Directive to Physicians (Texas)
Client Information
Name of person making this designation
*
Address of person making this designation
*
County of residence
*
Check one of the three choices below (Usually the third item will be chosen):
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 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 kept alive in this terminal condition using available life- sustaining treatment. (THIS SELECTION DOES NOT APPLY TO HOSPICE CARE)
I request that my agent acting under my Medical Power of Attorney make treatment decisions with my physician compatible with my personal values.
Check one of the three choices below (Usually the third item will be chosen):
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 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 kept alive in this terminal condition using available life- sustaining treatment. (THIS SELECTION DOES NOT APPLY TO HOSPICE CARE)
I request that my agent acting under my Medical Power of Attorney make treatment decisions with my physician compatible with my personal values.
Preview PDF
Submit
Should be Empty: