Texas Health & Safety Code - Section 166.033. Form Of Written Directive
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§ 166.033. FORM OF WRITTEN DIRECTIVE. A written
directive may be in the following form:
DIRECTIVE TO PHYSICIANS AND FAMILY OR SURROGATES
Instructions for completing 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 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 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 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 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 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; OR __________ I 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 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 without life-sustaining
treatment provided in accordance with prevailing standards of 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; OR __________ I request that I be kept alive in this irreversible condition using available life-sustaining treatment. (THIS 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 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 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 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, State of
Residence __________
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 patient 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 __________
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:
(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-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 judgment, 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
judgment will produce death within six months, even with available
life-sustaining 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 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.
Acts 1989, 71st Leg., ch. 678, § 1, eff. Sept. 1, 1989. Amended
by Acts 1991, 72nd Leg., ch. 14, § 209, eff. Sept. 1, 1991; Acts
1997, 75th Leg., ch. 291, § 2, eff. Jan. 1, 1998. Renumbered
from § 672.004 and amended by Acts 1999, 76th Leg., ch. 450, §
1.03, eff. Sept. 1, 1999.
Section: 166.006 166.007 166.008 166.009 166.010 166.031 166.032 166.033 166.034 166.035 166.036 166.037 166.038 166.039 166.040
Last modified: August 11, 2007
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