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Texas portant persons in your life. 4 ed. 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 imndard 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 advancry, 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 staperformance 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 injue support such as mechanical breathing machines, kidney dialysis treatment, and artificial hydration and nutrition. The term does not include the administration of 3 pain management medication, the 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 lif 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 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 anay 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 tandard of medical care, is fatal. 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 mcured 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 sin 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 ________ Witness 2: ____________________________________________________________________ Definitions "Artificial nutrition and hydration" means the provision of nutrients or fluids by a tube inserted yee 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: ____________________________________________________________ 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 emplot 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 inot 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 noe of Residence: __________________________________________________ Two competent adult witnesses must sign below, acknowledging the signature of the decrement The witness designated as Witness 1 may nsed as pregnant. This directive will remain in effect until I revoke it. No other person may do so. Signed: ______________________________________________ Date: ____________________ City, County, Stat 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 2 diagnoin 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 ofional names in this document.) If the above persons are not available, or it I have not designated a spokesperson, I understand that a spokesperson will be chosen for me following standards specified ___ 2. ___________________________________________________________________________ (If a Medical Power of Attorney has been executed, then an agent already has been named and you should not list additknown, I designate the following person(s) to make treatment decisions with my physician compatible with my personal values: 1. ________________________________________________________________________eatments 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 ____ _____________________________________________________________________________ After signing this directive, if my representative or I elect hospice care, I understand and agree that only those tr________________________________________________ _____________________________________________________________________________ _________________________________________________________________________n 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.) _____________________________S 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 intinued 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 lifesustaining treatment. (THIut life-sustaining treatment provided in accordance with prevailing standards of care (initial one):: ____________ I request that all treatments other than those needed to keep me comfortable be disco 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 myself or make decisions for myself and am expected to die withoeld 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 lifesustaining treatment. (THIS SELECTION DOES NOTtment provided in accordance with prevailing standards of medical care (initial one): ____________ I request that all treatments other than those needed to keep me comfortable be discontinued or withhatment preferences be honored: 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 life-sustaining trealong 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 tre_________________________, 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 ur 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_________________________________other types of directives that can be important during a serious illness. These are the Medical Power of Attorney and the Outof-Hospital Do-Not-Resuscitate Order. You may wish to discuss these with yon. 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 scussions 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 spokespersoer 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 dicular 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, othcause 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 partitant legal document known as an Advance Directive. It is designed to help you communicate your wishes about medical treatment at sometime in the future when you are unable to make your wishes known behese forms is subject to the Disclaimers and Terms of Use found at findlegalforms.com Texas Directive To Physicians And Family Or Surrogates Instructions For Completing This Document This is an impory is always recommended when dealing with estate planning matters. Any possible tax consequences arising out of this document should be discussed with a tax professional. [_] The purchase and use of te. 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 particular situation. Advice from a local attorney 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. Laws vary from time to time and from state to statection unless the person has actual knowledge of the revocation. [_] These forms are provided "as is" and no implied or express warranties have been made or are provided as to their suitability for anof the directive in the patient's medical record. (d) Except as otherwise provided by this subchapter, a person is not civilly or criminally liable for failure to act on a revocation made under this sfferent, the time, date, and place that the physician received notice of the revocation. The attending physician or the physician's designees shall also enter the word "VOID" on each page of the copy fies the attending physician of the revocation. The attending physician or the physician's designee shall record in the patient's medical record the time, date, and place of the revocation, and, if di the directive in the patient's medical record. (c) An oral revocation issued as prescribed by Subsection (a)(3) takes effect only when the declarant or a person acting on behalf of the declarant notiician's designee shall record in the patient's medical record the time and date when the physician received notice of the written revocation and shall enter the word "VOID" on each page of the copy ofen the declarant or a person acting on behalf of the declarant notifies the attending physician of its existence or mails the revocation to the attending physician. The attending physician or the physt to revoke the directive; or (3) the declarant orally stating the declarant's intent to revoke the directive. (b) A written revocation executed as prescribed by Subsection (a)(2) takes effect only wht's direction canceling, defacing, obliterating, burning, tearing, or otherwise destroying the directive; (2) the declarant signing and dating a written revocation that expresses the declarant's inten regard to the declarant's mental state or competency. A directive may be revoked by: Information & Instructions ­ Page 3 (1) the declarant or someone in the declarant's presence and at the declaran; 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 declarant may revoke a directive at any time withoutor 166.035 is effective without regard to whether the document has been notarized. (b) A physician, health care facility, or health care professional may not require that: (1) a directive be notarizedmake the directive a part of the declarant's medical record. § 166.036. Notarized Document Not Required; Requirement of Specific Form Prohibited (a) A written directive executed under Section 166.033 incompetent or otherwise mentally or physically incapable of communication, another person may notify the attending physician of the existence of the written directive. The attending physician shall nt becomes incompetent or otherwise mentally or physically incapable of communication. (d) A declarant shall notify the attending physician of the existence of a written directive. If the declarant isant 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 decision for the declarant in the event the declarae 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 witnesses must sign the directive. (c) A declarhe attending physician. § 166.032. Written Directive by Competent Adult; Notice to Physician (a) A competent adult may at any time execute a written directive. (b) The declarant must sign the directiv treatment in the event of a terminal or irreversible condition. (2) "Qualified patient" means a patient with a terminal or irreversible condition that has been diagnosed and certified in writing by tions Information & Instructions ­ Page 2 In this subchapter: (1) "Directive" means an instruction made under Section 166.032, 166.034, or 166.035 to administer, withhold, or withdraw life-sustaininga 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 declarant's death. § 166.031. Definitfice 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 executed or, if the directive is ian; (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, director, partner, or business ofart 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 attending physician; (E) an employee of the attending physicwitnesses 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; (C) a person entitled to any p 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 adult; and (2) at least one of the ction 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. Witnesses In any circumstance in whichSurrogates (Living Will); (2) Texas Directive To Physicians And Family Or Surrogates (Living Will). This Texas Directive To Physicians And Family Or Surrogates (Living Will) is based on Chapter 166 SeInformation and Instructions Texas Directive To Physicians And Family Or Surrogates (Living Will) This package contains (1) Information and Instruction for Texas Directive To Physicians And Family Or Texas