Texas Directive to Physicians Form

TEXAS DIRECTIVE TO PHYSICIANS Directive made this _____ day of _______________, 20___. I ____________________ , being of sound mind, willfully and voluntarily make known my desire that my life shall not be artificially prolonged under the circumstances set forth in this directive. 1. If at any time I should have an incurable condition caused by injury, disease, or illness certified to be a terminal condition by two physicians, and if the application of life-sustaining procedures would serve only to artificially postpone the moment of my death, and if my attending physician determines that my death is imminent whether or not life-sustaining procedures are used, I direct that those procedures be withheld or withdrawn, and that I be permitted to die naturally.

2. In the absence of my ability to give directions regarding the use of those life-sustaining procedures, it is my intention that this directive be honored by my family and physicians as the final expression of my legal right to refuse medical or surgical treatment and accept the consequences from that refusal. 3. If I have been diagnosed as pregnant and that diagnosis is known to my physician, this directive has no effect during my pregnancy. 4. This directive is in effect until it is revoked. 5. I understand the full import of this directive and I am emotionally and mentally competent to make this directive. 6. I understand that I may revoke this directive at any time. Signed ____________________________________ (City, County and State of Residence) _________________________ The declarant has been personally known to me and I believe the declarant to be of sound mind. I am not related to the declarant by blood or marriage. I would not be entitled to any portion of the declarant's estate on the declarant's death. I am not the attending physician of the declarant or an employee of the attending physician or a health facility in which the declarant is a patient. I am not a patient in the health care facility in which the declarant is a patient. I have no claim against any portion of the declarant's estate on the declarant's death. Witness ____________________________________ Witness ____________________________________