uncategorized/2011/2011-aging-gship-elss-2010.authcheckdam.pdf, accessed 27 January 2012.
27. http://www.guardianshipsummit.org/, accessed 27 January 2012.
28. S. 1744, 112th Cong., 1st Sess. (2011) (Klobuchar, D-Minn.).
29. C. Frank, "Surrogate Decision-Making for 'Friendless' Patients", Colorado Lawyer 34, no. 4(April 2005):71-6.
30. C. Griggins, "Patients without Proxies: What's Happening in Other States?" Mid-Atlantic Ethics Committee Newsletter (Summer 2010): 7-9.
31. L. Nerenberg, "Unbefriended Elders Receive Court Protection in California", Aging Today 27, no. 3(2006):10, 15;
32. Cal. Prob. Code § 4650 (c) ("[A] court is normally not the proper forum in which to make healthcare decisions, including decisions regarding life-sustaining treatment.").
33. C. Shay, "Guardianship in Israeli Law-Need for Revisions", ABA Bifocal 31, no. 5(2010):101, 104-7.
34. Shanbuag v. Union of India, Item No. 1A, Court 6, Section 10 (3 July 2011).
35. Guardianship Alliance of Colorado, "Guardianship Alliance Programs and Services", http://guardianshipallianceofcolorado.org/programs.html, accessed 27 January 2012.
36. Guidelines for Emergency Guardianships of Adults in Marion County (Marion County, Ind.: Bureau of Quality Improvement Services, Division of Developmental Disabilities and Rehabilitative Services, Indiana Family and Social Services Administration, March 2008).
37. http://www.arcind.org/index/iags/projectmission-and-goals.asp, accessed 27 January 2012.
38. "Adult Guardianship Issues & Needs", symposium, Indiana Adult Guardianship Services, 12 May 2009, Indianapolis, Ind.
39. The task force consists of various organizations and state agencies, including the Indiana State Guardianship Association (ISGA). The ISGA is a non-profit organization formed to strengthen guardianship and related services through networking, education, and tracking, and commenting on legislation. Among other events, this group conducts annual educational conferences, the most recent being held on 14 June 2011, http://indianaguardian. org/about, accessed 27 January 2012.
40. Ind. Code § 29-3-8-5-1.
41. Ind. Code § 29-3-8.5-4.
42. P. B. Teaster, "The Wards of Public Guardians: Voices of the Unbefriended", Family Relations 51, no. 4(2002):344-50.
43. In re Yeager, 93 P.3d 589 (Colo. App. 2004).
44. P. B. Teaster, E. F. Wood, W. C. Schmidt, and S. A. Lawrance, Public Guardianship after 25 Years: In the Best Interests of Incapacitated People (Washington, D. C.: ABA, 2007), apps.americanbar.org/aging/docs/Guard-report- Exec-Summ.pdf, accessed 27 January 2012.
45. E.g. Minn. Admin. Rule 9525. 3055 (2);
46. In re Shirey, No. 98005210-DD (Mich. Prob. Ct., Montoremcy Cty., 17 Oct. 2005).
47. Ontario Health Care Consent Act of 1996 § 20 (5).
48. NSW Guardianship Act of 1987, Section 36.
49. Va. Code § 37.2-1101 (as amended by S. B. 371 in 2012).
50. Cal. Prob. Code § 3200;
51. Fla. Prob. R. 5.900;
52. Ga. Code Ann. § 31-36A-1 (placement only);
53. Ind. Code Ann. § 16-36-1-8;
54. N. J. Court R. 4:86-12 (special medical guardian);
55. S. D. Cod. L. § 34-12C-4;
56. VA Code Ann. § 37.2-1101
57. formerly cited as Va. Code § 37.1-134.21.
58. In re JM, No. P-036-10 (N. J. Sup. Ct., Chancery Div., Bergen Cty., 2 July 2010).
59. Ga. Code Ann. § 31-9-2 (al). Sample petition forms for the appointment of a temporary medical consent guardian are available at http://www.gaprobate.org/forms/forms10/pdf/11GPCSF%2036.pdf, accessed 27 January 2012.
60. The implementation of this act is being studied. Georgia Appleseed Center for Law and Justice, "Safeguarding Seniors: Informed End of Life Decision Making", http://www.gaappleseed.org/initiatives/elder/, accessed 27 January 2012.
61. Ga. Code Ann. § 29-4-18 (i).
62. E. Phipps and R. Allman, "Potential Impact of Advance Directive Law Act 169 of Decisions and Care for Patients at End of Life: Reflections of Ethics Consultants", http://jdc.jefferson. edu/cgi/view content.cgi?article= 1538&context=hpn, accessed 27 January 2012.
63. W. M. Norris, E. L. Nielsen, R. A. Engelberg, and J. R. Curtis, "Treatment Preferences for Resuscitation and Critical Care among Homeless Persons", Chest 127, no. 6(2005):2180-7. Many states specifically prohibit healthcare providers or employees of a facility to which a patient has been admitted from serving as a patient's surrogate unless they are related to the patient or are a close friend whose friendship preceded the patient's admission.
64. 16 Del. Code § 2503 (h).
65. Sometimes physicians are given far narrower roles with respect to the unbefriended. For example, in Utah, physicians may "complete and sign new Life with Dignity Orders for individuals with prior forms who no longer have capacity to complete new orders, and who do not have a surrogate/guardian to authorize the new order." Utah Admin. Code § R432-31-ll (3).
66. S. C. Code Ann. § 44-66-50.
67. S. C. Code Ann. § 44-66-70 (D).
68. Mo. H. B. 392 §§ 191. 1306 & 191.1310(4), 96th Gen. Assembly (2011) (White).
69. N. C. Gen. Stat. Ann § 90-322 (b).
70. Or. Rev. Stat. Ann. § 127. 635 (3).
71. Conn. Gen. Stat. § 19a-571 (a).
72. Several years ago, in Michigan, a physician was treating 97-year-old Hazel Wagner, a heart attack victim with no chance of recovery. The patient was screaming to the physician, "Help me Jesus!" The physician petitioned the court to end life-support efforts, but the court denied the petition. The court ruled that the petition would have to come from the patient's guardian and that a physician's role was not to advocate, but simply advise. B. Booth, "Doctor's Request to End Patient's Care Denied", American Medical News, 12 June 2006;
73. J. Agar, "Judge Rules Lawton Woman's Life Must Be Preserved", Kalamazoo Gazette, 25 April 2006.
74. N. Sadovnikoff and M. Jurchak, "Substituted Judgment in the Absence of Surrogates", Critical Care Medicine 35, no. 10(2007):2467-8;
75. D. B. White, A. Jonsen, and B. Lo, "Ethical Challenge: When Clinicians Act as Surrogates for Unrepresented Patients", American Journal of Critical Care 21, no. 3(2012):202-7.
76. T. E. Miller, C. H. Coleman, and A. M. Cugliari, "Treatment Decisions for Patients without Surrogates: Rethinking Policies for a Vulnerable Population", Journal of the American Geriatrics Society 45, no. 3(1997):371.
77. Tenn. Code Ann. § 68-11-1806 (c) (5) (alternatively allowing confirmation from an ethics committee).
78. Tex. Health & Safety Code §§ 166.039 (e) & 166.088 (f) ("If there is not a qualified relative available⋯ an out-of-hospital DNR order must be concurred in by another physician who is not involved in the treatment of the patient or who is a representative of the ethics or medical committee of the health care facility in which the person is a patient.").
79. N. C. Gen. Stat. Ann § 90-21. 13 (d).
80. Ariz. Rev. Stat. § 36-3231 (B). The statute prefers that the attending physician consult with and obtain the recommendations of an institutional ethics committee. But if this is not possible, then concurrence of second physician is sufficient.
81. M. Varughese et al., "Ethics and Clinical Practice Guided by the Family Health Care Decisions Act", NYSBA Health Law Journal 16, no. 1(2011):75-82.
82. In re a Patient, 2011 NSWSC 432.
83. The New York State Health Facilities Association has developed model forms that help assure compliance with the statute. "Model Nursing Home Forms for the Family Health Care Decisions Act", http://www.nyshfa.org/ Downloads/FHCDAForms. doc, accessed 27 January 2012.
84. N. Y. Pub. Health Code 2994-g (3) (B);
85. N. J. A. B. 4098 § 3 (a) (1), 214th Legis. (2011) (Conaway). In these cases, pursuant to its institutional policy that is not expressly authorized by Ohio law, the Cleveland Clinic also requires a "social work consultation" to locate surrogates, to assess whether guardianship is appropriate, and to confirm that the patient's best interests are being served.
86. Cleveland Clinic, "Policy on Medical Decision-Making for Patients Lacking Decision-Making Capacity Who Do Not Have a Surrogate Decision-maker", http://my.clevelandclinic.org/Documents/Bioethics/Policy- on-Patients-without-Surrogates.pdf accessed 27 January 2012.
87. N. Y Pub. Health Code § 2994-g (4) (B);
88. N. J. A. B. 4098 § 3 (a) (2), 214th Legis. (2011) (Conaway). In facilities other than general hospitals, the medical director shall make the independent determination that the recommendation is appropriate. In these cases, the Cleveland Clinic also requires a "social work consultation" and a "consultation by the ethics consult service"
89. N. Y. Pub. Health Code §§ 2994-a (19), 2994-g (3) (A) & 2994-g (4) (A);
90. N. J. A. B. 4098 § 1, 214th Legis. (2011) (Conaway).
91. N. Y. Pub. Health Code § 2994-g (5);
92. N. J. A. B. 4098 § 3 (b), 214th Legis. (2011) (Conaway). The Cleveland Clinic does not have a substantive rule like New York. Instead, it requires both a "concurring medical opinion" and approval of a "multidisciplinary subcommittee of the Ethics Committee"
93. N. Y. Pub. Health Code § 2966.
94. 38 C. F. R. § 17.32 (f);
95. VHA Handbook 1004.01 (14) (c). Still, treatment must not be provided indefinitely without review of the treatment plan at least every six months by the attending practitioner of record and the service chief, or designee, to ensure that clinical objectives are being met and the treatment plan is in the best interests of the patient.
96. NSW Guardianship Act of 1987, § 37 (2)-(3).
97. NSW Guardianship Act of 1987, § 36 (l) (b).
98. Fla. Stat. § 765. 401 (h).
99. L. A. Frolic, "Aging and the Law", paper presented at the 2012 Annual Meeting of the American Association of American Law Schools on 6 January 2012 in Washington, D. C.
100. The authors thank Carol S. Huffman, owner of a Florida-based surrogate service, Social Work Advantage, for a telephone interview, 12 January 2012. They thank Ken Goodman for a telephone interview, 3 February 2012.
101. Tex. Health & Safety Code § 313. 004 (a) (5). The original Consent to Medical Treatment Act was limited to patients in a nursing facility or hospital. In 2007, the legislature added "home and community support services"
102. Tex. H. B. 3473, 80th Legis. (2007) (Delisi).
103. The scope of consent does not include life-sustaining treatment. Tex. Health & Safety Code § 313. 003 (b).
104. Tex. H. B. 1128, 82nd Legis. (2011)
105. enacted, Tex, L. ch. 253.
106. D. C. Code § 21-2210 (a) (5a);
107. Ind. Code Ann. § 16-36-l-5 (a) (3);
108. Ind. Code § 16-36-4-13 (g) (7);
109. Tex. Health & Safety Code § 313.004 (a) (5).
110. Or. Rev. Stat. § 127. 635 (3) ("If none of the persons described in subsection (2) of this section is available, then life-sustaining procedures may be withheld or withdrawn upon the direction and under the supervision of the attending physician. ").
111. Ore. S. B. 579 § 2 (a), 76th Legis. Assembly (2011) (Johnson), enacted
112. 2011 Ore. Laws Ch. 512. The authors thank Barbara Glidwell, the longtime patient advocate at Oregon Health Sciences University, for her generous telephone interview, 27 September 2011.
113. Miss. Code Ann. § 41-41-215 (9).
114. W. Va. Code Ann. § 16-30-8 (a) (7).
115. W. Va. Admin. Rule 64-86-4.
116. D. B. White et al., "Life Support for Patients without a Surrogate Decision Maker: Who Decides?" Annals of Internal Medicine 147, no. 1(2007):34-40;
117. D. B. White et al., "Decisions to Limit Life-Sustaining Treatment for Critically Ill Patients Who Lack Both Decision-Making Capacity and Surrogate Decision-Makers", Critical Care Medicine 34, no. 8(2006):2053-9.
118. AMA, Code of Medical Ethics § 8.081.
119. D. Meier, "Editorial-Voiceless and Vulnerable: Dementia Patients without Surrogates in an Era of Capitation", Journal of the American Geriatrics Society 45, no. 3(1997):375-7.
120. Ala. Code § 22-8A-ll (d) (7). "In the event a surrogate decision is being made by an ethics committee or appointed committee of the facility where the patient is undergoing treatment or receiving care, the facility shall notify the Alabama Department of Human Resources for the purpose of allowing the department to participate in the review of the matter"
121. Ga. Code Ann. § 31-39-4 (e).
122. R. M. Gibson, "IDT Decision-Making in California Long-Term Care Facilities", California Association of Long-Term Care Medicine (December 2011), http://caltcm.org/news/dec2011/idt, accessed 27 January 2012. IDTs are sometimes known as "Epple Committees" because they are named after California State Assemblyman Bob Epple, who sponsored the legislation that created them.
123. Cal. A. B. 3209 (1992).
124. Cal. Health & Safety Code § 1418.8 (e).
125. Rains v. Belshe, 38 Cal. Rptr. 2d 185 (Ct. App. 1995).
126. The original bill, A. B. 891 (1999) (Alquist), proposed new Probate Code sections 4720 to 4725, which would have addressed decision making for the unbefriended. Indeed, the problem of the unbefriended was an original and key motivation for the entire Health Care Decisions Act. But these provisions were politically controversial.
127. They were removed so that the rest of the bill could move forward. California Law Review Commission, Memo 99-39 (6 October 1999), http://www.clrc.ca.gov/pub/1999ZM99-39.pdf, accessed 27 January 2012;
128. California Law Review Commission, 2000 Health Care Decisions Law and Revised Power of Attorney Law (March 2000), http://www.clrc.ca.gov/pub/Printed- Reports/Pub208.pdf, accessed 27 January 2012.
129. Ariz. Rev. Stat. § 36-3231 (B).
130. De Kalb, 655 S. E.2d at 825;
131. Guidelines on the Termination of Life-Sustaining Treatment and the Care of the Dying, see note 3 above, § II (3) (c) (3).
132. 38 C. F. R. § 17. 32 (f) (2);
133. "Informed Consent for Clinical Treatments and Procedures", VHA Handbook 1004.01 (14) (14 August 2009). The chief of staff and the facility director must approve the withdrawal of any life sustaining treatment. The patient's record must be documented accordingly. The treating physician is not permitted to be a member of the committee. The committee must use the substituted judgment standard, if possible, and, if not, must decide based on the best interest of the patient. The committee should seek input from the patient's religious, ethnic, or cultural groups.
134. Ore. S. B. 579 § 2 (b), 76th Legis. Assembly (2011) (Johnson).
135. E. D. Isaacs and R. V. Brody, "The Unbefriended Adult Patient", San Francisco Medicine (July/August 2010): 25-6 (describing the process at San Francisco General Hospital);
136. In re Browning, 543 So. 2d 258, 273 (Fla. App. 1989) ("Until we see evidence of some abuse by an informal forum, we believe its advantages outweigh its disadvantages.");
137. T. M. Pope, "Multi-Institutional Healthcare Ethics Committees: the Procedurally Fair Internal Dispute Resolution Mechanism", Campbell Law Review 31, no. 2(2009):257-331;
138. http://www.sccma-mcms.org, accessed 27 January 2012. While not specifically authorized in California law, the Santa Clara policy has received judicial endorsement and deference.
139. "Ethics Subcommittee Surrogate for Patients", Medical Ethics Advisor, 1 September 2004.
140. Santa Clara Valley Medical Center, "Administrative Policies and Procedures Manual, VMC 301.14, Healthcare Decisions for Incapacitated Patients without Surrogates", 18 January 2011.
141. I. C. Freeman, "One More Faulty Solution Is Novelty without Progress: A Reply to "Medical Decision-Making for the Unbefriended Nursing Home Resident", Journal of Ethics, Law, and Aging 1, no. 2(1995):93-6.
142. C. J. Sundram, "Informed Consent for Major Medical Treatment of Mentally Disabled People: A New Approach", New England Journal of Medicine 318, no. 21(1988):1368-73;
143. S. S. Herr and B. L. Hopkins, "Health Care Decision Making for Persons with Disabilities: An Alternative to Guardianship", Journal of the American Medical Association 271, no. 13(1994):1017-22;
144. R. S. Olick and K. Faber-Langendoen, "Caring for Patients without Surrogates under the FHCDA", Bioethics in Brief (March 2011): 1-3;
145. C. J. Sundram et al., "The First Ten Years of New York's Surrogate Decision-Making Law: History of Development", in Representing People with Disabilities, 3rd ed., ed. P. W. Johnson et al., 2007, http://cqc.ny.gov/first- ten-years-history-and-development, accessed 27 January 2012.
146. N. Y. Mental Hygiene Code § 80.01, http://cqc.ny.gov/advocacy/ surrogate-decision-making/SDMC-statute, accessed 27 January 2012.
147. 14 NYCRR§ 710.4 (c) (13), http://cqc.ny.gov/advocacy/surrogate- decision-making/new-yorkstate-SDMC-regulations, accessed 27 January 2012.
148. 14 NYCRR § 710.5 (a).
149. New York Commission on Quality of Care and Advocacy for Persons with Disabilities, "Surrogate Decision-Making", http://www.cqc.ny.gov/ advocacy/surrogate-decision-making, accessed 27 January 2012.
150. Tex. Health & Safety Code § 597. 042;
151. 40 Tex. Admin. Code, Part 1, Chapter 9, Subchapter E, Division 10.
152. Texas Department of Aging and Disability Services, "Surrogate Decision Making Program", http://www.dads.state.tx.us/services/crs/ surrogate/index.html, accessed 27 January 2012.
153. Tex. H. B. 1270, 76th Legis. (1999) (Lewis, Glenn).
154. Iowa Code Ann. § 135.29.
155. Iowa Code Ann. § 135.29;
156. Iowa Department of Public Health, "Substitute Medical Decision-Making Board", http://www.idph.state.ia.us/bh/substitute-decision. asp, accessed 27 January 2012.
157. Iowa Admin. Code R. 641-85.2 (5).
158. Iowa Admin. Code R. 641-85.3 (1).
159. Iowa State Board of Health, "Agenda", 14 March 2012, http://www.idph.state.ia.us/IDPHChannelsService/file.ashx?file= 21EFBB4A-221C-46E0-8F3B-98414FF2C08E, accessed 5 May 2012.
160. Iowa Code, Ann. § 231E.4.