Texas Living Will
This Living Will is designed to reflect the directives and wishes of the undersigned, in accordance with the Texas Advance Directives Act. It is a declaration instructing healthcare providers on the continuation, withholding, or withdrawal of life-sustaining treatment if I, the undersigned, become unable to make my own healthcare decisions and am diagnosed with a terminal or irreversible condition.
Part 1: Information of the Declarant
Full Name: ________________________________________
Date of Birth: _____________________________________
Address: __________________________________________
City: __________________________ State: TX Zip: ____
Phone Number: ____________________________________
Part 2: Declaration
I, _________________, being of sound mind, willfully and voluntarily make known my desire that my dying shall not be artificially prolonged under the circumstances set forth below, and I hereby declare:
- If I am in a terminal condition, 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.
- If I am diagnosed with an irreversible condition, I direct that life-sustaining treatments that only prolong the process of dying be withheld or discontinued.
- Life-sustaining treatment is defined as treatment that, based on reasonable medical judgment, sustains life and without which the patient will die. This includes mechanical ventilation, artificially administered nutrition and hydration, and other forms of treatment which, in reasonable medical judgment, could sustain, restore, or supplant vital bodily functions.
- I understand that this decision will not affect the provide of comfort care, including pain relief.
- I understand the full import of this declaration and I am emotionally and mentally competent to make this declaration.
Part 3: Signature
Signature: _______________________________ Date: ________________
Witness: __________________________________ Date: ________________
Part 4: Optional - Appointment of a Health Care Agent
If you wish to appoint a health care agent to make decisions on your behalf if you are incapable of doing so, complete the following:
I designate ___________________________________________ as my agent to make health care decisions for me as authorized in this document. My agent's authority becomes effective when my primary physician determines that I am unable to make my own health care decisions.
If the person named as my health care agent is not available or able to act as agent, I name ___________________________________________ as my alternate agent.
Signature of Primary Agent: _______________________________ Date: ________________
Signature of Alternate Agent: _____________________________ Date: ________________
Note: This document does not create a Durable Power of Attorney for Health Care. A separate document is required to appoint someone to make health care decisions for you if you become incapable of making them yourself.
Important: Keep the original signed document in a secure but accessible place. Provide a copy to your appointed agent, if applicable, and to your primary physician. Make sure your family knows where to find this document.