$23.95

Add to cart

Texas and discuss your wishes with your physician, family, or other important persons in your life. 4 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 treatmentstaining 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 "Terminal Condition" means an incurable cond ition caused by injury, disease, or illness that according to reasonable medical judgment will produce death within six months, even with available life-suclude the administration of 3 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. erm 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 inther 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 t 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 o 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 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 patientustaining treatment provided in accordance with the prevailing standard of medical care, is fatal. Explanation: Many serious illnesses such as cancer, failure of major organs (kidney, heart, liver, orition, 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-s" 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 cond: ____________________________________________________________________ Witness 2: ____________________________________________________________________ Definitions "Artificial nutrition and hydrationnot 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 1n. 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 tness 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 physiciaure of the decrement 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 wi________________ Date: ____________________ City, County, State of Residence: __________________________________________________ Two competent adult witnesses must sign below, acknowledging the signatxas law this directive has no effect if I have been 2 diagnosed as pregnant. This directive will remain in effect until I revoke it. No other person may do so. Signed: ______________________________e 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 Tekesperson 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 availabl an agent already has been named and you should not list additional names in this document.) If the above persons are not available, or it I have not designated a spokesperson, I understand that a spo_________________________________________________________________ 2. ___________________________________________________________________________ (If a Medical Power of Attorney has been executed, then 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. __________ 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_________________________________________________________________ _____________________________________________________________________________ After signing this directive, if my representative or Iwant the particular treatment.) _____________________________________________________________________________ _____________________________________________________________________________ ____________ticular 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 ible condition using available lifesustaining treatment. (THIS SELECTION DOES NOT APPLY TO HOSPICE CARE) Additional requests: (After discussion with your physician you may wish to consider listing parments 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 irreverself or make decisions for myself and am expected to die without life-sustaining treatment provided in accordance with prevailing standards of care (initial one):: ____________ I request that all treat available lifesustaining treatment. (THIS SELECTION DOES NOT APPLY TO HOSPICE CARE) 1 If, in the judgment of my physician, I am suffering with an irreversible condition so that I cannot care for mys 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 usinge within six months, even with available life-sustaining treatment provided in accordance with prevailing standards of medical care (initial one): ____________ I request that all treatments other thanbecause of illness or injury, I direct that the following treatment preferences be honored: If, in the judgment of my physician, I am suffering with a terminal condition from which I am expected to di 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 ns and tissues. DIRECTIVE I__________________________________________________________, recognize that the best health care is based upon a partnership of trust and communication with my physician. My-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 orgadition 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 Outof-Hospital Do 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 adBrief 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 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. ships 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 chosenn 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 hards Instructions For Co mpleting 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 sometime iussed with a tax professional. [_] The purchase and use of these forms is subject to the Disclaimers and Terms of Use found at findlegalforms.com Texas Directive To Physicians And Family Or Surrogate fits your particular situation. Advice from a local attorney is always recommended when dealing with estate planning matters. Any possible tax consequences arising out of this document should be discx advice. Laws vary from time to time and from state to state. These forms should only be a starting point for you and should not be used or signed without consulting an attorney first to make sure itave been made or are provided as to their suitability for any specific purpose or as to their legal effect or completeness. [_]These forms are not intended and are not a substitute for legal and/or taliable for failure to act on a revocation made under this section unless the person has actual knowledge of the revocation. [_] These forms are provided "as is" and no implied or express warranties h shall also enter the word "VOID" on each page of the copy of the directive in the patient's medical record. (d) Except as otherwise provided by this subchapter, a person is not civilly or criminally ord the time, date, and place of the revocation, and, if different, the time, date, and place that the physician received notice of the revocation. The attending physician or the physician's designeeseclarant or a person acting on behalf of the declarant notifies the attending physician of the revocation. The attending physician or the physician's designee shall record in the patient's medical recand shall enter the word "VOID" on each page of the copy of the directive in the patient's medical record. (c) An oral revocation issued as prescribed by Subsection (a)(3) takes effect only when the dhe attending physician. The attending physician or the physician's designee shall record in the patient's medical record the time and date when the physician received notice of the written revocation ted as prescribed by Subsection (a)(2) takes effect only when the declarant or a person acting on behalf of the declarant notifies the attending physician of its existence or mails the revocation to tg a written revocation that expresses the declarant's intent to revoke the directive; or (3) the declarant orally stating the declarant's intent to revoke the directive. (b) A written revocation execu or someone in the declarant's presence and at the declarant's direction canceling, defacing, obliterating, burning, tearing, or otherwise destroying the directive; (2) the declarant signing and datinrant may revoke a directive at any time without regard to the declarant's mental state or competency. A directive may be revoked by: Living Will Information & Instructions ­ Page 3 (1) the declarantnot require that: (1) a directive be notarized; or (2) a person use a form provided by the physician, health care facility, or health care professional. § 166.042. Revocation of Directive (a) A declatten directive executed under Section 166.033 or 166.035 is effective without regard to whether the document has been notarized. (b) A physician, health care facility, or health care professional may ten directive. The attending physician shall make the directive a part of the declarant's medical record. § 166.036. Notarized Document Not Required; Requirement of Specific Form Prohibited (a) A wrie of a written directive. If the declarant is incompetent or otherwise mentally or physically incapable of communication, another person may notify the attending physician of the existence of the writon for the declarant in the event the declarant becomes incompetent or otherwise mentally or physically incapable of communication. (d) A declarant shall notify the attending physician of the existenctnesses must sign the directive. (c) A declarant may include in a directive directions other than those provided by Section 166.033 and may designate in a directive a person to make a treatment decisiive. (b) The declarant must sign the directive in the presence of two witnesses who qualify under Section 166.003, at least one of whom must be a witness who qualifies under Section 166.003(2). The wibeen diagnosed and certified in writing by the attending physician. § 166.032. Written Directive by Competent Adult; Notice to Physician (a) A competent adult may at any time execute a written directister, withhold, or withdraw life-sustaining treatment in the event of a terminal or irreversible condition. (2) "Qualified patient" means a patient with a terminal or irreversible condition that has ant's death. § 166.031. Definitions Living Will Information & Instructions ­ Page 2 In this subchapter: (1) "Directive" means an instruction made under Section 166.032, 166.034, or 166.035 to adminecuted or, if the directive is a nonwritten directive issued under this chapter, at the time the nonwritten directive is issued, has a claim against any part of the declarant's estate after the declarrector, partner, or business office employee of the health care facility or of any parent organization of the health care facility; or (G) a person who, at the time the written advance directive is exmployee of the attending physician; (F) an employee of a health care facility in which the declarant is a patient if the employee is providing direct patient care to the declarant or is an officer, di(C) a person entitled to any part of the declarant's estate after the declarant's death under a will or codicil executed by the declarant or by operation of law; (D) the attend ing physician; (E) an e; and (2) at least one of the witnesses must be a person who is not: (A) a person designated by the declarant to make a treatment decision; (B) a person related to the declarant by blood or marriage; s In any circumstance in which this chapter requires the execution of an advance directive or the issuance of a nonwritten advance directive to be witnessed: (1) each witness must be a competent adultll) is based on Chapter 166 Section 166.001 et. Seq. of the Texas Statutes. For your convenience, we have included useful excerpts from the Texas Statutes relating to Living Wills. § 166.003. Witnessee To Physicians And Family Or Surrogates (Living Will); (2) Texas Directive To Physicians And Family Or Surrogates (Living Will). This Texas Directive To Physicians And Family Or Surrogates (Living Wi______ Page 3 Living Will Information and Instructions Texas Directive To Physicians And Family Or Surrogates (Living Will) This package contains (1) Informa tion and Instruction for Texas Directiv_____________________________ Print Name: _____________________________________________________________ Date: ______________________ Address: _________________________________________________________________________________ Date: ______________________ Address: ________________________________________________________________ Signature of Second Witness Signature: _________________________________ealth care facility or of any parent organization of the health care facility. Signature: _______________________________________________________________ Print Name: __________________________________th 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 hphysician 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 healed 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 Signature) ____________________________________________________________ (Print Name) ___________________________________________________________ Statement of First Witness I am not the person appointr of Attorney) Page 2 I sign my name to this medical power of attorney on _____________ day of _________ (month, year) at _________________________________________________________, (City and State) (e been provided with a disclosure statement explaining the effect of this document. I have read and understand the information contained in this disclosure statement. (You Must Date and Sign This Poweplicable) This power of attorney ends on the following date: __________________ Prior Designations Revoked I revoke any prior medical power of attorney. Acknowledgement of Disclosure Statement I havth 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 Apration 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 heal________________________________________________ Name: __________________________________________________________________ Address: ________________________________________________________________ Du______________________________________ The following individuals or institutions have signed copies: Name: __________________________________________________________________ Address: ______________________________ Phone: ________________________________________________________________ The original of the document is kept at _______________________________________ ________________________________ame: _________________________________________________________________ Address: _______________________________________________________________ ________________________________________________________________________________ ______________________________________________________________________ Phone: ________________________________________________________________ Page 1 Second Alternate Agent Nrized by this document, who serve in the following order: First Alternate Agent Name: _________________________________________________________________ Address: _______________________________________f the person designated as my agent is unable or unwilling to make health care decisions for me, I designate the following person(s), to serve as my agent to make health care decisions for me as authoed 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.) I________________ Designation of an 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 designat______________________________________________________________________ ________________________________________________________________________ ________________________________________________________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: __________________________________________________ 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 attorne y ________________________________ Address: _______________________________________________________________ ______________________________________________________________________ Phone: ________________ TEXAS MEDICAL POWER OF ATTORNEY FOR HEALTH CARE Designation of Health Care Agent: I, _____________________________________________ (insert your name) appoint: Name: _________________________________ty 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. Page 2 of a 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 facili 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 phys ician; (6) an employeeNT 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 entitledct 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 COMPETEfied. 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 awriting or by your execution of a subsequent medical power of attorney. Unless you state otherwise, your appointment of a spouse dissolves on divorce. Page 1 This document may not be changed or modiannot 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 e decisions made in good faith on your behalf. 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 c with your agent and your phys ician 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 carprovider; 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 documentmployee 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 st 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 e 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 muf 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,hat 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. I 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 tallow 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 followaining 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 ake 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 lifesustonger 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 mnt 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 ledical Power of Attorney for Health Care This is an important legal document. Before signing this document, you should know these important facts: Except to the extent you state otherwise, this documeax professional. [_] The purchase and use of these forms is subject to the Disclaimers and Terms of Use found at findlegalforms.com Power of Attorney for Health Care Disclosure Statement for Texas Mticular situation. Advice from a local attorney is always recommended when dealing with estate planning matters. Any possible tax consequences arising out of this document should be discussed with a t vary from time to time and from state to state. These forms should only be a starting point for you and should not be used or signed without consulting an attorney first to make sure it fits your paror are provided as to their suitability for any specific purpose or as to their legal effect or completeness. [_]These forms are not intended and are not a substitute for legal and/or tax advice. Lawsre Directive. The first form is the Power of Attorney for Health Care and the second form is the Living Will. [_] These forms are provided "as is" and no implied or express warranties have been made Texas Advance Health Care Directive This package contains both a Texas Power of Attorney for Health Care and a Texas Living Will. Together these forms are also sometimes known as an Advance Health Ca Texas