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Health Care Directive

Create Your Living Will


Create Your Living Will

Do you want to appoint someone to make your health care decisions if you are unable to?


Frequently Asked Questions
What is a Living Will?A Living Will allows you to have a say in the type of health care treatment you receive should you find yourself unable to act for yourself. A Living Will is also commonly known as a Health Care Directive.What is a Medical Power of Attorney?A Medical Power of Attorney allows you to appoint someone to make health care decisions on your behalf should you find yourself unable to act for yourself.What is the difference between a Living Will and a Last Will and Testament?A Living Will deals with the type of health care treatment you will receive while alive. In contrast, a Last Will determines how your estate will be dispersed after you pass. Both documents are part of a strong estate plan.


Your Health Care Directive

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ADVANCE DIRECTIVE FOR HEALTH CARE

MEDICAL POWER OF ATTORNEY

DISCLOSURE STATEMENT

THIS IS AN IMPORTANT LEGAL DOCUMENT. BEFORE SIGNING THIS DOCUMENT, YOU SHOULD KNOW THESE IMPORTANT FACTS:

Except to the extent you state otherwise, this document gives the person you name as your agent the authority to make any and all health care decisions for you in accordance with your wishes, including your religious and moral beliefs, when you are no longer capable of making these decisions yourself. Because "health care" means any treatment, service, or procedure to maintain, diagnose, or treat your physical or mental condition, your agent has the power to make a broad range of health care decisions for you. Your agent may consent, refuse to consent, or withdraw consent to medical treatment and may make decisions about withdrawing or withholding life-sustaining treatment. Your agent may not consent to voluntary inpatient mental health services, convulsive treatment, psychosurgery, or abortion. A physician must comply with your agent's instructions or allow you to be transferred to another physician.

Your agent's authority begins when your doctor certifies that you lack the competence to make health care decisions.

Your agent is obligated to follow your instructions when making decisions on your behalf. Unless you state otherwise, your agent has the same authority to make decisions about your health care as you would have had.

It is important that you discuss this document with your physician or other health care provider before you sign it to make sure that you understand the nature and range of decisions that may be made on your behalf. If you do not have a physician, you should talk with someone else who is knowledgeable about these issues and can answer your questions. You do not need a lawyer's assistance to complete this document, but if there is anything in this document that you do not understand, you should ask a lawyer to explain it to you.

The person you appoint as agent should be someone you know and trust. The person must be 18 years of age or older or a person under 18 years of age who has had the disabilities of minority removed. If you appoint your health or residential care provider (e.g., your physician or an employee of a home health agency, hospital, nursing home, or residential care home, other than a relative), that person has to choose between acting as your agent or as your health or residential care provider; the law does not permit a person to do both at the same time.

You should inform the person you appoint that you want the person to be your health care agent. You should discuss this document with your agent and your physician and give each a signed copy. You should indicate on the document itself the people and institutions who have signed copies. Your agent is not liable for health care decisions made in good faith on your behalf.

Even after you have signed this document, you have the right to make health care decisions for yourself as long as you are able to do so and treatment cannot be given to you or stopped over your objection. You have the right to revoke the authority granted to your agent by informing your agent or your health or residential care provider orally or in writing or by your execution of a subsequent medical power of attorney. Unless you state otherwise, your appointment of a spouse dissolves on divorce.

This document may not be changed or modified. If you want to make changes in the document, you must make an entirely new one.

You may wish to designate an alternate agent in the event that your agent is unwilling, unable, or ineligible to act as your agent. Any alternate agent you designate has the same authority to make health care decisions for you.

THIS POWER OF ATTORNEY IS NOT VALID UNLESS IT IS SIGNED IN THE PRESENCE OF TWO COMPETENT ADULT WITNESSES. THE FOLLOWING PERSONS MAY NOT ACT AS ONE OF THE WITNESSES:

  1. the person you have designated as your agent;
  2. a person related to you by blood or marriage;
  3. a person entitled to any part of your estate after your death under a will or codicil executed by you or by operation of law;
  4. your attending physician;
  5. an employee of your attending physician;
  6. an employee of a health care facility in which you are a patient if the employee is providing direct patient care to you or is an officer, director, partner, or business office employee of the health care facility or of any parent organization of the health care facility; or
  7. a person who, at the time this power of attorney is executed, has a claim against any part of your estate after your death.

I have read this disclosure and I understand it.

Signature: ____________________________________


DESIGNATION OF HEALTH CARE AGENT

I, _________________________, appoint:

Name: _______________________
Address: _______________________
City: _______________________
State: The State of Texas
Phone: ______________________________

as my agent to make any and all health care decisions for me, except to the extent I state otherwise in this document. This Medical Power of Attorney takes effect if I become unable to make my own health care decisions and my physician certifies this fact in writing.

My agent is subject to no limitations other than those imposed by law or expressed herein.

In accordance with the Health Insurance Portability and Accountability Act of 1996, 42 USC 1320d ("HIPAA"), I authorize my health care agent to review and receive any information regarding my physical or mental health, including medical and hospital records.

LOCATION OF DOCUMENTS:
The original of this document is kept at:

_________________________________________________________________________


The following individuals or institutions have signed copies:

Name: _____________________________

Address: __________________________________

Phone: _______________



Name: ____________________________

Address: __________________________________

Phone: _______________

DURATION:
I understand that this power of attorney exists indefinitely from the date I execute this document unless I establish a shorter time or revoke the power of attorney. If I am unable to make health care decisions for myself when this power of attorney expires, the authority I have granted my agent continues to exist until the time I become able to make health care decisions for myself.

This power of Attorney ends on the following date: Not Applicable

PRIOR DESIGNATIONS REVOKED:
I revoke any prior Medical Power of Attorney.

ACKNOWLEDGMENT OF DISCLOSURE STATEMENT:
I have been provided with a disclosure statement explaining the effect of this document. I have read and understand that information contained in the disclosure statement.

I sign my name to this medical power of attorney on ________ day of ________________, ________, at ______________ (city), _________ (State).

Signature: ________________
Name: _________________________

STATEMENT OF WITNESSES (Use only if document is not notarized.)
I am not the person appointed as agent by this document. I am not related to _________________________ by blood or marriage. I would not be entitled to any portion of _________________________'s estate on her death. I am not the attending physician of the principal or an employee of the attending physician. I have no claim against any portion of _________________________'s estate on her death. Furthermore, if I am an employee of a health care facility in which _________________________ is a patient, I am not involved in providing direct patient care to her and am not an officer, director, partner, or business office employee of the health care facility or of any parent organization of the health care facility.

Signature: ____________________

Name: ________________________

Address: _____________________

Date: ___________________



Signature: ____________________

Name: ________________________

Address: _____________________

Date: ___________________

NOTARY ACKNOWLEDGMENT (Use only if document is not witnessed.)

STATE OF TEXAS

COUNTY OF  ___________________

The instrument was acknowledged before me on the ______ day of ______________, 20___, by_________________________.


______________________________________
Notary Public

My commission expires:  ___________________



RECORD OF COPIES

Record of people and institutions to whom I have given a signed copy of this document:

1. ____________________________________  Date: ____________________
2. ____________________________________  Date: ____________________
3. ____________________________________  Date: ____________________
4. ____________________________________  Date: ____________________
5. ____________________________________  Date: ____________________


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. 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:

DEFINITIONS
For the purposes of this document, the following definitions apply:

  1. "Artificially administered food and water" (or artificial nutrition and hydration) means the provision of nutrients or fluids by a tube inserted in vein, under the skin in the subcutaneous tissues, or in the stomach (gastrointestinal tract).
  2. "Attending physician" means the physician licensed by the state board of medicine, selected by or assigned to the patient, and who has primary responsibility for the treatment and care of the patient.
  3. "Comfort care" means treatment, including prescription medication, provided to the patient for the sole purpose of alleviating pain. Artificially administered food and water is not included.
  4. "Health care provider" or "provider" means any person licensed, certified, or otherwise authorized by law to administer health care in the ordinary course of business or practice of a profession.
  5. "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.
  6. "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.
  7. "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.

MEDICAL DIRECTIONS AND END-OF-LIFE DECISIONS
I direct that my health care providers and others involved in my care, provide, withhold, or withdraw treatment in accordance with my directions below:

  1. 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 direct that:
    • I be kept on any artificial life support as long as possible within the limits of generally accepted health care standards.
    • I be artificially administered food and water, even if that has the effect of prolonging my life.
    • I be provided comfort care, and relief from pain, including any pain reduction medication, even if doing so would prolong my life.
  2. 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 direct that:
    • I be kept on any artificial life support as long as possible within the limits of generally accepted health care standards.
    • I be artificially administered food and water, even if that has the effect of prolonging my life.
    • I be provided comfort care, and relief from pain, including any pain reduction medication, even if doing so would prolong my life.

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.

This directive will remain in effect until I revoke it.  No other person may do so.

HOSPICE CARE
After signing this directive, if my agent 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.

PREGNANCY
I understand that under Texas law this directive has no effect if I have been diagnosed as pregnant.


ADDITIONAL INSTRUCTIONS
I have no additional instructions. I understand that I may change the above-listed directives at any time by revoking this declaration and writing a new one.

EFFECT OF COPY
A copy of this Directive has the same effect as the original.

SEVERABILITY
If any part or parts of this Directive is found to be invalid or illegal under applicable law by a court of competent jurisdiction, the invalidity or illegality of such part or parts shall not in any way affect the remaining parts, and this document shall be construed as though the invalid or illegal part or parts had never been included herein. But if the intent of this Directive would be defeated by such construction, then it shall not be so construed.

SIGNATURE
This document is made upon careful reflection. Options that I have considered and rejected are not printed above. I confirm that the health care directions contained herein were made after careful consideration and in full awareness of other options that may have been available to me. I declare that I am an adult in the State of Texas, that I understand the full import of this declaration, and that I am emotionally and mentally competent to give these directions.

Signed at ____________________, in the State of Texas, this ________ day of ________________, ________.

Signature:

_________________________

Name:

_________________________

Address:

____________________________

 

______________________________, Texas


STATEMENT OF WITNESSES
(Use only if the document is not notarized.)

  1. I declare under penalty of perjury under the laws of the State of Texas that:
  2. The individual who signed or acknowledged this Directive, _________________________, is personally known to me, or her identity was proven to me by convincing evidence;
  3. _________________________ appeared to be eighteen (18) years of age or older, or of the legal age in this state to create this type of document;
  4. I am of at least eighteen (18) years of age and _________________________ signed or acknowledged this Directive in my presence;
  5. _________________________ appears to be of sound mind and under no duress, fraud, or undue influence;
  6. I am not a person appointed as _________________________'s health care agent;
  7. I am not _________________________'s health care provider, an employee of _________________________'s health care provider, the operator of a community care facility, an employee of an operator of a community care facility, the operator of a residential care facility for the elderly, nor an employee of an operator of a residential care facility for the elderly; and
  8. I am not related to _________________________ by blood or marriage and I would not be entitled to any portion of _________________________'s estate on her death.

First witness

____________________________
(signature of witness)

_______________________
(print name)

____________________________
(address)

____________________________
(city) (state)

______________
(date)

Second witness

____________________________
(signature of witness)

_______________________
(print name)

____________________________
(address)

____________________________
(city) (state)

______________
(date)


NOTARY ACKNOWLEDGMENT
(Use only if document is not witnessed.)

STATE OF TEXAS

COUNTY OF  ___________________

The instrument was acknowledged before me on the ______ day of ______________, 20___, by_________________________.


______________________________________
Notary Public

My commission expires:  ___________________


RECORD OF COPIES

Record of people and institutions to whom I have given a signed copy of this document:

1. ____________________________________  Date: ____________________
2. ____________________________________  Date: ____________________
3. ____________________________________  Date: ____________________
4. ____________________________________  Date: ____________________
5. ____________________________________  Date: ____________________

Health Care Directive

What is a Health Care Directive?

A directive allows you to plan your medical treatment in advance should there ever come a time when you are unable to express your personal health care wishes.

A Health Care Directive is also known as:

  • Advance Directive
  • Living Will Form
  • Advance Health Care Directive
  • Advance Medical Directive
  • Living Will
  • Advance Decision Form

What is a Medical Power of Attorney?

A Medical Power of Attorney is a document used to appoint someone to make medical decisions on your behalf.

A Medical Power of Attorney is also known as:

  • Health Care Power of Attorney
  • Health Care Proxy
  • Durable Power of Attorney for Health Care
  • Power of Attorney Medical

What is a Living Will?

A Living Will is a document that you use to indicate your medical wishes in the event you are incapacitated or cannot consent to your health care treatment.

Is a Living Will the same as a Health Care Directive?

Some states use the terms Living Will and Health Care Directive interchangeably, and some states use one term but not the other. Generally, a Living Will and a Health Care Directive both dictate your health care preferences in the event of a medical emergency or incapacitation.

A Health Care Directive may also be used to refer to a document that contains a Living Will and a Medical Power of Attorney. In addition, different states have varying requirements in what constitutes a Living Will or Health Care Directive.

It's important to check your state's laws regarding these documents to determine exactly which documents you need to express your wishes.

What is the difference between a Living Will and a Last Will and Testament?

If you are unable to express your health care wishes in the future, hospitals and family can reference your Living Will as a statement of your medical wishes.

Alternatively, a Last Will and Testament is a document used to indicate how you would like your assets divided or children cared for after your death. You cannot specify medical treatment preferences with a Last Will.

Why should I create a Health Care Directive?

Without a Health Care Directive, the burden of making your medical decisions falls on your family members. Creating a personal directive not only gives you control of your medical wishes but it saves your family from making tough treatment choices on your behalf.

Additionally, implementing a Medical Power of Attorney allows you to discuss your treatment wishes with someone you trust prior to any unforeseen medical circumstance so they can make health care decisions in your best interest.

What medical decisions can I make with a Living Will?

Every state has its own limits as to what you are legally permitted to include in your directive. While you may specify instructions for a variety of medical situations and describe your feelings towards quality of life, keep in mind that health care providers can only carry out certain procedures according to your state laws.

With LawDepot's Living Will template, you can make decisions regarding the following medical situations:

Terminal Illness or Injury

If you are terminally ill or injured, you can document which, if any, treatment options you would like to pursue.

Terminally ill or injured means that medical professionals have concluded that you have a condition that cannot be cured and that is expected to result in limited life expectancy.

Life Support

You can specify whether you would like to receive any form of life support in the event of a medical emergency.

Life support means any life-sustaining procedures done to a patient to restore function to an organ through medical intervention.

Common forms of life support include CPR (Cardiopulmonary Resuscitation), defibrillators, assisted breathing, dialysis, and artificially administered food and water.

DNR stands for "Do Not Resuscitate", which means you do not wish to receive life support or resuscitation if an organ fails.

Permanent Unconsciousness

You can address which, if any, treatments you would like to receive in the event of permanent unconsciousness, such as a coma or persistent vegetative state.

Permanent unconsciousness is when there is a reasonable degree of medical certainty that the patient can no longer think, feel, knowingly move, or be aware that they are alive, and there is no hope for improvement.

When does my Health Care Directive come into effect?

The terms of your directive are binding once you sign the document. It comes into use when you have been found to be incapable of making your own medical decisions. Typically, this may be when you are incapacitated, in a coma, or in a vegetative state.

Can I make changes to my Health Care Directive?

You can make changes to your personal directive if you destroy your current one, notify your health care representative or hospital of your changes, and create and distribute a new directive. It's important to let everyone in your family know where you keep your advance directive so they can easily find it during an emergency.

Related Documents:

  • Power of Attorney: a document used to grant someone the authority to act on your behalf, such as tending to your finances or maintaining property
  • Last Will and Testament: a document specifying how you would like your estate divided upon your death
  • Child Medical Consent: a form granting a guardian the authorization to make medical decisions on behalf of your child
  • Medical Records Release: a form requesting your medical records be released to you or a third party
  • End-of-Life Plan: a document used to outline your wishes regarding memorial services or how you want your remains to be taken care of

Related Articles:

Frequently Asked Questions:

Health Care Directive FAQ
Sample Health Care Directive

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