TEXAS
Advance Directive
Planning for Important Healthcare Decisions
Caring Connections, 1700 Diagonal Road, Suite 625, Alexandria, VA 22314
www.caringinfo.org, 800/658-8898
Caring Connections, a program of the National Hospice and Palliative Care Organization
(NHPCO), is a national consumer engagement initiative to improve care at the end of life, supported
by a grant from The Robert Wood Johnson Foundation.
The goal of Caring Connections is for consumers to hear a unified message promoting awareness
and action for improved end-of-life care. Through these efforts, NHPCO seeks to support those
working across the country to improve end-of-life care and conditions for all Americans.
Caring Connections tracks and monitors all state and federal legislation and significant court cases
related to end-of-life care to ensure that our advance directives are always up to date.
CARING CONNECTIONS
HelpLine
You can call our toll-free HelpLine, 800/658-8898, if you have any difficulty understanding your
state-specific advance directive, or if you are dealing with a difficult end-of-life situation and need
immediate information. We can help provide resources and information on questions like these:
• How do I communicate my end-of-life wishes to my family?
• What type of end-of-life care is available to me?
• What questions should I ask my mother’s doctors about her end-of-life care?
It’s About How You LIVE
It’s About How You LIVE is a national community engagement campaign encouraging individuals
to make informed decisions about end-of-life care and services. The campaign encourages people
to:
Learn about options for end-of-life services and care
Implement plans to ensure wishes are honored
Voice decisions to family, friends and health care providers
Engage in personal or community efforts to improve end-of-life care
Please call the HelpLine at 800/658-8898 to learn more about the LIVE campaign, obtain free
resources, or to join the effort to improve community, state and national end-of-life care.
HOW TO USE THESE MATERIALS
1. Check to be sure that you have the
materials for your state. You should complete
a form for the state in which you expect to
receive health care.
2. These materials include:
• Instructions for preparing your
advance directive.
• Your state-specific advance directive
forms, which are the pages with the
gray instruction bar on the left side.
3. Read the instructions in their entirety.
They give you specific information about the
requirements in your state.
4. You may want to photocopy these forms
before you start so you will have a clean copy
if you need to start over.
5. When you begin to complete the form,
refer to the gray instruction bars - they
indicate where you need to mark, insert your
personal instructions, or sign the form.
6. Talk with your family, friends, and
physicians about your decision to complete an
advance directive. Be sure the person you
appoint to make decision on your behalf
understands your wishes.
If you have questions or need guidance in
preparing your advance directive or about
what you should do with it after you have
completed it, you may call our toll free
number 800/ 658-8898 and a staff member
will be glad to assist you.
For more information contact:
The National Hospice and Palliative Care Organization
1700 Diagonal Road, Suite 625
Alexandria, VA 22314
Call our HelpLine: 800/658-8898
Visit our Web site: www.caringinfo.org
Formerly a publication of Last Acts Partnership.
Support for this program is provided by a grant from
The Robert Wood Johnson Foundation, Princeton,
New Jersey.
Copyright © 2005 National Hospice and Palliative Care Organization. All rights reserved. Revised
May 2005. Reproduction and distribution by an organization or organized group without the written
permission of the National Hospice and Palliative Care Organization is expressly forbidden.
INTRODUCTION TO YOUR TEXAS ADVANCE DIRECTIVES
This packet contains two legal documents that protect your right to refuse medical treatment you
do not want, or to request treatment you do want, in the event you lose the ability to make
decisions yourself:
1. The Texas Medical Power of Attorney lets you name someone to make decisions about your
medical care—including decisions about life support—if you can no longer speak for yourself.
Your attending physician must certify in writing that you are unable to make health care
decisions and file the certification in your medical record. The Medical Power of Attorney is
especially useful because it appoints someone to speak for you any time you are unable to make
your own medical decisions, not only at the end of life.
2. The Texas Directive to Physicians and Family or Surrogates is your state’s living will. It
lets you state your wishes about medical care in the event that you develop a terminal or
irreversible condition and can no longer make your own medical decisions. The Directive
becomes effective when your attending physician certifies in writing that you are in a terminal or
irreversible condition.
Caring Connections recommends that you complete both of these documents to best ensure that
you receive the medical care you want when you can no longer speak for yourself.
Note: These documents will be legally binding only if the person completing them is a competent
adult, 18 years or older or a person under 18 years of age who has had the disabilities of
minority removed.
COMPLETING YOUR TEXAS MEDICAL POWER OF ATTORNEY
Whom should I appoint as my agent?
Your agent is the person you appoint to
make decisions about your medical care if
you become unable to make those decisions
yourself. Your agent may be a family
member or a close friend whom you trust to
make serious decisions. The person you
name as your agent should clearly
understand your wishes and be willing to
accept the responsibility of making medical
decisions for you. (An agent may also be
called an “attorney-in-fact” or “proxy.”)
The person you appoint as your agent
cannot be:
• your doctor or other treating health care
provider,
• an employee of your treating health care
provider, unless he or she is related to
you,
• your residential care provider, or
• an employee of your residential care
provider, unless he or she is related to
you.
You can appoint a second and third person
as your alternate agent. The alternate will
step in if the first person you name as agent
is unable, unwilling or unavailable to act for
you.
How do I make my Texas Medical Power
of Attorney legal?
The law requires that you sign your Medical
Power of Attorney, or direct another to sign
it, in the presence of two witnesses.
At least one witness cannot be:
• the person you name as your agent,
• related to you by blood or marriage,
• your doctor or an employee of your
doctor,
• an employee of a health care facility in
which you are a patient (if he or she is
involved in your care),
• an officer, director, partner, or business
office employee of the health care
facility or of any parent organization of
the health care facility,
• a person entitled to any part of your
estate upon your death, or
• any other person who has a claim against
your estate at the time you sign the
Medical Power of Attorney.
Note: You do not need to notarize your
Texas Medical Power of Attorney.
COMPLETING YOUR TEXAS MEDICAL POWER OF ATTORNEY (CONTINUED)
Should I add personal instructions to my
Texas Medical Power of Attorney?
Caring Connections advises you not to add
instructions to this document. One of the
strongest reasons for naming an agent is to
have someone who can respond flexibly as
your medical condition changes and deal
with situations that you did not foresee. If
you add instructions to this document, you
might unintentionally restrict your agent’s
power to act in your best interest.
Instead, we urge you to talk with your agent
about your future medical care and describe
what you consider to be an acceptable
“quality of life.” If you want to record your
wishes about specific treatments or
conditions, you should use your Texas
Directive to Physicians and Family or
Surrogates.
What if I change my mind?
You may revoke your Texas Medical Power
of Attorney at any time by:
• notifying your agent, doctor or
residential care provider of your
revocation (this may be done orally, in
writing or by any other act which
demonstrates your intent to revoke your
agent’s power); or
• executing another medical power of
attorney.
If you appoint your spouse as your agent,
and your marriage is dissolved or annulled,
your agent’s authority is automatically
revoked.
COMPLETING YOUR TEXAS DIRECTIVE
How do I make my Texas Directive legal?
In order to make your Directive legally
binding, you must sign it, or direct another
to sign it, in the presence of two witnesses
who must also sign the document. At least
one witness cannot be:
• designated by you to make a treatment
decision,
• related to you by blood or marriage,
• entitled to any part of your estate after
your death,
• your doctor or an employee of your
doctor,
• an employee of a health care facility in
which you are a patient, if he or she is
directly involved in your care,
• an officer, director, partner, or business
office employee of the health care
facility or of any parent organization of
the health care facility, or
• a person who, at the time you sign the
Directive, has a claim against your estate
after your death.
Note: You do not need to notarize your
Texas Directive to Physicians.
Can I add personal instructions to my
Directive?
Yes. You can add personal instructions in
the part of the document called “Additional
Requests.” You may want to refuse specific
treatments by a statement such as, “I
especially do not want cardiopulmonary
resuscitation, a respirator, artificial feeding
or antibiotics,” or to emphasize pain control
by adding instructions such as, “I want to
receive as much pain medication as
necessary to ensure my comfort, even if it
may hasten my death.”
If you have appointed an agent through a
medical power of attorney, it is a good idea
to write a statement such as, “Any questions
about how to interpret or when to apply my
Directive are to be decided by my agent.”
It is important to learn about the kinds of
life-sustaining treatment you might receive.
Consult your doctor or order the Caring
Connections booklet, “Advance Directives
and End-of-Life Decisions.”
What if I change my mind?
You may revoke your Texas Directive at
any time by:
• canceling, defacing, obliterating,
burning, tearing or otherwise destroying
the directive,
• signing and dating a written revocation,
or
• orally stating your intent to revoke the
directive.
You or someone acting on your behalf must
notify your doctor of the revocation.
What other important facts should I
know?
A pregnant patient’s Texas Directive will
not be honored due to restrictions in the state
law.
AFTER YOU HAVE COMPLETED YOUR DOCUMENTS
1. Your Texas Medical Power of Attorney
and Texas Directive are important legal
documents. Keep the original signed
documents in a secure but accessible
place. Do not put the original documents
in a safe deposit box or any other
security box that would keep others from
having access to them.
2. Give photocopies of the signed originals
to your agent and alternate agent(s),
doctor(s), family, close friends, clergy
and anyone else who might become
involved in your health care. If you enter
a nursing home or hospital, have
photocopies of your documents placed in
your medical records.
3. Be sure to talk to your agent and
alternate agent(s), doctor(s), clergy, and
family and friends about your wishes
concerning medical treatment. Discuss
your wishes with them often, particularly
if your medical condition changes.
4. If you want to make changes to your
documents after they have been signed
and witnessed, you must complete new
documents.
5. Remember, you can always revoke one
or both of your Texas documents.
6. Be aware that your Texas documents
will not be effective in the event of a
medical emergency. Ambulance
personnel are required to provide
cardiopulmonary resuscitation (CPR)
unless they are given a separate order
that states otherwise. These orders,
commonly called “non-hospital do-notresuscitate
orders,” are designed for
people whose poor health gives them
little chance of benefiting from CPR.
These orders must be signed by your
physician and instruct ambulance
personnel not to attempt CPR if your
heart or breathing should stop. Currently
not all states have laws authorizing nonhospital
do-not-resuscitate orders.
Caring Connections does not distribute
these forms. We suggest you speak to
your physician.
If you would like more information about
this topic contact Caring Connections or
consult the Caring Connections booklet
“Cardiopulmonary Resuscitation, Do-
Not-Resuscitate Orders and End-Of-Life
Decisions.”
TEXAS MEDICAL POWER OF ATTORNEY
PAGE 1 OF 6
INFORMATION CONCERNING THE MEDICAL POWER OF ATTORNEY THIS IS AN
IMPORTANT LEGAL DOCUMENT. BEFORE SIGNING THIS DOCUMENT, YOU
SHOULD KNOW THESE IMPORTANT FACTS:
Except to the extent you state otherwise, this document gives the person you name as your agent
the authority to make any and all health care decisions for you in accordance with your wishes,
including your religious and moral beliefs, when you are no longer capable of making them
yourself. Because “health care” means any treatment, service, or procedure to maintain,
diagnose, or treat your physical or mental condition, your agent has the power to make a broad
range of health care decisions for you. Your agent may consent, refuse to consent, or withdraw
consent to medical treatment and may make decisions about withdrawing or withholding lifesustaining
treatment. Your agent may not consent to voluntary inpatient mental health services,
convulsive treatment, psychosurgery, or abortion. A physician must comply with your agent’s
instructions or allow you to be transferred to another physician.
Your agent’s authority begins when your doctor certifies that you lack the competence to make
health care decisions.
Your agent is obligated to follow your instructions when making decisions on your behalf.
Unless you state otherwise, your agent has the same authority to make decisions about your
health care as you would have had.
It is important that you discuss this document with your physician or other health care provider
before you sign it to make sure that you understand the nature and range of decisions that may be
made on your behalf. If you do not have a physician, you should talk with someone else who is
knowledgeable about these issues and can answer your questions. You do not need a lawyer’s
assistance to complete this document, but if there is anything in this document that you do not
understand, you should ask a lawyer to explain it to you.
The person you appoint as agent should be someone you know and trust. The person must be 18
years of age or older or a person under 18 years of age who has had the disabilities of minority
removed. If you appoint your health or residential care provider (e.g., your physician or an
employee of a home health agency, hospital, nursing home, or residential care home, other than a
relative), that person has to choose between acting as your agent or as your health or residential
care provider; the law does not permit a person to do both at the same time.
You should inform the person you appoint that you want the person to be your health care agent.
You should discuss this document with your agent and your physician and give each a signed
copy. You should indicate on the document itself the people and institutions who have signed
copies. Your agent is not liable for health care decisions made in good faith on your behalf.
TEXAS MEDICAL POWER OF ATTORNEY – PAGE 2 OF 6
Even after you have signed this document, you have the right to make health care decisions for
yourself as long as you are able to do so and treatment cannot be given to you or stopped over
your objection. You have the right to revoke the authority granted to your agent by informing
your agent or your health or residential care provider orally or in writing, or by your execution of
a subsequent medical power of attorney. Unless you state otherwise, your appointment of a
spouse dissolves on divorce.
This document may not be changed or modified. If you want to make changes in the document,
you must make an entirely new one.
You may wish to designate an alternate agent in the event that your agent is unwilling, unable, or
ineligible to act as your agent. Any alternate agent you designate has the same authority to make
health care decisions for you.
THIS POWER OF ATTORNEY IS NOT VALID UNLESS IT IS SIGNED IN THE PRESENCE
OF TWO COMPETENT ADULT WITNESSES. THE FOLLOWING PERSONS MAY NOT
ACT AS ONE OF THE WITNESSES:
(1) the person you have designated as your agent;
(2) a person related to you by blood or marriage;
(3) a person entitled to any part of your estate after your death under a will or codicil executed
by you or by operation of law;
(4) your attending physician;
(5) an employee of your attending physician;
(6) an employee of your health care facility in which you are a patient if the employee is
providing direct patient care to you or is an officer, director, partner, or business office
employee of the health care facility or of any parent organization of the health care facility;
or
(7) a person who, at the time this power of attorney is executed, has a claim against any part of
your estate after your death.
TEXAS MEDICAL POWER OF ATTORNEY – PAGE 3 OF 6
TEXAS MEDICAL POWER OF ATTORNEY
DESIGNATION OF HEALTH CARE AGENT.
I, ________________________________________________________, appoint:
(name)
_________________________________________________________________
(name of agent)
_________________________________________________________________
(address)
_________________________________________________________________
(work telephone number) (home telephone number)
as my agent to make any and all health care decisions for me, except to the extent
I state otherwise in this document. This medical power of attorney takes effect if I
become unable to make my own health care decisions and this fact is certified in
writing by my physician.
LIMITATIONS ON THE DECISION MAKING AUTHORITY OF MY AGENT
ARE AS FOLLOWS:
INSTRUCTIONS
PRINT YOUR
NAME
PRINT THE NAME,
ADDRESS AND
HOME AND WORK
TELEPHONE
NUMBERS OF
YOUR AGENT
STATE
LIMITATIONS ON
YOUR AGENT’S
POWER
(IF ANY)
© 2005 National
Hospice and Palliative
Care Organization
TEXAS MEDICAL POWER OF ATTORNEY — PAGE 4 OF 6
DESIGNATION OF ALTERNATE AGENT.
(You are not required to designate an alternate agent but you may do so. An
alternate agent may make the same health care decisions as the designated
agent if the designated agent is unable or unwilling to act as your agent. If the
agent designated is your spouse, the designation is automatically revoked by
law if your marriage is dissolved.)
If the person designated as my agent is unable or unwilling to make health care
decisions for me, I designate the following persons to serve as my agent to
make health care decisions for me as authorized by this document, who serve in
the following order:
A. First Alternate Agent
________________________________________________________________
(name of first alternate agent)
________________________________________________________________
(home address)
________________________________________________________________
(work telephone number) (home telephone number)
B. Second Alternate Agent
________________________________________________________________
(name of second alternate agent)
________________________________________________________________
(home address)
________________________________________________________________
(work telephone number) (home telephone number)
The original of this document is kept at: _______________________________
PRINT THE NAME,
ADDRESS AND
HOME AND WORK
TELEPHONE
NUMBERS OF
YOUR FIRST AND
SECOND
ALTERNATE
AGENTS
FIRST
ALTERNATE
SECOND
ALTERNATE
LOCATION OF
ORIGINAL
© 2005 National
Hospice and Palliative
Care Organization
TEXAS MEDICAL POWER OF ATTORNEY — PAGE 5 OF 6
The following individuals or institutions have signed copies:
Name: _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
Address: ________________________________________________________
Name: _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
Address:_________________________________________________________
DURATION.
I understand that this power of attorney exists indefinitely from the date I
execute this document unless I establish a shorter time or revoke the power of
attorney. If I am unable to make health care decisions for myself when this
power of attorney expires, the authority I have granted my agent continues to
exist until the time I become able to make health care decisions for myself.
(IF APPLICABLE) This power of attorney ends on the following date:
_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
PRIOR DESIGNATIONS REVOKED.
I revoke any prior medical power of attorney.
ACKNOWLEDGMENT OF DISCLOSURE STATEMENT.
I have been provided with a disclosure statement explaining the effect of this
document. I have read and understood that information contained in the
disclosure statement.
(YOU MUST DATE AND SIGN THIS POWER OF ATTORNEY)
I sign my name to this medical power of attorney on _____________________
(date)
day of ____________________ _______, at ___________________________.
(month) (year) (city and state)
_________________________________________
(signature)
_________________________________________
(print name)
LOCATION OF
COPIES
EXPIRATION
DATE (IF ANY)
PRINT THE DATE
PRINT YOUR
LOCATION
SIGN THE
DOCUMENT AND
PRINT YOUR NAME
© 2005 National
Hospice and Palliative
Care Organization
TEXAS MEDICAL POWER OF ATTORNEY — PAGE 6 OF 6
STATEMENT OF FIRST WITNESS.
I am not the person appointed as agent by this document. I am not related to the
principal by blood or marriage. I would not be entitled to any portion of the
principal’s estate on the principal’s death. I am not the attending physician of
the principal or an employee of the attending physician. I have no claim against
any portion of the principal’s estate on the principal’s death. Furthermore, if I
am an employee of a health care facility in which the principal is a patient, I am
not involved in providing direct patient care to the principal and am not an
officer, director, partner or business office employee of the health care facility
of any parent organization of the health care facility.
SIGNATURE OF FIRST WITNESS
Signature: _______________________________________________________
Print Name: ____________________________________ Date: ____________
Address: ________________________________________________________
SIGNATURE OF SECOND WITNESS
Witness Signature: _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
Print Name: ____________________________________ Date: ____________
Address: _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
Courtesy of Caring Connections
1700 Diagonal Road, Suite 625, Alexandria, VA 22314
www.caringinfo.org, 800/658-8898
WITNESSING
PROCEDURE
YOUR TWO
WITNESSES MUST
SIGN AND DATE
YOUR DOCUMENT
BELOW THEY
MUST ALSO PRINT
THEIR NAMES AND
ADDRESSES
WITNESS #1
WITNESS #2
© 2005 National
Hospice and Palliative
Care Organization
TEXAS DIRECTIVE
TO PHYSICIANS AND FAMILY OR SURROGATES – PAGE 1 OF 5
Instructions for completing this document:
This is an important legal document known as an Advance Directive. It is
designed to help you communicate your wishes about medical treatment at
some time in the future when you are unable to make your wishes known
because of illness or injury. These wishes are usually based on personal values.
In particular, you may want to consider what burdens or hardships of treatment
you would be willing to accept for a particular amount of benefit obtained if you
were seriously ill.
You are encouraged to discuss your values and wishes with your family or
chosen spokesperson, as well as your physician. Your physician, other health
care provider, or medical institution may provide you with various resources to
assist you in completing your advance directive. Brief definitions are listed
below and may aid you in your discussions and advance planning. Initial the
treatment choices that best reflect your personal preferences. Provide a copy of
your directive to your physician, usual hospital, and family or spokesperson.
Consider a periodic review of this document. By periodic review, you can best
assure that the directive reflects your preferences.
In addition to this advance directive, Texas law provides for two other types of
directives that can be important during a serious illness. These are the Medical
Power of Attorney and the Out-of-Hospital Do-Not-Resuscitate Order. You may
wish to discuss these with your physician, family, hospital representative, or
other advisers. You may also wish to complete a directive related to the
donation of organs and tissues.
DIRECTIVE
I, ______________________________, recognize that the best health care is
based upon a partnership of trust and communication with my physician. My
physician and I will make health care decisions together as long as I am of
sound mind and able to make my wishes known, If there comes a time that I am
unable to make medical decisions about myself because of illness or injury, I
direct that the following treatment preferences be honored:
INSTRUCTIONS
PRINT YOUR
NAME
© 2005 National
Hospice and Palliative
Care Organization
TEXAS DIRECTIVE
TO PHYSICIANS AND FAMILY OR SURROGATES – PAGE 2 OF 5
If, in the judgment of my physician, I am suffering with a terminal condition
from which I am expected to die within six months, even with available lifesustaining
treatment provided in accordance with prevailing standards of
medical care:
_______ I request that all treatments other than those needed to keep me
comfortable be discontinued or withheld and my physician allow me to die as
gently as possible; OR
_______ I request that I be kept alive in this terminal condition using available
life-sustaining treatment. (THIS SELECTION DOES NOT APPLY TO
HOSPICE CARE)
If, in the judgment of my physician, I am suffering with an irreversible
condition so that I cannot care for myself or make decisions for myself and am
expected to die without life-sustaining treatment provided in accordance with
prevailing standards of care:
_______ I request that all treatments other than those needed to keep me
comfortable be discontinued or withheld and my physician allow me to die as
gently as possible; OR
_______ I request that I be kept alive in this irreversible condition using
available life-sustaining treatment. (THIS SELECTION DOES NOT APPLY
TO HOSPICE CARE)
Additional requests: (After discussion with your physician, you may wish to
consider listing particular treatments in this space that you do or do not want in
specific circumstances, such as artificial nutrition and fluids, intravenous
antibiotics, etc. Be sure to state whether you do or do not want the particular
treatment.)
________________________________________________________________
TERMINAL
CONDITION
INITIAL THE
STATEMENT
THAT REFLECTS
YOUR WISHES
IRREVERSIBLE
CONDITION
INITIAL THE
STATEMENT
THAT REFLECTS
YOUR WISHES
STATE SPECIFIC
TREATMENT
REQUESTS
(IF ANY)
© 2005 National
Hospice and Palliative
Care Organization
TEXAS DIRECTIVE
TO PHYSICIANS AND FAMILY OR SURROGATES – PAGE 3 OF 5
After signing this directive, if my representative or I elect hospice care, I
understand and agree that only those treatments needed to keep me comfortable
would be provided and I would not be given available life-sustaining treatments.
If I do not have a Medical Power of Attorney, and I am unable to make my
wishes known, I designate the following person(s) to make treatment decisions
with my physician compatible with my personal values:
1. _______________________________________
(name of person)
2. _______________________________________
(name of second person)
(IF A MEDICAL POWER OF ATTORNEY HAS BEEN EXECUTED, THEN
AN AGENT HAS BEEN NAMED AND YOU SHOULD NOT LIST
ADDITIONAL NAMES IN THIS DOCUMENT.)
If the above persons are not available, or if I have not designated a spokesperson, I
understand that the spokesperson will be chosen for me following standards
specified in the laws of Texas. If, in the judgment of my physician, my death is
imminent within minutes to hours, even with the use of all available medical
treatment provided within the prevailing standard of care, I acknowledge that all
treatments may be withheld or removed except those needed to maintain my
comfort. I understand that under Texas law this directive has no effect if I have
been diagnosed as pregnant. This directive will remain in effect until I revoke it. No
other person may do so.
SIGNED _______________________________________ DATE ___________
(your name) (date)
CITY, COUNTY, STATE OF RESIDENCE
_________________________, _________________________, ____________
(city) (county) (State)
DESIGNATION OF A
SPOKESPERSON
IF YOU HAVE
COMPLETED A
MEDICAL POWER
OF ATTORNEY DO
NOT COMPLETE
THIS SECTION
SIGN THE
DOCUMENT AND
PRINT YOUR
PLACE OF
RESIDENCE
© 2005 National
Hospice and Palliative
Care Organization
TEXAS DIRECTIVE
TO PHYSICIANS AND FAMILY OR SURROGATES – PAGE 4 OF 5
WITNESSES
Two competent adult witnesses must sign below, acknowledging the signature
of the declarant. The witness designated as Witness 1 may not be a person
designated to make a treatment decision for the patient and may not be related
to the patient by blood or marriage. This witness may not be entitled to any part
of the estate and may not have a claim against the estate of the patient. This
witness may not be the attending physician or an employee of the attending
physician. If this witness is an employee of a health care facility in which the
patient is being cared for, this witness may not be involved in providing direct
patient care to the patient. This witness may not be an officer, director, partner,
or business office employee of a health care facility in which the patient is being
cared for or of any parent organization of the health care facility.
WITNESS #1: ______________________________________________
WITNESS #2: ______________________________________________
DEFINITIONS:
“ARTIFICIAL NUTRITION AND HYDRATION” means the provision of
nutrients or fluids by a tube inserted in a vein, under the skin in the
subcutaneous tissues, or in the stomach (gastrointestinal tract).
“IRREVERSIBLE CONDITION” means a condition, injury, or illness:
1. that may be treated, but is never cured or eliminated;
2. that leaves a person unable to care for or make decisions for the person’s
own self; and
3. that, without life-sustaining treatment provided in accordance with the
prevailing standard of medical care, is fatal.
WITNESSING
PROCEDURE
TWO WITNESSES
MUST SIGN YOUR
DOCUMENT
WITNESS #1
WITNESS #2
DEFINITIONS OF
IMPORTANT
TERMS
© 2005 National
Hospice and Palliative
Care Organization
TEXAS DIRECTIVE
TO PHYSICIANS AND FAMILY OR SURROGATES – PAGE 5 OF 5
EXPLANATION: Many serious illnesses such as cancer, failure of major
organs (kidney, heart, liver or lung), and serious brain disease such as
Alzheimer’s dementia may be considered irreversible early on. There is no cure,
but the patient may be kept alive for prolonged periods of time if the patient
receives life-sustaining treatments. Late in the course of the same illness, the
disease may be considered terminal when, even with treatment, the patient is
expected to die. You may wish to consider which burdens of treatment you
would be willing to accept in an effort to achieve a particular outcome. This is a
very personal decision that you may wish to discuss with your physician,
family, or other important persons in your life.
“LIFE-SUSTAINING TREATMENT” means treatment that, based on
reasonable medical judgment, sustains the life of a patient and without which
the patient will die. The term includes both life-sustaining medications and
artificial life support such as mechanical breathing machines, kidney dialysis
treatment, and artificial hydration and nutrition. The term does not include the
administration of pain management medication, the performance of a medical
procedure necessary to provide comfort care, or any other medical care
provided to alleviate a patient’s pain.
“TERMINAL CONDITION” means an incurable condition caused by injury,
disease, or illness that according to reasonable medical judgment will produce
death within six months, even with available life-sustaining treatment provided
in accordance with the prevailing standard of medical care.
EXPLANATION: Many serious illnesses may be considered irreversible early
in the course of the illness, but they may not be considered terminal until the
disease is fairly advanced. In thinking about terminal illness and its treatment,
you again may wish to consider the relative benefits and burdens of treatment
and discuss your wishes with your physician, family, or other important persons
in your life.
Courtesy of Caring Connections
1700 Diagonal Road, Suite 625, Alexandria, VA 22314
www.caringinfo.org, 800/658-8898
DEFINITIONS OF
IMPORTANT
TERMS
(CONTINUED)
© 2005 National
Hospice and Palliative
Care Organization
Advance Directive
Planning for Important Healthcare Decisions
Caring Connections, 1700 Diagonal Road, Suite 625, Alexandria, VA 22314
www.caringinfo.org, 800/658-8898
Caring Connections, a program of the National Hospice and Palliative Care Organization
(NHPCO), is a national consumer engagement initiative to improve care at the end of life, supported
by a grant from The Robert Wood Johnson Foundation.
The goal of Caring Connections is for consumers to hear a unified message promoting awareness
and action for improved end-of-life care. Through these efforts, NHPCO seeks to support those
working across the country to improve end-of-life care and conditions for all Americans.
Caring Connections tracks and monitors all state and federal legislation and significant court cases
related to end-of-life care to ensure that our advance directives are always up to date.
CARING CONNECTIONS
HelpLine
You can call our toll-free HelpLine, 800/658-8898, if you have any difficulty understanding your
state-specific advance directive, or if you are dealing with a difficult end-of-life situation and need
immediate information. We can help provide resources and information on questions like these:
• How do I communicate my end-of-life wishes to my family?
• What type of end-of-life care is available to me?
• What questions should I ask my mother’s doctors about her end-of-life care?
It’s About How You LIVE
It’s About How You LIVE is a national community engagement campaign encouraging individuals
to make informed decisions about end-of-life care and services. The campaign encourages people
to:
Learn about options for end-of-life services and care
Implement plans to ensure wishes are honored
Voice decisions to family, friends and health care providers
Engage in personal or community efforts to improve end-of-life care
Please call the HelpLine at 800/658-8898 to learn more about the LIVE campaign, obtain free
resources, or to join the effort to improve community, state and national end-of-life care.
HOW TO USE THESE MATERIALS
1. Check to be sure that you have the
materials for your state. You should complete
a form for the state in which you expect to
receive health care.
2. These materials include:
• Instructions for preparing your
advance directive.
• Your state-specific advance directive
forms, which are the pages with the
gray instruction bar on the left side.
3. Read the instructions in their entirety.
They give you specific information about the
requirements in your state.
4. You may want to photocopy these forms
before you start so you will have a clean copy
if you need to start over.
5. When you begin to complete the form,
refer to the gray instruction bars - they
indicate where you need to mark, insert your
personal instructions, or sign the form.
6. Talk with your family, friends, and
physicians about your decision to complete an
advance directive. Be sure the person you
appoint to make decision on your behalf
understands your wishes.
If you have questions or need guidance in
preparing your advance directive or about
what you should do with it after you have
completed it, you may call our toll free
number 800/ 658-8898 and a staff member
will be glad to assist you.
For more information contact:
The National Hospice and Palliative Care Organization
1700 Diagonal Road, Suite 625
Alexandria, VA 22314
Call our HelpLine: 800/658-8898
Visit our Web site: www.caringinfo.org
Formerly a publication of Last Acts Partnership.
Support for this program is provided by a grant from
The Robert Wood Johnson Foundation, Princeton,
New Jersey.
Copyright © 2005 National Hospice and Palliative Care Organization. All rights reserved. Revised
May 2005. Reproduction and distribution by an organization or organized group without the written
permission of the National Hospice and Palliative Care Organization is expressly forbidden.
INTRODUCTION TO YOUR TEXAS ADVANCE DIRECTIVES
This packet contains two legal documents that protect your right to refuse medical treatment you
do not want, or to request treatment you do want, in the event you lose the ability to make
decisions yourself:
1. The Texas Medical Power of Attorney lets you name someone to make decisions about your
medical care—including decisions about life support—if you can no longer speak for yourself.
Your attending physician must certify in writing that you are unable to make health care
decisions and file the certification in your medical record. The Medical Power of Attorney is
especially useful because it appoints someone to speak for you any time you are unable to make
your own medical decisions, not only at the end of life.
2. The Texas Directive to Physicians and Family or Surrogates is your state’s living will. It
lets you state your wishes about medical care in the event that you develop a terminal or
irreversible condition and can no longer make your own medical decisions. The Directive
becomes effective when your attending physician certifies in writing that you are in a terminal or
irreversible condition.
Caring Connections recommends that you complete both of these documents to best ensure that
you receive the medical care you want when you can no longer speak for yourself.
Note: These documents will be legally binding only if the person completing them is a competent
adult, 18 years or older or a person under 18 years of age who has had the disabilities of
minority removed.
COMPLETING YOUR TEXAS MEDICAL POWER OF ATTORNEY
Whom should I appoint as my agent?
Your agent is the person you appoint to
make decisions about your medical care if
you become unable to make those decisions
yourself. Your agent may be a family
member or a close friend whom you trust to
make serious decisions. The person you
name as your agent should clearly
understand your wishes and be willing to
accept the responsibility of making medical
decisions for you. (An agent may also be
called an “attorney-in-fact” or “proxy.”)
The person you appoint as your agent
cannot be:
• your doctor or other treating health care
provider,
• an employee of your treating health care
provider, unless he or she is related to
you,
• your residential care provider, or
• an employee of your residential care
provider, unless he or she is related to
you.
You can appoint a second and third person
as your alternate agent. The alternate will
step in if the first person you name as agent
is unable, unwilling or unavailable to act for
you.
How do I make my Texas Medical Power
of Attorney legal?
The law requires that you sign your Medical
Power of Attorney, or direct another to sign
it, in the presence of two witnesses.
At least one witness cannot be:
• the person you name as your agent,
• related to you by blood or marriage,
• your doctor or an employee of your
doctor,
• an employee of a health care facility in
which you are a patient (if he or she is
involved in your care),
• an officer, director, partner, or business
office employee of the health care
facility or of any parent organization of
the health care facility,
• a person entitled to any part of your
estate upon your death, or
• any other person who has a claim against
your estate at the time you sign the
Medical Power of Attorney.
Note: You do not need to notarize your
Texas Medical Power of Attorney.
COMPLETING YOUR TEXAS MEDICAL POWER OF ATTORNEY (CONTINUED)
Should I add personal instructions to my
Texas Medical Power of Attorney?
Caring Connections advises you not to add
instructions to this document. One of the
strongest reasons for naming an agent is to
have someone who can respond flexibly as
your medical condition changes and deal
with situations that you did not foresee. If
you add instructions to this document, you
might unintentionally restrict your agent’s
power to act in your best interest.
Instead, we urge you to talk with your agent
about your future medical care and describe
what you consider to be an acceptable
“quality of life.” If you want to record your
wishes about specific treatments or
conditions, you should use your Texas
Directive to Physicians and Family or
Surrogates.
What if I change my mind?
You may revoke your Texas Medical Power
of Attorney at any time by:
• notifying your agent, doctor or
residential care provider of your
revocation (this may be done orally, in
writing or by any other act which
demonstrates your intent to revoke your
agent’s power); or
• executing another medical power of
attorney.
If you appoint your spouse as your agent,
and your marriage is dissolved or annulled,
your agent’s authority is automatically
revoked.
COMPLETING YOUR TEXAS DIRECTIVE
How do I make my Texas Directive legal?
In order to make your Directive legally
binding, you must sign it, or direct another
to sign it, in the presence of two witnesses
who must also sign the document. At least
one witness cannot be:
• designated by you to make a treatment
decision,
• related to you by blood or marriage,
• entitled to any part of your estate after
your death,
• your doctor or an employee of your
doctor,
• an employee of a health care facility in
which you are a patient, if he or she is
directly involved in your care,
• an officer, director, partner, or business
office employee of the health care
facility or of any parent organization of
the health care facility, or
• a person who, at the time you sign the
Directive, has a claim against your estate
after your death.
Note: You do not need to notarize your
Texas Directive to Physicians.
Can I add personal instructions to my
Directive?
Yes. You can add personal instructions in
the part of the document called “Additional
Requests.” You may want to refuse specific
treatments by a statement such as, “I
especially do not want cardiopulmonary
resuscitation, a respirator, artificial feeding
or antibiotics,” or to emphasize pain control
by adding instructions such as, “I want to
receive as much pain medication as
necessary to ensure my comfort, even if it
may hasten my death.”
If you have appointed an agent through a
medical power of attorney, it is a good idea
to write a statement such as, “Any questions
about how to interpret or when to apply my
Directive are to be decided by my agent.”
It is important to learn about the kinds of
life-sustaining treatment you might receive.
Consult your doctor or order the Caring
Connections booklet, “Advance Directives
and End-of-Life Decisions.”
What if I change my mind?
You may revoke your Texas Directive at
any time by:
• canceling, defacing, obliterating,
burning, tearing or otherwise destroying
the directive,
• signing and dating a written revocation,
or
• orally stating your intent to revoke the
directive.
You or someone acting on your behalf must
notify your doctor of the revocation.
What other important facts should I
know?
A pregnant patient’s Texas Directive will
not be honored due to restrictions in the state
law.
AFTER YOU HAVE COMPLETED YOUR DOCUMENTS
1. Your Texas Medical Power of Attorney
and Texas Directive are important legal
documents. Keep the original signed
documents in a secure but accessible
place. Do not put the original documents
in a safe deposit box or any other
security box that would keep others from
having access to them.
2. Give photocopies of the signed originals
to your agent and alternate agent(s),
doctor(s), family, close friends, clergy
and anyone else who might become
involved in your health care. If you enter
a nursing home or hospital, have
photocopies of your documents placed in
your medical records.
3. Be sure to talk to your agent and
alternate agent(s), doctor(s), clergy, and
family and friends about your wishes
concerning medical treatment. Discuss
your wishes with them often, particularly
if your medical condition changes.
4. If you want to make changes to your
documents after they have been signed
and witnessed, you must complete new
documents.
5. Remember, you can always revoke one
or both of your Texas documents.
6. Be aware that your Texas documents
will not be effective in the event of a
medical emergency. Ambulance
personnel are required to provide
cardiopulmonary resuscitation (CPR)
unless they are given a separate order
that states otherwise. These orders,
commonly called “non-hospital do-notresuscitate
orders,” are designed for
people whose poor health gives them
little chance of benefiting from CPR.
These orders must be signed by your
physician and instruct ambulance
personnel not to attempt CPR if your
heart or breathing should stop. Currently
not all states have laws authorizing nonhospital
do-not-resuscitate orders.
Caring Connections does not distribute
these forms. We suggest you speak to
your physician.
If you would like more information about
this topic contact Caring Connections or
consult the Caring Connections booklet
“Cardiopulmonary Resuscitation, Do-
Not-Resuscitate Orders and End-Of-Life
Decisions.”
TEXAS MEDICAL POWER OF ATTORNEY
PAGE 1 OF 6
INFORMATION CONCERNING THE MEDICAL POWER OF ATTORNEY THIS IS AN
IMPORTANT LEGAL DOCUMENT. BEFORE SIGNING THIS DOCUMENT, YOU
SHOULD KNOW THESE IMPORTANT FACTS:
Except to the extent you state otherwise, this document gives the person you name as your agent
the authority to make any and all health care decisions for you in accordance with your wishes,
including your religious and moral beliefs, when you are no longer capable of making them
yourself. Because “health care” means any treatment, service, or procedure to maintain,
diagnose, or treat your physical or mental condition, your agent has the power to make a broad
range of health care decisions for you. Your agent may consent, refuse to consent, or withdraw
consent to medical treatment and may make decisions about withdrawing or withholding lifesustaining
treatment. Your agent may not consent to voluntary inpatient mental health services,
convulsive treatment, psychosurgery, or abortion. A physician must comply with your agent’s
instructions or allow you to be transferred to another physician.
Your agent’s authority begins when your doctor certifies that you lack the competence to make
health care decisions.
Your agent is obligated to follow your instructions when making decisions on your behalf.
Unless you state otherwise, your agent has the same authority to make decisions about your
health care as you would have had.
It is important that you discuss this document with your physician or other health care provider
before you sign it to make sure that you understand the nature and range of decisions that may be
made on your behalf. If you do not have a physician, you should talk with someone else who is
knowledgeable about these issues and can answer your questions. You do not need a lawyer’s
assistance to complete this document, but if there is anything in this document that you do not
understand, you should ask a lawyer to explain it to you.
The person you appoint as agent should be someone you know and trust. The person must be 18
years of age or older or a person under 18 years of age who has had the disabilities of minority
removed. If you appoint your health or residential care provider (e.g., your physician or an
employee of a home health agency, hospital, nursing home, or residential care home, other than a
relative), that person has to choose between acting as your agent or as your health or residential
care provider; the law does not permit a person to do both at the same time.
You should inform the person you appoint that you want the person to be your health care agent.
You should discuss this document with your agent and your physician and give each a signed
copy. You should indicate on the document itself the people and institutions who have signed
copies. Your agent is not liable for health care decisions made in good faith on your behalf.
TEXAS MEDICAL POWER OF ATTORNEY – PAGE 2 OF 6
Even after you have signed this document, you have the right to make health care decisions for
yourself as long as you are able to do so and treatment cannot be given to you or stopped over
your objection. You have the right to revoke the authority granted to your agent by informing
your agent or your health or residential care provider orally or in writing, or by your execution of
a subsequent medical power of attorney. Unless you state otherwise, your appointment of a
spouse dissolves on divorce.
This document may not be changed or modified. If you want to make changes in the document,
you must make an entirely new one.
You may wish to designate an alternate agent in the event that your agent is unwilling, unable, or
ineligible to act as your agent. Any alternate agent you designate has the same authority to make
health care decisions for you.
THIS POWER OF ATTORNEY IS NOT VALID UNLESS IT IS SIGNED IN THE PRESENCE
OF TWO COMPETENT ADULT WITNESSES. THE FOLLOWING PERSONS MAY NOT
ACT AS ONE OF THE WITNESSES:
(1) the person you have designated as your agent;
(2) a person related to you by blood or marriage;
(3) a person entitled to any part of your estate after your death under a will or codicil executed
by you or by operation of law;
(4) your attending physician;
(5) an employee of your attending physician;
(6) an employee of your health care facility in which you are a patient if the employee is
providing direct patient care to you or is an officer, director, partner, or business office
employee of the health care facility or of any parent organization of the health care facility;
or
(7) a person who, at the time this power of attorney is executed, has a claim against any part of
your estate after your death.
TEXAS MEDICAL POWER OF ATTORNEY – PAGE 3 OF 6
TEXAS MEDICAL POWER OF ATTORNEY
DESIGNATION OF HEALTH CARE AGENT.
I, ________________________________________________________, appoint:
(name)
_________________________________________________________________
(name of agent)
_________________________________________________________________
(address)
_________________________________________________________________
(work telephone number) (home telephone number)
as my agent to make any and all health care decisions for me, except to the extent
I state otherwise in this document. This medical power of attorney takes effect if I
become unable to make my own health care decisions and this fact is certified in
writing by my physician.
LIMITATIONS ON THE DECISION MAKING AUTHORITY OF MY AGENT
ARE AS FOLLOWS:
INSTRUCTIONS
PRINT YOUR
NAME
PRINT THE NAME,
ADDRESS AND
HOME AND WORK
TELEPHONE
NUMBERS OF
YOUR AGENT
STATE
LIMITATIONS ON
YOUR AGENT’S
POWER
(IF ANY)
© 2005 National
Hospice and Palliative
Care Organization
TEXAS MEDICAL POWER OF ATTORNEY — PAGE 4 OF 6
DESIGNATION OF ALTERNATE AGENT.
(You are not required to designate an alternate agent but you may do so. An
alternate agent may make the same health care decisions as the designated
agent if the designated agent is unable or unwilling to act as your agent. If the
agent designated is your spouse, the designation is automatically revoked by
law if your marriage is dissolved.)
If the person designated as my agent is unable or unwilling to make health care
decisions for me, I designate the following persons to serve as my agent to
make health care decisions for me as authorized by this document, who serve in
the following order:
A. First Alternate Agent
________________________________________________________________
(name of first alternate agent)
________________________________________________________________
(home address)
________________________________________________________________
(work telephone number) (home telephone number)
B. Second Alternate Agent
________________________________________________________________
(name of second alternate agent)
________________________________________________________________
(home address)
________________________________________________________________
(work telephone number) (home telephone number)
The original of this document is kept at: _______________________________
PRINT THE NAME,
ADDRESS AND
HOME AND WORK
TELEPHONE
NUMBERS OF
YOUR FIRST AND
SECOND
ALTERNATE
AGENTS
FIRST
ALTERNATE
SECOND
ALTERNATE
LOCATION OF
ORIGINAL
© 2005 National
Hospice and Palliative
Care Organization
TEXAS MEDICAL POWER OF ATTORNEY — PAGE 5 OF 6
The following individuals or institutions have signed copies:
Name: _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
Address: ________________________________________________________
Name: _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
Address:_________________________________________________________
DURATION.
I understand that this power of attorney exists indefinitely from the date I
execute this document unless I establish a shorter time or revoke the power of
attorney. If I am unable to make health care decisions for myself when this
power of attorney expires, the authority I have granted my agent continues to
exist until the time I become able to make health care decisions for myself.
(IF APPLICABLE) This power of attorney ends on the following date:
_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
PRIOR DESIGNATIONS REVOKED.
I revoke any prior medical power of attorney.
ACKNOWLEDGMENT OF DISCLOSURE STATEMENT.
I have been provided with a disclosure statement explaining the effect of this
document. I have read and understood that information contained in the
disclosure statement.
(YOU MUST DATE AND SIGN THIS POWER OF ATTORNEY)
I sign my name to this medical power of attorney on _____________________
(date)
day of ____________________ _______, at ___________________________.
(month) (year) (city and state)
_________________________________________
(signature)
_________________________________________
(print name)
LOCATION OF
COPIES
EXPIRATION
DATE (IF ANY)
PRINT THE DATE
PRINT YOUR
LOCATION
SIGN THE
DOCUMENT AND
PRINT YOUR NAME
© 2005 National
Hospice and Palliative
Care Organization
TEXAS MEDICAL POWER OF ATTORNEY — PAGE 6 OF 6
STATEMENT OF FIRST WITNESS.
I am not the person appointed as agent by this document. I am not related to the
principal by blood or marriage. I would not be entitled to any portion of the
principal’s estate on the principal’s death. I am not the attending physician of
the principal or an employee of the attending physician. I have no claim against
any portion of the principal’s estate on the principal’s death. Furthermore, if I
am an employee of a health care facility in which the principal is a patient, I am
not involved in providing direct patient care to the principal and am not an
officer, director, partner or business office employee of the health care facility
of any parent organization of the health care facility.
SIGNATURE OF FIRST WITNESS
Signature: _______________________________________________________
Print Name: ____________________________________ Date: ____________
Address: ________________________________________________________
SIGNATURE OF SECOND WITNESS
Witness Signature: _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
Print Name: ____________________________________ Date: ____________
Address: _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
Courtesy of Caring Connections
1700 Diagonal Road, Suite 625, Alexandria, VA 22314
www.caringinfo.org, 800/658-8898
WITNESSING
PROCEDURE
YOUR TWO
WITNESSES MUST
SIGN AND DATE
YOUR DOCUMENT
BELOW THEY
MUST ALSO PRINT
THEIR NAMES AND
ADDRESSES
WITNESS #1
WITNESS #2
© 2005 National
Hospice and Palliative
Care Organization
TEXAS DIRECTIVE
TO PHYSICIANS AND FAMILY OR SURROGATES – PAGE 1 OF 5
Instructions for completing this document:
This is an important legal document known as an Advance Directive. It is
designed to help you communicate your wishes about medical treatment at
some time in the future when you are unable to make your wishes known
because of illness or injury. These wishes are usually based on personal values.
In particular, you may want to consider what burdens or hardships of treatment
you would be willing to accept for a particular amount of benefit obtained if you
were seriously ill.
You are encouraged to discuss your values and wishes with your family or
chosen spokesperson, as well as your physician. Your physician, other health
care provider, or medical institution may provide you with various resources to
assist you in completing your advance directive. Brief definitions are listed
below and may aid you in your discussions and advance planning. Initial the
treatment choices that best reflect your personal preferences. Provide a copy of
your directive to your physician, usual hospital, and family or spokesperson.
Consider a periodic review of this document. By periodic review, you can best
assure that the directive reflects your preferences.
In addition to this advance directive, Texas law provides for two other types of
directives that can be important during a serious illness. These are the Medical
Power of Attorney and the Out-of-Hospital Do-Not-Resuscitate Order. You may
wish to discuss these with your physician, family, hospital representative, or
other advisers. You may also wish to complete a directive related to the
donation of organs and tissues.
DIRECTIVE
I, ______________________________, recognize that the best health care is
based upon a partnership of trust and communication with my physician. My
physician and I will make health care decisions together as long as I am of
sound mind and able to make my wishes known, If there comes a time that I am
unable to make medical decisions about myself because of illness or injury, I
direct that the following treatment preferences be honored:
INSTRUCTIONS
PRINT YOUR
NAME
© 2005 National
Hospice and Palliative
Care Organization
TEXAS DIRECTIVE
TO PHYSICIANS AND FAMILY OR SURROGATES – PAGE 2 OF 5
If, in the judgment of my physician, I am suffering with a terminal condition
from which I am expected to die within six months, even with available lifesustaining
treatment provided in accordance with prevailing standards of
medical care:
_______ I request that all treatments other than those needed to keep me
comfortable be discontinued or withheld and my physician allow me to die as
gently as possible; OR
_______ I request that I be kept alive in this terminal condition using available
life-sustaining treatment. (THIS SELECTION DOES NOT APPLY TO
HOSPICE CARE)
If, in the judgment of my physician, I am suffering with an irreversible
condition so that I cannot care for myself or make decisions for myself and am
expected to die without life-sustaining treatment provided in accordance with
prevailing standards of care:
_______ I request that all treatments other than those needed to keep me
comfortable be discontinued or withheld and my physician allow me to die as
gently as possible; OR
_______ I request that I be kept alive in this irreversible condition using
available life-sustaining treatment. (THIS SELECTION DOES NOT APPLY
TO HOSPICE CARE)
Additional requests: (After discussion with your physician, you may wish to
consider listing particular treatments in this space that you do or do not want in
specific circumstances, such as artificial nutrition and fluids, intravenous
antibiotics, etc. Be sure to state whether you do or do not want the particular
treatment.)
________________________________________________________________
TERMINAL
CONDITION
INITIAL THE
STATEMENT
THAT REFLECTS
YOUR WISHES
IRREVERSIBLE
CONDITION
INITIAL THE
STATEMENT
THAT REFLECTS
YOUR WISHES
STATE SPECIFIC
TREATMENT
REQUESTS
(IF ANY)
© 2005 National
Hospice and Palliative
Care Organization
TEXAS DIRECTIVE
TO PHYSICIANS AND FAMILY OR SURROGATES – PAGE 3 OF 5
After signing this directive, if my representative or I elect hospice care, I
understand and agree that only those treatments needed to keep me comfortable
would be provided and I would not be given available life-sustaining treatments.
If I do not have a Medical Power of Attorney, and I am unable to make my
wishes known, I designate the following person(s) to make treatment decisions
with my physician compatible with my personal values:
1. _______________________________________
(name of person)
2. _______________________________________
(name of second person)
(IF A MEDICAL POWER OF ATTORNEY HAS BEEN EXECUTED, THEN
AN AGENT HAS BEEN NAMED AND YOU SHOULD NOT LIST
ADDITIONAL NAMES IN THIS DOCUMENT.)
If the above persons are not available, or if I have not designated a spokesperson, I
understand that the spokesperson will be chosen for me following standards
specified in the laws of Texas. If, in the judgment of my physician, my death is
imminent within minutes to hours, even with the use of all available medical
treatment provided within the prevailing standard of care, I acknowledge that all
treatments may be withheld or removed except those needed to maintain my
comfort. I understand that under Texas law this directive has no effect if I have
been diagnosed as pregnant. This directive will remain in effect until I revoke it. No
other person may do so.
SIGNED _______________________________________ DATE ___________
(your name) (date)
CITY, COUNTY, STATE OF RESIDENCE
_________________________, _________________________, ____________
(city) (county) (State)
DESIGNATION OF A
SPOKESPERSON
IF YOU HAVE
COMPLETED A
MEDICAL POWER
OF ATTORNEY DO
NOT COMPLETE
THIS SECTION
SIGN THE
DOCUMENT AND
PRINT YOUR
PLACE OF
RESIDENCE
© 2005 National
Hospice and Palliative
Care Organization
TEXAS DIRECTIVE
TO PHYSICIANS AND FAMILY OR SURROGATES – PAGE 4 OF 5
WITNESSES
Two competent adult witnesses must sign below, acknowledging the signature
of the declarant. The witness designated as Witness 1 may not be a person
designated to make a treatment decision for the patient and may not be related
to the patient by blood or marriage. This witness may not be entitled to any part
of the estate and may not have a claim against the estate of the patient. This
witness may not be the attending physician or an employee of the attending
physician. If this witness is an employee of a health care facility in which the
patient is being cared for, this witness may not be involved in providing direct
patient care to the patient. This witness may not be an officer, director, partner,
or business office employee of a health care facility in which the patient is being
cared for or of any parent organization of the health care facility.
WITNESS #1: ______________________________________________
WITNESS #2: ______________________________________________
DEFINITIONS:
“ARTIFICIAL NUTRITION AND HYDRATION” means the provision of
nutrients or fluids by a tube inserted in a vein, under the skin in the
subcutaneous tissues, or in the stomach (gastrointestinal tract).
“IRREVERSIBLE CONDITION” means a condition, injury, or illness:
1. that may be treated, but is never cured or eliminated;
2. that leaves a person unable to care for or make decisions for the person’s
own self; and
3. that, without life-sustaining treatment provided in accordance with the
prevailing standard of medical care, is fatal.
WITNESSING
PROCEDURE
TWO WITNESSES
MUST SIGN YOUR
DOCUMENT
WITNESS #1
WITNESS #2
DEFINITIONS OF
IMPORTANT
TERMS
© 2005 National
Hospice and Palliative
Care Organization
TEXAS DIRECTIVE
TO PHYSICIANS AND FAMILY OR SURROGATES – PAGE 5 OF 5
EXPLANATION: Many serious illnesses such as cancer, failure of major
organs (kidney, heart, liver or lung), and serious brain disease such as
Alzheimer’s dementia may be considered irreversible early on. There is no cure,
but the patient may be kept alive for prolonged periods of time if the patient
receives life-sustaining treatments. Late in the course of the same illness, the
disease may be considered terminal when, even with treatment, the patient is
expected to die. You may wish to consider which burdens of treatment you
would be willing to accept in an effort to achieve a particular outcome. This is a
very personal decision that you may wish to discuss with your physician,
family, or other important persons in your life.
“LIFE-SUSTAINING TREATMENT” means treatment that, based on
reasonable medical judgment, sustains the life of a patient and without which
the patient will die. The term includes both life-sustaining medications and
artificial life support such as mechanical breathing machines, kidney dialysis
treatment, and artificial hydration and nutrition. The term does not include the
administration of pain management medication, the performance of a medical
procedure necessary to provide comfort care, or any other medical care
provided to alleviate a patient’s pain.
“TERMINAL CONDITION” means an incurable condition caused by injury,
disease, or illness that according to reasonable medical judgment will produce
death within six months, even with available life-sustaining treatment provided
in accordance with the prevailing standard of medical care.
EXPLANATION: Many serious illnesses may be considered irreversible early
in the course of the illness, but they may not be considered terminal until the
disease is fairly advanced. In thinking about terminal illness and its treatment,
you again may wish to consider the relative benefits and burdens of treatment
and discuss your wishes with your physician, family, or other important persons
in your life.
Courtesy of Caring Connections
1700 Diagonal Road, Suite 625, Alexandria, VA 22314
www.caringinfo.org, 800/658-8898
DEFINITIONS OF
IMPORTANT
TERMS
(CONTINUED)
© 2005 National
Hospice and Palliative
Care Organization