Directive to Physicians and Family or Surrogates
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.
Text Version of this Form
———————– Page 1———————–
Directive to Physicians and Family or Surrogates
Advance Directives Act (see §166.033, Health and Safety Code)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 the
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:If, in the judgement 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 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; ORI 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 judgement 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 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; ORI request that I be kept alive in this irreversible condition using available life-sustaining
treatment. (This selection does not apply to Hospice care.)———————– Page 2———————–
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.)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:
1.2.
(If a Medical Power of Attorney has been executed, then an agent already 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
a spokesperson will be chosen for me, following standards specified in the laws of Texas.If, in the judgement 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
City, County and State of Residence
Two witnesses must sign in the spaces below.
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 declarant 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)
———————– Page 3———————–
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:
a. that may be treated, but is never cured;
b. that leaves a person unable to care for or make decisions for the person’s own self; and
c. that, without life-sustaining 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,
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 judgement,
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 judgement will produce death within six months, even with
available life-sustaining treatment provided in accordance with the prevailing standard of medical
careExplanation: 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.Version 10/26/99