Texas Advance Health Care Directive(Living Will) Form

DirectivetoPhysiciansandFamilyorSurrogates

AdvanceDirectivesAct(see§166.033,HealthandSafetyCode)

ThisisanimportantlegaldocumentknownasanAdvanceDirective. Itisdesignedtohelpyoucommunicateyourwishesaboutmedicaltreatmentatsometimeinthefuturewhenyouareunabletomakeyourwishesknownbecauseofillnessorinjury. Thesewishesareusuallybasedonpersonalvalues.Inparticular,youmaywanttoconsiderwhatburdensorhardshipsoftreatmentyouwouldbewillingtoacceptforaparticularamountofbenefitobtainedifyouwereseriouslyill.

Youareencouragedtodiscussyourvaluesandwisheswithyourfamilyorchosenspokesperson,aswellasyourphysician.Yourphysician,otherhealthcareprovider,ormedicalinstitutionmayprovideyouwithvariousresourcestoassistyouincompletingyouradvancedirective. Briefdefinitionsarelistedbelowandmayaidyouinyourdiscussionsandadvanceplanning.Initialthetreatmentchoicesthatbestreflectyourpersonalpreferences.Provideacopyofyourdirectivetoyourphysician,usualhospital,andfamilyorspokesperson. Consideraperiodicreviewofthedocument.Byperiodicreview,youcanbestassurethatthedirectivereflectsyourpreferences.

Inadditiontothisadvancedirective,Texaslawprovidesfortwoothertypesofdirectivesthatcanbeimportantduringaseriousillness. ThesearetheMedicalPowerofAttorneyandtheOut-of-HospitalDo-Not-ResuscitateOrder. Youmaywishtodiscussthesewithyourphysician,family,hospitalrepresentative,orotheradvisers.Youmayalsowishtocompleteadirectiverelatedtothedonationoforgansandtissues.

Directive

I ,recognizethatthebesthealthcareisbaseduponapartnershipoftrustandcommunicationwithmyphysician.MyphysicianandIwillmakehealthcaredecisionstogetheraslongasIamofsoundmindandabletomakemywishesknown.IftherecomesatimethatIamunabletomakemedicaldecisionsaboutmyselfbecauseofillnessorinjury,Idirectthatthefollowingtreatmentpreferencesbehonored:

If,inthejudgementofmyphysician,IamsufferingwithaterminalconditionfromwhichIamexpectedtodiewithinsixmonths,evenwithavailablelife-sustainingtreatmentprovidedinaccordancewithprevailingstandardsofmedicalcare:

Irequestthatalltreatmentsotherthanthoseneededtokeepmecomfortablebediscontinuedorwithheldandmyphysicianallowmetodieasgentlyaspossible;OR

IrequestthatIbekeptaliveinthisterminalconditionusingavailablelife-sustainingtreatment.

(ThisselectiondoesnotapplytoHospicecare.)

If,inthejudgementofmyphysician,IamsufferingwithanirreversibleconditionsothatIcannotcareformyselformakedecisionsformyselfandamexpectedtodiewithoutlife-sustainingtreatmentprovidedinaccordancewithprevailingstandardsofmedicalcare:

Irequestthatalltreatmentsotherthanthoseneededtokeepmecomfortablebediscontinuedorwithheldandmyphysicianallowmetodieasgentlyaspossible;OR

IrequestthatIbekeptaliveinthisirreversibleconditionusingavailablelife-sustainingtreatment.(ThisselectiondoesnotapplytoHospicecare.)

AdditionalRequests: (Afterdiscussionwithyourphysician,youmaywishtoconsiderlistingparticulartreatmentsinthisspacethatyoudoordonotwantinspecificcircumstances,suchasartificialnutritionandfluids,intravenousantibiotics,etc.Besuretostatewhetheryoudoordonotwanttheparticulartreatment.)

Aftersigningthisdirective,ifmyrepresentativeorIelecthospicecare,IunderstandandagreethatonlythosetreatmentsneededtokeepmecomfortablewouldbeprovidedandIwouldnotbegivenavailablelife-sustainingtreatments.

IfIdonot haveaMedicalPowerofAttorney,andIamunabletomakemywishesknown,Idesignatethefollowingperson(s)tomaketreatmentdecisionswithmyphysiciancompatiblewithmypersonalvalues:

1.

2.

(IfaMedicalPowerofAttorneyhasbeenexecuted,thenanagentalreadyhasbeennamedandyoushould notlistadditionalnamesinthisdocument.)

Iftheabovepersonsarenotavailable,orifIhavenotdesignatedaspokesperson,Iunderstandthataspokespersonwillbechosenforme,followingstandardsspecifiedinthelawsofTexas.

If,inthejudgementofmyphysician,mydeathisimminentwithinminutestohours,evenwiththeuseofallavailablemedicaltreatmentprovidedwithintheprevailingstandardofcare,Iacknowledgethatalltreatmentsmaybewithheldorremovedexceptthoseneededtomaintainmycomfort. IunderstandthatunderTexaslawthisdirectivehasnoeffectifIhavebeendiagnosedaspregnant.ThisdirectivewillremainineffectuntilIrevokeit. Nootherpersonmaydoso.

SignedDateCity,CountyandStateofResidence

Twowitnessesmustsigninthespacesbelow.

Twocompetentadultwitnessesmustsignbelow,acknowledgingthesignatureofthedeclarant.ThewitnessdesignatedasWitness(1)maynotbeapersondesignatedtomakeatreatmentdecisionforthepatientandmaynotberelatedtothedeclarantbybloodormarriage.Thiswitnessmaynotbeentitledtoanypartoftheestateandmaynothaveaclaimagainsttheestateofthepatient.Thiswitnessmaynotbetheattendingphysicianoranemployeeoftheattendingphysician. Ifthiswitnessisanemployeeofahealthcarefacilityinwhichthepatientisbeingcaredfor,thiswitnessmaynotbeinvolvedinprovidingdirectpatientcaretothepatient. Thiswitnessmaynotbeanofficer,director,partner,orbusinessofficeemployeeofahealthcarefacilityinwhichthepatientisbeingcaredfororofanyparentorganizationofthehealthcarefacility.

Witness(1) Witness(2)

Definitions:

"Artificialnutritionandhydration"meanstheprovisionofnutrientsorfluidsbyatubeinsertedinavein,undertheskininthesubcutaneoustissues,orinthestomach(gastrointestinaltract).

"Irreversiblecondition"meansacondition,injury,orillness:

a. thatmaybetreated,butisnevercured;

b. thatleavesapersonunabletocareforormakedecisionsfortheperson'sownself;and

c. that,withoutlife-sustainingtreatmentprovidedinaccordancewiththeprevailingstandardofmedicalcareisfatal.

Explanation:Manyseriousillnessessuchascancer,failureofmajororgans(kidney,heart,liver,orlung),andseriousbraindiseasesuchasAlzheimer'sdementiamaybeconsideredirreversibleearlyon. Thereisnocure,butthepatientmaybekeptaliveforprolongedperiodsoftimeifthepatientreceiveslife-sustainingtreatments.Lateinthecourseofthesameillness,thediseasemaybeconsideredterminalwhen,evenwithtreatment,thepatientisexpectedtodie. Youmaywishtoconsiderwhichburdensoftreatmentyouwouldbewillingtoacceptinanefforttoachieveaparticularoutcome. Thisisaverypersonaldecisionthatyoumaywishtodiscusswithyourphysician,family,orotherimportantpersonsinyourlife.

"Life-sustainingtreatment"meanstreatmentthat,basedonreasonablemedicaljudgement,sustainsthelifeofapatientandwithoutwhichthepatientwilldie. Thetermincludesbothlife-sustainingmedicationsandartificiallifesupportsuchasmechanicalbreathingmachines,kidneydialysistreatment,andartificialhydrationandnutrition. Thetermdoesnotincludetheadministrationofpainmanagementmedication,theperformanceofamedicalprocedurenecessarytoprovidecomfortcare,oranyothermedicalcareprovidedtoalleviateapatient'spain.

"Terminalcondition"meansanincurableconditioncausedbyinjury,disease,orillnessthataccordingtoreasonablemedicaljudgementwillproducedeathwithinsixmonths,evenwithavailablelife-sustainingtreatmentprovidedinaccordancewiththeprevailingstandardofmedicalcare

Explanation: Manyseriousillnessesmaybeconsideredirreversibleearlyinthecourseoftheillness,buttheymaynotbeconsideredterminaluntilthediseaseisfairlyadvanced. Inthinkingaboutterminalillnessanditstreatment,youagainmaywishtoconsidertherelativebenefitsandburdensoftreatmentanddiscussyourwisheswithyourphysician,family,orotherimportantpersonsinyourlife.