Texas Advance Health Directive Power of Attorney Form

01 Jul, 2017 Legal Forms, power-of-attorney, texas 0

The Texas Advance Health Directive Power of Attorney Form allows you to choose someone who will be able to act on your behalf in any medical decision in case you were mentally not able to do so.

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6
TEXAS ADVANCE DIRECTIVE – PAGE 1 OF 14

P ART I : Medical Power of Attorney

Disclosure Statement for Medical Power of Attorney

INFORMATION CONCERNING THE MEDICAL POWER OF ATTORNEY
THIS IS AN IMPORTANT LEGAL DOCUMENT. BEF ORE 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 wishe s, including your religious
and moral beliefs, when you are no longer capable of making them
yourself. Because “ health care” means any treatment, service, or
procedure to maintain, diagnose, or treat your physical or mental
condition, your agent has the po wer 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 m ake 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 a ppoint
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

DISCLOSURE
STATEMENT

7
TEXAS ADVANCE DIRECTIVE – PAGE 2 OF 14

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 wa nt the person to be
your health care agent. You should discuss thi s 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, yo u 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 grante d 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 d ocument 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 WITNESSE S:

(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 emplo yee of your attending physician;

DISCLOSURE
STATEMENT
(CONTINUED)

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TEXAS ADVANCE DIRECTIVE – PAGE 3 OF 14

(6) an employee of your 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 busines s office employee of the health care facility
or of any pa rent 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.

Acknowledgement of Disclosure St atement

I am signing this acknowledgement that I have received, read, and
understand the above disclosure statement prior to executing the medical
power of attorney in this document.

______________________________ ________________
Signature Date
Printed Name

IF YOU PLAN TO
DESIGNATE AN
AGENT IN PART I,
YOU MUST READ
AND UNDERSTAND
THE DISCLOSURE
STATEMENT AND
SIGN AND DATE
HERE BEFORE
EXECUTING YOUR
ADVANCE
DIRECTIVE

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TEXAS ADVANCE DIRECTIVE – PAGE 4 OF 14
TEXAS MEDICAL POWER OF ATTORNEY

DESIGNATION OF HEALTH CARE AGENT.

I, _________________________________________________, appoint:
(name)

_______________________________________________ _____________
(name of agent)

____________________________________________________________
(address)

____________________________________________________________
(work telephone number) (home telephone number)

as my agent to make any and all health car e 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 this fact is certified in writing by my physician.

LIMITATIONS ON THE DE CISION-MAKING AUTHORITY OF MY AGENT
ARE AS FOLLOWS:

____________________________________________________________

PRINT YOUR
NAME

PRINT THE NAME,
ADDRESS AND
HOME AND WORK
TELEPHONE
NUMBERS OF YOUR
AGENT

ADD INSTRUCTIONS
HERE ONLY IF YOU
WANT TO LIMIT
YOUR AGENT'S
AUTHORITY

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TEXAS ADVANCE DIRECTIVE — PAGE 5 OF 14

DESIGNATION OF ALTERNATE AGENT.
(
You are not required to designate an alternate agent but you may do so. An alternate agent may make the same health care decisions as the designated agent if the designated agent is unable or unwilling to act as
your agent. If the agent designated is your spouse, the designation is
automatically revoked by law if your marriage is dissolved
.)

If the person designated as my agent is unable or unwilling to make
health care decisions for me, I designate the fo llowing persons to serve
as my agent to make health care decisions for me as authorized by this
document, who serve in the following order:

A. First Alternate Agent

__________________________________________________________
(name of first alternate agent )

__________________________________________________________
(home address)

__________________________________________________________
(work telephone number) (home telephone number)

B. Second Alternate Agent

__________________________________________________________
(name of second alternate agent)

__________________________________________________________
(home address)

__________________________________________________________
(work telephone number) (home telephone number)

The original of t his document is kept at: ______________________ ____

____

PRINT THE NAME,
ADDRESS AND
HOME AND WORK
TELEPHONE
NUMBERS OF YOUR
FIRST ALTERNATE
AGENT

PRINT THE NAME,
ADDRESS AND
HOME AND WORK
TELEPHONE
NUMBERS OF YOUR
SECOND
ALTERNATE
AGENT

PRINT LOCATION
OF
ORIGINAL

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TEXAS ADVANCE DIRECTIVE — PAGE 6 OF 14

The following individuals or institutions have signed copies:

Name: ______________________________ ________________________

Address: ________________________ ____________________________

Name: _______________________ _______________________________

Address:_____________________________________________________

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.

(IF APPLICABLE) This power of attorney ends on the following date:

____________________________________________________________

PRIOR DESIGNATIONS REVOKED.
I revoke any prior medical power of atto rney.

ACKNOWLEDGMENT OF DISCLOSURE STATEMENT.
I have been provided with a disclosure statement explaining the effect of
this document. I have read and understood that information contained in
the disclosure statement , and signed the acknowledgment on page 2 of
this form prior to execution of this advance directive .

PRINT THE NAMES
AND ADDRESSES OF
PEOPLE OR
INSTITUTIONS YOU
PLAN TO GIVE
COPIES OF YOUR
ADVANCE
DIRECTIVE

EXPIRATION
DATE (IF ANY)

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TEXAS ADVANCE DIRECTIVE — PAGE 7 OF 14

P ART II: Directive to Phys icians 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 pa rticular, 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 yo ur discussions and
advance planning. Initial the treatment choices that best reflect your
personal preferences. 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 A ttorney (Part I) 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
tissue s.

INSTRUCTIONS FOR
DIRECTIVE

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TEXAS ADVANCE DIRECTIVE – PAGE 8 OF 14
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 to gether
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:

If, in the jud gment 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 request that all t reatments other than those needed to keep
me comfortable be discontinued or withheld and my physician allow me
to die as gently as possible; OR

_______ I request that I be kept alive in this terminal condition using
available life -sustaining treatment. (T HIS SELECTION DOES NOT APPLY
TO HOSPICE CARE)

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 provide d in
accordance with prevailing standards of care:

_______ 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; OR

_______ I request that I be kep t alive in this irreversible condition using
available life -sustaining treatment. (THIS SELECTION DOES NOT APPLY
TO HOSPICE CARE)

PRINT YOUR NAME

INITIAL THE
STATEMENT
THAT REFLECTS
YOUR WISHES
ABOUT TREAT MENT
IN THE EVENT OF A
TERMINAL
CONDITION

INITIAL ONLY ONE

INITIAL THE
STATEMENT
THAT REFLECTS
YOUR WISHES
IN THE EVENT OF
AN IRREVERSIBLE
CONDITION

INITIAL ONLY ONE

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TEXAS ADVANCE DIRECTIVE – PAGE 9 OF 14

Additional requests:
( After discussion with your physician, you may wish
to consider listing particular treatments in this space that you do or do not want in specific circumstances, such as artificial nutrition and fluids, intravenous antibiotics, etc. Be sure to state whether you do or do not want the particular treatment
. If you wish, you can also specify that you
would like to make an organ donation. Be sure to include any restrictions, such as who may become a donee, what organs you authorize to be
donated, etc .)

_________________________________________________________________

ADD OTHER
INSTRUCTIONS, IF
ANY, REGARDING
YOUR ADVANCE
CARE PLANS

THESE
INSTRUCTIONS CAN
FURTHER ADDRESS
YOUR HEALTH CARE
PLANS, SUCH AS
YOUR WISHES
REGARDING
HOSPICE
TREATMENT, BUT
CAN ALSO ADDRESS
OTHER ADVANCE
PLANNING ISSUES,
SUCH AS YOUR
BURIA L WISHES

ATTACH
ADDITIONAL PAGES
IF NEEDED

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TEXAS ADVANCE DIRECTIVE – PAGE 10 OF 14

After signing this directive, if my representative 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.

If I do not have a Medical Power of Attorney and/or have not filled out
Part I , and I am unable to make my wishes known, I designate the
following person(s) to make treatment decisi ons with my physician
compatible with my personal values:

1. _______________________________________
(name of person)

2. _______________________________________
(name of second person)

(IF A MEDICAL PO WER OF ATTORNEY SUCH AS PART I, HAS BEEN
EXECUTED, THEN AN AGENT HAS BEEN NAMED AND YOU SHOULD NOT
LIST ADDITIONAL NAMES IN THIS PART.)

If the above persons are not available, or if I have not designated a
spokesperson, I understand that the spokesperson will be chosen for me
following standards specified in the laws of Texas. 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 car e, I acknowledge that all treatments may be withheld or
removed except those needed to maintain my comfort. I understand that
under Texas law this directive has no effect if I have been diagnosed as
pregnant. This directive will remain in effect until I re voke it. No other
person may do so.

DESIGNATION OF A
SPOKESPERSON

IF YOU HAVE
COMPLETED A
MEDICAL POWER OF
ATTORNEY (PART I)
DO NOT COMPLETE
TH IS SECTION

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TEXAS ADVANCE DIRECTIVE – PAGE 11 OF 14

PART III : Explanation of Terms

“ARTIFICIAL NUTRITION AND HYDRATION” means the provision of nutrients
or fluids by a tube inserted in a vein, under the skin in the subcutan eous
tissues, or in the stomach (gastrointestinal tract).

“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 ow n self; and
3. that, without life -sustaining treatment provided in accordance with the
prevailing standard of medical care, is fatal.

EXPLANATION: Many serious illnesses such as cancer, failure of major organs
(kidney, heart, liver or lung), and serious brai n disease such as Alzheimer’s
dementia may be considered irreversible early on. There is no cure, but the
patient may be kept alive for prolonged periods of time if the patient receives
life -sustaining treatments. Late in the course of the same illness, th e disease
may be considered terminal when, even with treatment, the patient is
expected to die. You may wish to consider which burdens of treatment you
would be willing to accept in an effort to achieve a particular outcome. This is
a very personal decisio n that you may wish to discuss with your physician,
family, or other important persons in your life.

“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 me dication, the performance of a medical procedure
necessary to provide comfort care, or any other medical care provided to
alleviate a patient’s pain.

“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.

EXPLANATION: Many serious illnesses may be considered irreversible early in
the course of the illness, but they may not be considered terminal until the
disease is fairly advanced. In thinking about terminal illness and its treatment,
you again may wish to consider the relative benefits and burdens of treatment
and discuss your wishes with your physician, family, or other important
persons in your life.

EXPLANATION OF
IMPORTANT TERMS

IF YOU DO NOT
UNDERSTAND
THESE TERMS, OR
ANY OTHER PART
OF THIS ADVANCE
DIRECTIVE, YOU
SHOULD ASK A
LAWYER TO
EXPLAIN THEM TO
YOU

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TEXAS ADVANCE DIRECTIVE – PAGE 12 OF 14

PART IV : EXECUTION

This Advance Directive will not be valid unless it is EITHER:

(A) Signed by two (2) adult witnesses who are present when you sign
or acknowledge your signature .

Two competent adult witnesses must sign as witnesses, acknowledging
the signature of the declarant.

Witness 1 may not be a person designated to make a treatment decision
for you and may not be related to you by blood or marriage. This
witness may not be entitled to any part of your estate and may not have
a claim against your estate. This witness may not be your attending
physician or an employee of your attending physician. If this witness is
an employ ee of a health care facility in which you are being cared for,
this witness may not be involved in providing direct patient care to you.
This witness may not be an officer, director, partner, or business office
employee of a health care facility in which you are being cared for or of
any parent organization of the health care facility.

Any competent adult can sign as Witness 2.

(If you decide to have your advanced directive witnessed, use
alternative No. 1, below.)

(B) Witnessed by a notary.

( If you decide to have your advance directive notarized, use alternative
No. 2, below .)

NOTE: IF YOU HAVE FILLED OUT PART I, YOU MUST SIGN THE
ACKNOWLEDGMENT ON PAGE 3 STATING THAT YOU HAVE READ AND
UNDERSTAND THE DISCLOSURE STATEMENT ON PAGES 1 -3 BE FORE
YOU EXECUTE THIS DOCUMENT.

IF YOU DECIDE TO
HAVE YOUR
ADVANCE
DIRECTIVE
WITNESSED, USE
ALTERNATIVE NO.
1, BELOW (P. 18)

IF YOU DECI DE TO
HAVE YOUR
ADVANCE
DIRECTIVE
NOTARIZED, USE
ALTERNATIVE NO.
2, BELOW (P. 19)

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TEXAS ADVANCE DIRECTIVE – PAGE 13 OF 14

Alternative No. 1: Sign Before Witnesses

____________________________________ ______________
(signature) (date)

(printed name)
WITNESSES

Witness No. 1

I am not the person appointed as agent by this document. I am not
related to the principal by blood or marriage. I would not be entitled to
any portion of the principal’s estate on the principal’s death. I am not
the attending physician o f the principal or an employee of the
attending physician. I have no claim against any portion of the
principal’s estate on the principal’s death. Furthermore, if I am an
employee of a health care facility in which the principal is a patient, I
am not invo lved in providing direct patient care to the principal and am
not an officer, director, partner or business office employee of the
health care facility of any parent organization of the health care
facility.

_________________________________ _______________________
(signature of W itness 1) (date)

________________________________________
(printed name of W itness 1 )

Witness No. 2

__________________________________ ______________________
(signature of Witness 2 ) (date)

________________________________________
(printed name of W itness 2 )

SIGN AND DATE
YOUR ADVANCE
DIRECTIVE

PRINT YOUR NAME

AT LEAST ONE
WITNESS MUST
MEET THESE
REQUIREMENTS
AND SIGN AS
WITNESS 1

YOUR WITNESSES
MUST SIGN, DATE,
AND PRINT THEIR
NAMES HERE

ANY COMPETENT
ADULT CAN SIGN AS
WITNESS 2

19
TEXAS ADVANCE DIRECTIVE – PAGE 14 OF 14

Alternative No. 2: Sign Before a Notary Public

____________________________________ ______________
(sign ature) (date)

(printed name)

State of Texas, )
) ss.
County of _______________________________)

On this _ _____ day of ________________________ 20______, before me,

____________________________________________, a notary public in

____________________________________________ County, personally

came___________________________________________________,
persona lly to known to be the identical person whose name is affixed
above, and I declare that he or she appears in sound mind and not under
duress or undue influence, that he or she acknowledges the execution of
the same to be hi s or her voluntary act and deed .

Witness my hand and notarial seal at ______________________________
in such county the day and year last above written.

SEAL

________________________________________
signature of notary public

Courtesy of Caring Connections
1731 King St., Suite 10 0, Alexandria, VA 22314
www.caringinfo.org, 800/658 -8898

SIGN AND DA TE
YOUR ADVANCE
DIRECTIVE

PRINT YOUR NAME

A NOTARY
PUBLIC SHOULD
COMPLETE THIS
SECTION OF YOUR
DOCUMENT

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TEXAS ORGAN DONATION FORM – PAGE 1 OF 1

Initial the line next to the statement below that best reflects your
wishes. You do not have to initial any of the statements. If you do not
initial any o f the statements, your attorney for health care, proxy, or
other agent, or your family, may have the authority to make a gift of all
or part of your body under Texas law.

_____ I do not want to make an organ or tissue donation and I do not
want my a ttor ney for health care, proxy, or other agent or family to do
so.

_____ I have already signed a written agreement or donor card
regarding organ and tissue donation with the following individual or
institution:

Name of individual/institution:________________ _____

_____ Pursuant to Texas law, I hereby give, effective on my death:

_____ Any needed organ or parts.
_____ The following part or organs listed below:

For (initial one):
_____ Any legally authorized purpose.
_____ Transplant or therapeutic purposes only.

Declarant name: ____________________________________________

Declarant signature: _______________________, Date: ____________

The declarant voluntarily signed or directed another person to sign this
writing in my presence.

Witness ____________________________Date__________________

Address __________________________________________________
____________________________________________________

I am a disinterested party with regard to the declarant and his or her
donation and estate. The declarant voluntarily signed or directed
another person to sign this writing in my presence.

Witness ______________________________Date________________

Address __________________________________________________
_________ _________________________________________

Courtesy of Caring Connections
1731 King St., Suite 100, Alexandria, VA 22314
www.caringinfo.org, 800/658- 8898

ORGAN DONATION
(OPTIONAL)

INITIAL THE
OPTION THAT
REFLECTS YOUR
WISHES

ADD NAME OR
INSTITUTION (IF
ANY)

PRINT YOUR NAME,
SIGN, AND DATE
THE DOCUMENT

YOUR WITNESSES
MUST SIGN AND
PRINT THEIR
ADDRESSES

AT LEAST ONE
WITNESS MUST BE
A DISINTERESTED
PARTY

21
You Have Filled Out Your Health Care Directive, Now What?

1. Your
Texas Advance Directive is an importa nt legal document. Keep the original signed
document in a secure but accessible place. Do not put the original document in a safe
deposit box or any other security box that would keep others from having access to it.

2. Give photocopies of the signed origi nal to your agent and alternate agent, doctor(s),
family, close friends, clergy, and anyone else who might become involved in your health
care . If you enter a nursing home or hospital, have photocopies of your document
placed in your medical records.

3. Be s ure to talk to your agent(s), doctor(s), clergy, family, and friends about your wishes
concerning medical treatment. Discuss your wishes with them often, particularly if your
medical condition changes.

4. You may also want to save a copy of your form in an o nline personal health records
application, program, or service that allows you to share your medical documents with
your physicians, family, and others who you want to take an active role in your advance
care planning.

5. If you want to make changes to your documents after they have been signed and
witnessed, you must complete a new document.

6. Remember, you can always revoke your Texas document.

7. Be aware that you r Texas document will not be effective in the event of a medical
emergency. Ambulance and hospi tal emergency department personnel are required to
provide cardiopulmonary resuscitation (CPR) unless they are given a separate directive
that states otherwise. These directives called “ Out-of -Hospital do-not -resuscitate
orders ” are designed for people whose poor health gives them little chance of
benefiting from CPR. These directives instruct ambulance and hospital emergency
personnel not to attempt CPR if your heart or breathing should stop.

Currently not all states have laws authorizing these orders. We suggest you speak to
your physician if you are interested in obtaining one. Caring Connections does not
distribute these forms.

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Texas Advance Health Directive Power of Attorney Form

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