Texas Living Will
This Living Will reflects my wishes regarding my healthcare and treatment in the event that I am unable to communicate my decisions. This document is in accordance with the Texas Advance Directives Act.
Personal Information
Full Name: ________________________
Address: ___________________________________________
City: ________________ State: TX Zip Code: _________
Date of Birth: _______________
Social Security Number: ___________________
Directive
I, _______________ [insert name], residing at _________________________ [insert address], being of sound mind, willfully and voluntarily make known my desire that my dying shall not be artificially prolonged under the circumstances set forth below, and I hereby declare:
Life-Sustaining Treatment
If, at any time, I should have an incurable condition certified by two physicians, where the application of life-sustaining procedures would serve only to prolong artificially the process of my dying, or if I am diagnosed in a persistent vegetative state, I direct that such procedures be withheld or withdrawn.
Nutrition and Hydration
I further direct that, under the conditions described above, hydration and nutrition be withdrawn or withheld when they would only serve to prolong my dying process artificially.
Designation of Health Care Agent
If I have appointed a Health Care Agent through a Medical Power of Attorney or any other instrument, I desire my Agent to make healthcare decisions in accordance with this Living Will.
Health Care Agent's Name: ________________________
Relationship: ________________
Contact Number: ________________
Signature
This Living Will shall remain in effect until I revoke it. I understand that I may revoke this Living Will at any time.
Date: _______________
Signature: ________________________
Witness (1) Name: ___________________ Signature: _________________ Date: ____________
Witness (2) Name: ___________________ Signature: _________________ Date: ____________
Additional Instructions
If there are any specific instructions you wish to provide that are not covered above, include them here:
________________________________________________________________________________________________________________
________________________________________________________________________________________________________________
Notarization (Optional)
This document may be notarized to verify the identity of the signatory. However, notarization is not required for this Living Will to be legally valid in the state of Texas.
Notary Public's Name: ________________________ Signature: _________________ Date: ____________
Seal: ______________________________________