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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: ____________________

Last Updated October 6, 2023

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What is a Living Will?

A Living Will is a document in which you can specify the medical treatments you wish to receive if you become incapacitated and can’t communicate.

As such, this document helps health care workers understand when to proceed with certain treatments when you’re:

  • In a coma
  • Terminally ill or injured
  • In the late stages of dementia
  • Near the end of life

The terms of your directive are binding once you sign the document. 

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

Generally, a Living Will and a Health Care Directive both dictate your health care preferences in the event of a medical emergency or incapacitation.

Some states use the terms Living Will and Health Care Directive interchangeably, while others use one term but not the other. The requirements for each document also vary by jurisdiction. LawDepot’s Living Will template will automatically customize your document to suit the laws in your selected location.

This document is sometimes called a Living Will because it only applies while you’re still alive. People also use the term Health Care Directive because it dictates which medical treatments and decisions you consent to. Other common names for this document include:

  • Advance Directive
  • Advance Medical Directive
  • Advance Decision Form
  • Personal Directive

In addition to your directives, LawDepot’s Living Will template allows you to grant decision-making powers to another person with a Medical Power of Attorney. 

What is a Medical Power of Attorney?

A Medical Power of Attorney is a document that appoints someone to make medical decisions on your behalf. This person becomes known as your health care agent or proxy.

If you’re incapacitated, your health care agent generally has the authority to:

  • Consent or refuse consent to treatments (per your Living Will)
  • Receive/review your medical and hospital records
  • Sign any medical releases or health care documents

A Medical Power of Attorney is also known as a Durable Power of Attorney for Health Care. For decision-making powers over legal, financial, and other personal areas of your life, use a Power of Attorney.

Who makes decisions if there’s no Medical Power of Attorney?

Typically, laws about family, health, and safety in your jurisdiction dictate who makes health care decisions for you if you’re unable to. In some states, surrogate consent laws create a hierarchy of people (e.g., family and friends) who should be able to convey your wishes accurately.

For example, in Arizona, the first five people health care workers defer to are:

  1. Any court-appointed guardian for making health care decisions
  2. Your health care agent
  3. Your spouse
  4. Your adult child
  5. Your domestic partner (if unmarried)

Notably, your spouse and family do not automatically have this authority if you’ve designated someone else as your health care agent. In this case, health care workers will defer to this person first and foremost.

Also, family members cannot override the directives you outlined in your Living Will. Nor can they override the decisions of your health care agent—who’s legally obligated to execute your Living Will. 

Why should I create a Living Will?

Creating a Living Will gives you control when you can’t speak for yourself and saves your family from making tough choices on your behalf.

Plus, when implementing a Medical Power of Attorney, you can discuss your wishes with someone you trust before you’re incapacitated. This way, you can trust they’ll make decisions in your best interest.

Imagine your family being asked to make medical decisions on your behalf. Would they struggle to agree on the best course of action? Who might argue or anguish over making “the right choice”? Avoid this situation by writing your health care wishes down in advance.

How to write a Living Will

Use LawDepot’s printable PDF template to customize a directive that suits your needs and preferences, while also complying with the laws of your state.

Specify your desired level of care if in a terminal condition, permanent coma, or vegetative state.

Terminally ill or injured means you have an incurable condition that limits your life expectancy. A permanent coma or vegetative state is when there’s a reasonable degree of certainty that you cannot think, feel, knowingly move, or be aware of living. Often, there’s little hope for improvement.

In these cases, consider if you wish to receive:

  • Life Support: life-sustaining procedures that restore function to an organ through medical intervention, such as CPR, defibrillators, assisted breathing, or dialysis.
  • Tube feeding: continuous life support that artificially administers food and water.
  • Comfort care: treatments that manage symptoms, pain relief, and quality of life.

2. Provide personal details

Include your full name and address.

If you can become pregnant, consider whether you want to suspend your Health Care Directive if there’s a chance your fetus can survive.

3. If desired, appoint a health care agent

LawDepot’s Living Will template allows you to include a Medical Power of Attorney. With this form, you can appoint a representative and an alternate to act if your first choice is unavailable. If doing so, include their:

  • Full name
  • Address
  • Phone number
  • Relationship to you

4. Add any special instructions, if applicable

Consider any unique circumstances or preferences you may want to include. For example, if your religious beliefs prohibit certain health care treatments.

Remember that you cannot include any instructions unrelated to health care planning.

5. Sign the document

Depending on your state’s law, you’ll need to sign your Living Will in front of at least two witnesses, a notary public, or both. LawDepot’s Living Will template will also include a Statement of Witnesses if your state requires it. In this statement, your witnesses swear they meet the legal requirements to witness and sign the document.

Also, it’s best practice to keep a record of any copies you make. For instance, you, your health care agent (if applicable), and your family doctor should each keep a copy. It’s helpful to keep a record of who owns a copy so that you know who to contact whenever you update your health care preferences.

Do I need to notarize a Living Will?

Even if your state doesn't require it, you may wish to notarize your document to help ensure its validity.

A notary public:

  • Verifies the identity of the signing parties
  • Ensures the parties understand the agreement
  • Puts their official stamp or seal on the document

How do I make changes to my Living Will?

You can make changes to your Living Will by:

  • Creating a new Living Will
  • Giving the new document and its copies to the appropriate people
  • Destroying any outdated versions

It's also important to let everyone in your family know where you keep your Living Will, so they can easily find it when needed.

What’s the difference between a Last Will and a Living Will?

Unlike a Living Will, a Last Will and Testament comes into effect when you die. Rather than dictate your choices for health care, a Last Will indicates how you’d like to divide your assets.

Still, both of these documents are powerful tools for managing your life and estate.

Related documents

  • Power of Attorney: grant someone authority to act on your behalf regarding your finances, family, or property
  • Last Will and Testament: dictate your legacy and how you’d like your estate divided upon your death
  • Child Medical Consent: give a temporary guardian the authority to make medical decisions on behalf of your child
  • Medical Records Release: request that your medical records be released to you or a third party
  • End-of-Life Plan: outline your wishes for memorial services and what to do with your remains

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