This Texas Living Will is a legally binding document that outlines your healthcare preferences in the event you become unable to make decisions for yourself. The directives stated in this document align with the Texas Advance Directives Act.
Full Name: ___________________________________
Date of Birth: _______________________________
Address: _____________________________________
City, State, Zip: _____________________________
Phone Number: _______________________________
Email Address: ______________________________
I, ____________ [Name], residing at ____________ [Address], City of ____________, in the state of Texas, 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 declare:
In the event that I suffer from an incurable or irreversible condition that will cause my death within a relatively short time, and I am no longer able to make decisions regarding my medical treatment, I direct that:
- Life-sustaining treatments that serve only to prolong the dying process or maintain me in a condition of permanent unconsciousness be withheld or withdrawn.
- Life-sustaining treatments be administered if there is a reasonable expectation of my recovery and return to a meaningful quality of life.
If I have been diagnosed as being in a permanent unconscious condition or if I am terminally ill and the application of artificial nutrition and hydration would only serve to prolong artificially the process of dying, I direct that:
- Artificial nutrition and hydration be withheld or withdrawn, except to the extent that it provides comfort care.
- Artificial nutrition and hydration be administered if it is likely to improve my condition or add to my comfort.
If I am unable to make my own healthcare decisions, I designate the following individual as my agent to make healthcare decisions for me:
Name of Agent: _______________________________
Relationship: _______________________________
Phone Number: _______________________________
Alternate Phone Number: ______________________
This Living Will becomes effective only upon my incapacity to give, withdraw, or withhold informed consent regarding my healthcare. It ceases to be effective upon my ability to give, withdraw, or withhold informed consent regarding my healthcare.
By signing below, I affirm that I am of sound mind and I fully understand the contents of this document. This declaration reflects my firm and settled commitment to refuse medical treatment that only prolongs the process of dying if I am unable to make my own healthcare decisions.
Signature: _______________________________
Date: ____________________________________
I declare that the individual who signed or acknowledged this document is personally known to me and appears to be of sound mind and under no duress, fraud, or undue influence. I am not the person appointed as agent by this document.
Witness 1 Signature: ________________________
Date: ______________________________________
Witness 2 Signature: ________________________
Date: ______________________________________