DIRECTIVE TO PHYSICIANS

LIVING WILL

I, __________________________________________ being of sound mind, willfully and voluntarily make known my desire that my life will not be artificially prolonged under the circumstances set forth below, and do hereby declare:

1. If at any time I should have an incurable or irreversible 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 postpone the moment of my death, and where my attending physician determines that my death is imminent or will result within a relatively short time without application of life-sustaining procedures, I direct that those procedures be withheld or withdrawn, and that I be permitted to die naturally, and without resuscitation.
2. In the absence of my ability to give directions regarding the use of such life-sustaining procedures, it is my intention, my family and physicians shall honor this DIRECTIVE, 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 my physician knows that diagnosis, this DIRECTIVE shall have no effect during the course of my pregnancy.
4. This DIRECTIVE shall be in effect until it is revoked.
5. I understand the full import of this DIRECTIVE and I am emotionally and mentally competent to make this DIRECTIVE.
6. I understand that I may revoke this DIRECTIVE at any time.
7. If any provision in this document is held to be invalid, such invalidity shall not affect the other provisions, which can be given effect without the invalid provision, and to this end the directions in this document are severable. It is not my intent to authorize affirmative or deliberate acts or omissions to shorten my life rather only to permit the natural process of dying.
8. I understand that Texas law allows me to designate another person to make a treatment decision for me if I should become comatose, incompetent or otherwise mentally or physically incapable of communication. I designate
   _____________________________________________________________
   address_______________________________________________________
   to make such a treatment decision for me if I should become incapable of communication with my physician. If the person I have named above is unable to act on my behalf, I authorize the following person to do so:
   _____________________________________________________________
   address_______________________________________________________
   I have discussed my wishes with these persons and trust their judgment.
9. Other directions: All life-sustaining measures, including nutrition and hydration, will be withheld unless you list different instructions in the space below;
   
   

Date:________________________
Signed:_________________________________________________________
Address:________________________________________________________
City:____________________________ State:________

Two witnesses must sign the DIRECTIVE in the spaces provided below, (Notarization not necessary in all states.)

I am not related to the declarant by blood or marriage; nor am I the attending physician of the declarant or an employee of the attending physician; nor am I a patient in the health care 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/her decease. Furthermore, if I am an employee of a health facility in which the declarant is a patient, I am not involved in providing direct patient care to the declarant nor am I directly involved in the financial affairs of the health facility.

Witness:____________________________________________________
Address:____________________________________________________
Phone:______________________________________________________

Witness:____________________________________________________
Address:____________________________________________________
Phone:______________________________________________________

Notary

The Declarant, whose signature appears above, is known to me, is eighteen years of age or older, of sound mind and voluntarily signed this document in my presence. I am eighteen years of age or older.

Signed this _______Day of __________, 20_____

______________________________________
Notary Signature

End of Document