Texas Advance Directive Form

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A Texas advance directive is a document that allows a person to outline their health care treatment preferences if they should become incapacitated. An advance directive is a health planning form that lets a person choose someone else to carry out their treatment requests. The form must be written and signed, with two (2) witnesses, while the person is still able to think for themselves.

Advance Directive Includes

Table of Contents

Laws

StatuteTitle 2, Chapter 166 (Advance Directives)

Signing Requirements (§ 166.154, § 166.003) – Two (2) witnesses or a notary public

State Definition – “Advance directive” means:

  • (A) a directive, as that term is defined by Section 166.031;
  • (B) an out-of-hospital DNR order, as that term is defined by Section 166.081; or
  • (C) a medical power of attorney under Subchapter D.

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How to Write

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Step 1 – Acquire Your Copy Of The Texas Advance Directive

The Texas Advance Directive can be downloaded through the “Adobe PDF” link or the similarly labeled “PDF” button on this page. Choose either of these objects to gain access to your copy of the Texas Advance Directive.

Step 2 – Review The Texas Advance Directive Introduction

The first few paragraphs of this directive focus on delivering information regarding the living will portion it opens with. Review all the material in these statements before tending to the template it refers to.   

 

Step 3 – Supplement The First Declaration With Your Information

To begin the process of completing the living will portion of the Texas Health Directives, document your full name (as the Texas Declarant) on the first blank line.

 

Step 4 – Identify Your Treatment Request When Your Condition Is Terminal

The next area is set to inform Texas Physicians of your preferred treatment goals when you have a fatal medical condition that will result with death within six months however, this statement will need some attention to be an accurate representation of your wishes. Notice the final term of the paragraph (“…In Accordance With Prevailing Standards Of Medical Care”) lead to two choices attached to a blank line apiece. Place your initials on the first blank line presented if you wish to inform Texas Physicians that all treatment courses administered will only have your authorization only if the treatment goal will be to keep you as pain-free and comfortable as possible. That is, when you are facing death within a number of months regardless of the treatment administered, you do not wish your life prolonged and prefer a natural death. Initial the line corresponding to “I Request That All Treatments Other Than Those Needed To keep Me Comfortable…” to make this declaration. If your intent to prolong your life regardless of a fatal medical condition, then select the second statement by initialing the space preceding the term “I Request That I Be Kept Alive…”

 

Step 5 – Define Treatment Preferences For A Fatal Medical Event

The next paragraph requiring your directives presents the situation where you cannot care for yourself because you are in the end-stages of a medical condition that results in death. If you have decided that you do not wish to prolong your life and will not authorize Texas Medical Physicians to put you on life support or continue life prolonging treatments, then initial the first statement choice presented. Do so by recording your initials just before the words “I Request That All Treatments…”If you can no longer care for yourself during the end-stages of an illness or traumatic medical event and can no longer communicate, you may still inform Texas Physicians that you wish your life prolonged or maintained even through the use of machines by selecting the next statement option “I Request That I Be Kept Alive In This Irreversible Condition Using Available Life-Sustaining Treatment.”

 

Step 6 – Include Additional Directives To Texas Physicians

The above statements have handled your treatment preferences when you are in the end-stage of a disease, when you can no longer care for yourself, and when this is irreversible however, if you wish to place additional requests and instructions to Texas Physicians when you are in this condition, you may do so by locating the paragraph starting with the phrase “Additional Requests” then using the blank lines provided to continue this document with treatment requirements, restrictions, and authorizations. 

 

Step 7 – Name A Representative To Safeguard Your Wishes With Texas Physicians

The next area requiring your attention begins with the language “If I Do Not Have A Medical Power Of Attorney And I Am Unable To Make My Wishes Known…” The blank lines that follow, numbered “1” and “2,” are set here to name an Agent who can act as your Representative with this paperwork. Be advised that if you have nominated a Texas Medical Attorney-in-Fact or Health Care Agent by issuing a Medical Power Of Attorney, then the Agent named in that document will be considered your Agent in this one. Naming different entities here then in a Texas Medical Power Of Attorney can create confusion regarding who can make your decisions thus, make sure your Agents remain consistent across all your paperwork. You may name two distinct Health Care Representatives to enforce this document by listing each name on a unique line (“1” or “2” respectively) along with his or her contact phone number (i.e., cell phone number). If you have not issued or will not issue a Medical Power of Attorney and do not name an Agent here, Texas Law will designate Spokesperson for you, but many would strongly recommend choosing one who understands your medical needs rather than having one appointed for you. 

 

Step 8 – Sign The Texas Directive Into Effect

For this document to be active, it will have to be signed by the Texas Principal or Patient issuing it before two observing Parties (Witnesses). This signature must also be dated, and your identity must be clear. Thus, locate the final paragraph (starting with “If In The Judgement Of My Physician”) then turn your attention to the signature area below it. Your signature, as the Texas Declarant, must be delivered to the line labeled as “Signed” while the current “Date” of your signing should be documented next to your signature.  The “City, County, State Of Residence” line seeks your residential information. Identify the area where your home is located by satisfying this line request for information.

 

Step 9 – Obtain Signed Testimony From Two Texas Witnesses

The Witnesses observing your signing must qualify as such in the State of Texas. This means that at least one of them (“Witness 1”) “May Not Be A Person Designated To Make Health Care Or Treatment Decisions For The Patient And May Not Be Related By Blood Or Marriage.” Neither Witness will qualify should he or she believe that they are entitled to an inheritance when you suffer death. Make sure both Witnesses read the statement directly below your signature.  The First Witness must sign the “Witness 1” line as the person who has observed your signing, is not related to you, does not work, or associated with a health care provider responsible for your care, and meets all criteria in the statement above this line.  The Second Witness, who may be related to you but must meet the remainder of the defined qualifying Witness requirements must sign the “Witness 2” line. 

 

Step 10 – Formally Issue A Texas Power Of Attorney

The second template provided in the Texas Advanced Directives, titled “Medical Power Of Attorney Designation Of Health Care Agent,” enables a formal appointment of your authority and decision making power as a Patient in Texas to another individual. This authority becomes effective when you are no longer able to communicate with Texas Physicians while in need of medical care and remain unable to do so for an extended period of time. This gives Texas Physicians a person to speak with on your behalf for directions on what your treatment choices would be. To begin, find the first blank line then produce your complete name just before the words “Insert Your Name.” 

 

Step 11 – Disclose The Name And Contact Information For Your Texas Health Care Agent

The Texas Medical Attorney-in-Fact can be anyone you trust even a Health or Residential Care Provider. Be advised however if selecting anyone associated with your care, then they must be informed and consent since they will not be able to act as your Texas Health Care Provider and your Texas Medical Attorney-in-Fact or Health Care Agent at the same time. That is, they would have to stop being your Health Care or Residential Provider in order to remain compliant with the law. You can also name a trusted Family Member, a close Friend, or anyone that can maintain a clear understanding of your stance on medical treatments and therapy. Generally, if possible, it is recommended that you select a trusted Family Member. Determine the identity of your Texas Health Care Agent then document his or her “Name” on the first line after the word “Appoint.”  Continue identifying the Texas Health Care Agent you are granting authority to with a record of his or her full “Address” and currently maintained “Phone” number. 

 

Step 11 – Document The Limitations Or Directives Placed On Your Texas Health Care Agent

While it should be considered crucial to make sure your Texas Health Care Agent agrees with your outlook at all times, complicated medical issues may arise that call for exceedingly difficult decisions to be made. Thus, you can place limitations on your Texas Medical Attorney-in-Fact so that your directives on certain issues are available to be complied with by the attending Texas Physicians. Any specific instructions to Texas Doctors or restrictions on the authority to access your medical records, to make medical decisions for you, to control your admittance to an institute or any other representational power granted to your Texas Health Care Agent (Attorney-in-Fact) should be listed on the blank lines beneath the heading “Limitations On The Decision-Making Authority Of My Agent As Follows.” If an extensive report for specific medications, procedures, or medical scenarios must be delivered then you are encouraged to report the name of an attachment then set your directives and limitations that should be applied to this document in writing. If you do name a document here, make sure it is physically attached to this paperwork before and at the time of your signing. 

 

Step 12 – Ensure Your Representation Is Consistent

There may be circumstances, conditions, or court orders in the future that prevent your Agent from representing your medical needs with Texas Doctors. For instance, your Health Care Agent may be a divorced Spouse, may become incapacitated themselves, leave the country or become unreachable for an extended period of time, or simply refuses to act according to your directives. When this happens, Texas Doctors will still need authorization or guidance regarding your treatment. If you are unconscious, they will have no choice but to clear up any confusion by being compliant with the law and the guidelines of the Medical Facility caring for you. This can be avoided by electing one or two people who can succeed your Texas Health Care Agent. Neither of the Alternate Agents assigned to this role will have any authority to represent you unless you are incapacitated, Texas Doctors are in need of your consent or refusals for treatment, and the original Texas Attorney-in-Fact has stepped down from this role or cannot perform it effectively. Document the full “Name” of the person you wish approached to act as your Texas Health Care Agent under the heading “First Alternate Agent.”  Make sure Texas Doctors reviewing this paperwork can contact your First Alternate Agent by producing his or her complete “Address” then “Phone” number in the area provided.  As mentioned earlier, you can use this paperwork to name two people as an Alternate Agent. The First Alternate Agent named above will be the person initially approached by Texas Doctors seeking guidance or consent for your medical treatment. If this person cannot be reached or refuses this role then a “Second Alternate Agent” would be helpful. Find the next line labeled “Name” then use it to identify the Second Alternate Agent that should be approached to represent your medical needs.    Continue to the next two lines where a record of the Second Alternate Agent’s currently maintained home “Address” and “Phone” number is required. 

 

Step 13 – Inform Reviewers Of The Whereabouts Of This Directive

Naturally, the original signed copy of your Texas Power Of Attorney is considered a powerful document. Thus, find the words “The Original Of the Document Is Kept At” then supply the physical address where the original power document will be stored. Make sure to include the name of the Entity or Party in charge of its storage as well.   Now that you have identified where the original paperwork will be kept, it will be important to document where copies of the Texas Power Of Attorney will be dispensed. Two sets of “Name” and “Address” lines are provided for your presentation of this material.

 

Step 14 – Set A Natural Termination Date As Needed

The “Duration” section enables a specific date to be named as the day when the Texas Attorney-in-Fact or Health Care Agent will no longer carry the authority to represent you. Normally, this document remains in effect unless you revoke it or the Agent(s) have demonstrated an interest in acting against your wishes however, you can set a specific day for it to expire organically. If desired, report this appointment’s termination date on the blank line following the statement “This Power Of Attorney Ends On The Following Date.” 

 

Step 15 – Read Through The Provided Disclosure Statement

To ensure that you are aware of the powers being granted, their limitations, requirements placed on all Parties by the State of Texas, a “Disclosure Statement” section has been provided for the Texas Principal behind this appointment to become up-to-date with such subject matter. Read through this area before continuing with the execution of this paperwork.

 

Step 16 – Sign The Power Appointment Before A Texas Notary Public Or Two Witnesses

Your dated signature is mandatory to execute this form. Additionally, this signature must be verifiable or provable through a second party who has physically watched you sign the completed appointment on the date you indicate in the final statement. Therefore, two signature areas have provided of which you must complete one. If you have determined this document’s execution is best proven by a Texas Notary Public, coordinate your schedule with one then locate the first statement in the “Signature Acknowledged Before Notary” section. Supply the calendar date of this execution across the blank lines following the words “…This Medical Power Of Attorney On…”  Continue through your signature statement to the line labeled “City And State” then satisfy its request with the location of the current signing. Now, proceed to the line “Signature” then sign your name to it. Make sure you are also following the Texas Notary Public’s instructions. Print your name on the line labeled “Print Name” then give this document to the Texas Notary Public. This signing will be notarized with the location, date, and Signature Party identity (You) as well as the Texas Notary Public’s signature and formal credential. He or she may also provide a seal depending upon the regulations your locality places.  If you will not be signing this power document before a Texas Notary Public, then it must be signed before two Witnesses. For this task, tend to only the signature area titled “Signature In Presence Of Two Competent Adult Witnesses.” The first statement of this signature area seeks to be supplemented with information detailing the date and location of this signing. Thus, present the calendar date of this power document’s signing across the first two spaces using the first space for the two-digit “Day Of” when you sign this document then completing this date on the blank line labeled “Month, Year.”  Next, dispense the city where this signing is being executed along with the state on the blank line labeled “City And State.”The line labeled “Signature” must be presented with your signed name as the Texas Principal.   The line beneath it (labeled “Print Name”) must be populated with your printed name.
The “Statement Of First Witness” must be agreed to with the signature of the Witness who has met all the requirements of the first statement, the remainder of this declaration, and has watched you sign this document. He or she must sign the “Signature” line presented. Continuing one row down, the First Witness must produce his or her name in print then the current “Date” on the lines labeled “Print Name” and “Date” in the “Statement Of First Witness” section.  The final requirement the First Witness must satisfy is to record his or her “Address” below the signature, name, and signature date he or she presented.  The “Signature Of Second Witness” section must also be signed by someone willing to testify that you have signed this document and possessed the capability of understanding its content at the time. He or she must provide the “Signature” line in the “Signature Of Second Witness” section with his or her sign name.  Once done, the Second Witness is obligated to display his or her printed name and signature date on the lines labeled “Print Name” and “Date.”  The Second Witness who has observed the Texas Principal’s act of signing is expected to produce his or her  “Address.” 

 

Step 17 – Complete The OOH-DNR With Your Texas Physician

The final form delivered for your use in this packet is the “Out Of Hospital Do Not Resuscitate Order” which will be completed with and issued by a Physician licensed in the State of Texas. This document shall formally state the level of medical care you prefer when you are unable to represent yourself and suffering a potentially life-threatening medical event. This document will be kept with your medical records thus, it should identify you as soon as it is viewed. To this end your full name, birthday, and sex must be defined with a reporting area at the top of the page consisting of the lines labeled “Person’s Full Legal Name” and “Date Of Birth” then the checkboxes “Male” and “Female” (only one may be chosen). 

 

Step 18 – Formally Declare Your DNR

If you are suffering from a terminal condition that results in death and experience cardiopulmonary arrest (where your hearts or lungs cease functioning) the attending Texas Physicians or Response Units will (in all likelihood) immediately attempt to resuscitate you by stimulating or physically maintaining the function of one or both of these organs. Statement “A” of this document will explicitly forbid this response but only if you execute it. Therefore, if you do not wish CPR (cardiopulmonary resuscitation) and other intervention methods used when suffering this event, the “Person’s Signature” line must be signed (by your), the “Date” line must be populated with the current “Date” as you sign this area, and the “Printed Name” line must be populated with your name in print or typeface. If you do not sign this area (as in the example below), it will be assumed that you authorize the use of CPR (unless this treatment is forbidden in another directive).

 

Step 19 – Indicate If You Are The Legal Guardian Or Agent/Proxy Of The Patient

If you are not the Patient identified above but have been instructed (in a reliable and provable manner) to execute this OOH-DNR in his or her name, then you must indicate this fact. Thus, locate Statement “B Declaration By Legal Guardian, Agent Or Proxy.” If you are the “Legal Guardian” then mark the first box after the words “I Am The,” if you are the “Agent In a Medical Power Of Attorney” then mark the second checkbox, or if you are the “Proxy In A Directive To Physicians Of The Above Noted Person Who Is Incompetent…Or Incapable Of Communication” then mark the third checkbox. Once you have identified yourself by marking one of the three checkboxes in Statement “B” you must sign your name on the “Signature” line, provide the signature “Date” on the next line,” then print your full name on the “Printed Name” line. Be advised, that if you do not sign this area it will be assumed that the Patient has issued this paperwork with the Texas Physician Office working with him or her on this.

 

Step 20 – Obtain The Declaration Of A Qualified Relative

It is particularly important to Texas Physicians that your medical needs are understood and met when you are suffering a terminal condition and unable to communicate. Thus, if someone other than the Patient is completing this document, it must be verified by a Qualified Relative who knows the Patient well enough to support the Issuing Texas Health Care Agent, Proxy, or Guardian’s treatment directives for the Patient. This Relative must indicate who he or she is to the Patient by placing a mark in the checkbox labeled “Spouse,” “Adult Child,” “Parent,” Or “Nearest Living Relative” qualified to make this assessment as per Health And Safety Code §166.088After reading the testimonial in Statement “C,” the Qualified Relative must show agreement by signing his or her name on the “Signature” line displayed then recording the “Date” for this signature on the adjacent line. In addition to these items, the Qualified Relative must print his or her name on the final line. 

 

Step 21 – A Report From The Texas Physician Must Be Supplied

In Statement “D Declaration By Physician…” requires the Texas Physician working to issue this OOH-DNR explain why it is being executed. If the Texas Physician has “Seen Evidence” of the Patient’s “Previously Issued Directive To Physicians” stating this DNR is appropriate, then he or she must mark the first checkbox however if the Texas Physician has personally observed a verbal issuance of the Patient’s OOH-DNR before two Witnesses then the Physician will select the second checkbox. One of these items must be marked by the attending Physician if the Patient is not present, verbal, or communicative.  Once the Texas Physician has displayed why this OOH-DNR is being issued, he or she must sign the “Signature” line provided then dispense the signature “Date” and his or her “Printed Name” on the next two lines. In addition to these items, the Texas Physician must dispense his or her medical license number to the line labeled “Lic #”  

 

Step 22 – Supply A Formal Declaration On Behalf Of A Texas Minor

If the Patient is a Minor (under the age of 18) and you have identified who you are to him or her then you must proceed to Statement “E Declaration On Behalf Of The Minor Person.” First, display the capacity in which you are representing the Texas Minor by marking the checkbox that best defines your status. Three are provided to choose from thus select the “Parent,” “Legal Guardian,” Or “Managing Conservator” checkbox to help identify yourself.  You must agree to the DNR statement by signing your name and providing the date of this action on the blank line labeled “Signature” and the blank line labeled “Date.”  After signing your name, make sure to present the printed form of your name on the “Printed Name” line.  

 

Step 23 – Gain The Confirmation Of Two Witnesses

Regardless of who is issuing this form, whether the Patient, a Relative, an Agent/Proxy/Conservator, or the Physician. Two Witnesses must observe the Signature Party(ies) sign this document. The “Two Witnesses” section will provide two rows where this can be done. Once Witness 1 has read and agreed to the statement in this area he or she must sign the “Witness 1 Signature” line then document the “Date” of this signature and provide his or her “Printed Name”  Witness 2 must also provide testimony by signing the “Witness 2” line and entering the “Date” of signature. Additionally, Witness 2 must print his or her name on the last line of this row.  If the Patient or Representative of the Patient is physically signing this document, then this signature can be notarized. The Texas Notary Public has been provided with a “Notary In The State Of Texas” area where the location and Notary’s verification can be completed.  

 

Step 23 – A Specific Statement From The Texas Physician Must Be Provided

The language necessary to direct other Physicians to refrain from engaging in CPR, transporting the Patient to hospital for treatment, and using invasive life maintenance procedures on the Patient when he or she is unconscious and unable to communicate is provided in the “Physician’s Statement” section but requires the Texas “Physician’s Signature” on the first line provided along with his or her “Date” to be taken as a valid directive from the Texas Physician.  The Signature Physician should also print his or her name on the “Printed Name” line then display the medical license number allowing him or her to practice in the State of Texas on the line labeled “Lic #.”  

 

Step 24 – If Needed Two Texas Physicians May Issue The OOH-DNR

If the attending Texas Physician possesses a “Reasonable Medical Judgement” that resuscitating the Patient is not in the Patient’s best interests (i.e., it may cause severe life-long damage), then he or she and a Second Physician may issue this paperwork. Statement “F Directive By Two Physicians On Behalf Of The Adult, Who Is Incompetent Or Unable To Communicate…” can be used to complete this document. The “Attending Physician’s Signature,” “Date” of signature, “Printed Name,” and “Lic #” should be provided on the first signature row in this section. The Second Physician must sign the “Signature Of Second Physician” line then also provide his or her official signature “Date,” “Printed Name,” then medical “Lic #” on the next row.

 

Step 25 – Gain A Second Verifying Signature From The Issuing Texas Parties Behind The OOH-DNR

Every person who has signed an area above to inform Texas Physicians of this Patient’s OOH-DNR order must verify the accuracy of this document by providing a second signature in the final section. The “Person’s Signature” line has been reserved for the Texas Patient if he or she has personally signed this document while the second line “Guardian/Agent/Proxy/Relative Signature” would need to be signed by the Representative of the Patient if this form was filled out and signed by the Texas Health Care Representativ (if applicable). In our example, the Patient (known as the Texas Declarant) is able to sign this document. If the OOH-DNR was issued by two Physician’s or one of the Parties above and one Physician, then the next row of lines must be attended. A blank line has been placed to receive the “Attending Physician’s Signature” and one has been made available to display the “Second Physician’s Signature.” Lastly the Parties obtained to verify the signing must provide a second signature in this area thus the “Witness 1 Signature” and “Witness 2 Signature” lines have been provided as well as the “Notary’s Signature” line.

 

 

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