Tex. Health & Safety Code Section 166.033
Form of Written Directive

A written directive may be in the following form:
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. 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 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.
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 or treatment 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:
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:
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:
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 artificially administered nutrition and hydration, intravenous antibiotics, etc. Be sure to state whether you do or do not want the particular treatment.)
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 I am unable to make my wishes known, I designate the following person(s) to make health care or treatment decisions with my physician compatible with my personal values:
1. __________
2. __________

(If a Medical Power of Attorney has been executed, then an agent already has been named and you should not list additional names in this document.)

If the above persons are not available, or if I have not designated a spokesperson, I understand that a 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 care, 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 revoke it. No other person may do so.
Signed__________ Date__________ City, County, State of Residence __________
Two competent adult witnesses must sign below, acknowledging the signature of the declarant. The witness designated as Witness 1 may not be a person designated to make a health care or treatment decision for the patient and may not be related to the patient by blood or marriage. This witness may not be entitled to any part of the estate and may not have a claim against the estate of the patient. This witness may not be the attending physician or an employee of the attending physician. If this witness is an employee of a health care facility in which the patient is being cared for, this witness may not be involved in providing direct patient care to the patient. This witness may not be an officer, director, partner, or business office employee of a health care facility in which the patient is being cared for or of any parent organization of the health care facility.
Witness 1 __________ Witness 2 __________
Definitions:
“Artificially administered nutrition and hydration” means the provision of nutrients or fluids by a tube inserted in a vein, under the skin in the subcutaneous tissues, or in the 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 own 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 brain 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, the 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 decision 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 artificially administered nutrition and hydration. 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.
“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.
Acts 1989, 71st Leg., ch. 678, Sec. 1, eff. Sept. 1, 1989. Amended by Acts 1991, 72nd Leg., ch. 14, Sec. 209, eff. Sept. 1, 1991; Acts 1997, 75th Leg., ch. 291, Sec. 2, eff. Jan. 1, 1998. Renumbered from Sec. 672.004 and amended by Acts 1999, 76th Leg., ch. 450, Sec. 1.03, eff. Sept. 1, 1999.
Amended by:
Acts 2015, 84th Leg., R.S., Ch. 435 (H.B. 3074), Sec. 4, eff. September 1, 2015.

Source: Section 166.033 — Form of Written Directive, https://statutes.­capitol.­texas.­gov/Docs/HS/htm/HS.­166.­htm#166.­033 (accessed Apr. 13, 2024).

166.001
Short Title 166.002
Definitions 166.003
Witnesses 166.004
Statement Relating to Advance Directive 166.005
Enforceability of Advance Directives Executed in Another Jurisdiction 166.006
Effect of Advance Directive on Insurance Policy and Premiums 166.007
Execution of Advance Directive May Not Be Required 166.008
Conflict Between Advance Directives 166.009
Certain Life-sustaining Treatment Not Required 166.010
Applicability of Federal Law Relating to Child Abuse and Neglect 166.011
Digital or Electronic Signature 166.031
Definitions 166.032
Written Directive by Competent Adult 166.033
Form of Written Directive 166.034
Issuance of Nonwritten Directive by Competent Adult Qualified Patient 166.036
Notarized Document Not Required 166.037
Patient Desire Supersedes Directive 166.038
Procedure When Declarant Is Incompetent or Incapable of Communication 166.039
Procedure When Person Has Not Executed or Issued a Directive and Is Incompetent or Incapable of Communication 166.040
Patient Certification and Prerequisites for Complying with Directive 166.041
Duration of Directive 166.042
Revocation of Directive 166.043
Reexecution of Directive 166.044
Limitation of Liability for Withholding or Withdrawing Life-sustaining Procedures 166.045
Liability for Failure to Effectuate Directive 166.046
Procedure if Not Effectuating Directive or Treatment Decision for Certain Patients 166.047
Honoring Directive Does Not Constitute Offense of Aiding Suicide 166.048
Criminal Penalty 166.049
Pregnant Patients 166.050
Mercy Killing Not Condoned 166.051
Legal Right or Responsibility Not Affected 166.052
Statements Explaining Patient’s Right to Transfer 166.053
Registry to Assist Transfers 166.054
Reporting Requirements Regarding Ethics or Medical Committee Processes 166.081
Definitions 166.082
Out-of-hospital Dnr Order 166.083
Form of Out-of-hospital Dnr Order 166.084
Issuance of Out-of-hospital Dnr Order by Nonwritten Communication 166.085
Execution of Out-of-hospital Dnr Order on Behalf of a Minor 166.086
Desire of Person Supersedes Out-of-hospital Dnr Order 166.087
Procedure When Declarant Is Incompetent or Incapable of Communication 166.088
Procedure When Person Has Not Executed or Issued Out-of-hospital Dnr Order and Is Incompetent or Incapable of Communication 166.089
Compliance with Out-of-hospital Dnr Order 166.090
Dnr Identification Device 166.091
Duration of Out-of-hospital Dnr Order 166.092
Revocation of Out-of-hospital Dnr Order 166.093
Reexecution of Out-of-hospital Dnr Order 166.094
Limitation on Liability for Withholding Cardiopulmonary Resuscitation and Certain Other Life-sustaining Procedures 166.095
Limitation on Liability for Failure to Effectuate Out-of-hospital Dnr Order 166.096
Honoring Out-of-hospital Dnr Order Does Not Constitute Offense of Aiding Suicide 166.097
Criminal Penalty 166.098
Pregnant Persons 166.099
Mercy Killing Not Condoned 166.100
Legal Right or Responsibility Not Affected 166.101
Duties of Department and Executive Commissioner 166.102
Physician’s Dnr Order May Be Honored by Health Care Personnel Other than Emergency Medical Services Personnel 166.151
Definitions 166.152
Scope and Duration of Authority 166.153
Persons Who May Not Exercise Authority of Agent 166.154
Execution 166.155
Revocation 166.156
Appointment of Guardian 166.157
Disclosure of Medical Information 166.158
Duty of Health or Residential Care Provider 166.159
Discrimination Relating to Execution of Medical Power of Attorney 166.160
Limitation on Liability 166.161
Liability for Health Care Costs 166.164
Form of Medical Power of Attorney 166.165
Civil Action 166.166
Other Rights or Responsibilities Not Affected 166.201
Definition 166.202
Applicability of Subchapter 166.203
General Procedures and Requirements for Do-not-resuscitate Orders 166.204
Notice Requirements for Do-not-resuscitate Orders 166.205
Revocation of Do-not-resuscitate Order 166.206
Procedure for Failure to Execute Do-not-resuscitate Order or Patient Instructions 166.207
Limitation on Liability for Issuing Dnr Order or Withholding Cardiopulmonary Resuscitation 166.208
Limitation on Liability for Failure to Effectuate Dnr Order 166.209
Enforcement 166.0445
Limitation on Liability for Performing Certain Medical Procedures 166.0465
Ethics or Medical Committee Decision Related to Patient Disability
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Accessed:
Apr. 13, 2024

§ 166.033’s source at texas​.gov