Directive to Physicians as Provided by Texas Natural Death Act: Section 3

DIRECTIVE TO PHYSICIANS 

Directive made this _________________ day of ___________. I ____________, being of sound mind, willfully and voluntarily make known my desire that my life shall not be artificially prolonged under the circumstances set forth below, and do hereby declare: 
1.  If at any time I should have an incurable condition caused by injury, disease or illness certified to be a terminal condition by two physicians, and where the application of life- sustaining procedures would serve only to artificially prolong the moment of my death and where my attending physician determines that my death is imminent whether or not life-sustaining procedures are utilized, I direct that such procedures be withheld or withdrawn, and that I be permitted to die naturally. 
2.  In the absence of my ability to give directions regarding the use of such life-sustaining procedures, it is my intention that this directive shall be honored by my family and physician(s) as the final expression of my legal right to refuse medical or surgical treatment and accept the consequences from such refusal. 
3.  If I have been diagnosed as pregnant and that diagnosis is known to my physician, this directive shall have no force or effect during the course of my pregnancy. 
4.  I have been diagnosed and notified at least 14 days ago as having a terminal condition by _________________, M.D., whose address is  ____________, ________.

I understand that if I have not filed in the physician’s name and address, it shall be presumed that I did not have a terminal condition when I made out this directive. 
5.  This directive shall be in effect until revoked. 
6.  I understand the full import of this directive and I am emotionally and mentally competent to make this directive. 
7.  I understand that I may revoke this directive at any time. 

Signed _________________________________________________ 

City of residence: _______________
County of residence: _____________
State of residence: ______________

The Declarant has been personally known to me and I believe him or her to be of sound mind. I am not related to the Declarant by blood or marriage, nor would I be entitled to any portion of the Declarant’s estate on his decease, nor am I the attending physician of Declarant or an employee of the attending physician or a health facility in which the Declarant is a patient or any person who has a claim against any portion of the estate of the Declarant upon his decease. 

Witness: 

__________________________________________________ 

Witness: 

__________________________________________________ 

Witness:  

__________________________________________________ 

STATE OF TEXAS 
COUNTY OF _______________________ 

Before me, the undersigned authority, on this day personally appeared __________________, __________________________ and __________________________ and _______________________________ known to me to be the Declarant and witnesses whose names are subscribed to the foregoing instrument in their respective capacities, and, all of said persons being by me duly sworn, the Declarant _________________ declared to me and to the said witnesses in my presence that the said instrument is his Directive to Physicians, and that he willingly and voluntarily made and executed it as his free act and deed for the purposes therein expressed. 

Declarant: 

___________________________________________________________ 

Subscribed and acknowledged before me by the said Declarant _____________ and by the said witnesses ________________________ and _____________________________ on This ______________ day of ___________________________________________, 20______. 

______________________________________________ 
Notary Public in and for 
___________________________ County, Texas  

Directive to Physicians as Provided by Texas Natural Death Act: Section 3
Review List

This review list is provided to inform you about this document in question and assist you in its preparation.  This simple Life Sustaining Declaration is valid in Texas. Check with a local hospital or doctor’s office, as well as with an experienced medical attorney, to assure yourself of its compliance with current statute (s) in your state.

1.	Make multiple copies.  Give one to your doctor (s), the local hospital, and have others available through your attorney and family.  Remember, these kinds of documents are needed in emergency situations at worst and under stressful circumstances at best.  So be sure they are available to the appropriate people easily, when needed.