Texas Living Will
This document is a Living Will created in accordance with the laws of the state of Texas. It provides guidance on your medical treatment preferences in situations where you are unable to communicate your wishes.
Individual Information:
- Name: ______________________________________
- Date of Birth: ______________________________
- Address: ____________________________________
- Phone Number: ______________________________
Declaration:
I, the undersigned, being of sound mind, willfully and voluntarily declare that if I become unable to make informed decisions due to a terminal condition or irreversible condition, I direct that my health care providers follow these instructions regarding my medical treatment:
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End-of-Life Decisions:
In the event of my terminal condition, I do not wish to have life-sustaining treatment that would only prolong the process of dying. I wish to receive comfort care.
-
Resuscitation:
In case of cardiac or respiratory arrest, I choose (select one):
- □ To be resuscitated
- □ Not to be resuscitated
-
Organ Donation:
I wish to donate my organs and tissues upon my death (select one):
-
Other Wishes:
__________________________________________________
__________________________________________________
Witnesses:
For this declaration to be valid in Texas, it must be signed in the presence of two witnesses who are at least 18 years old. Witnesses may not be a beneficiary of the estate or an individual involved in my care.
Witness 1: ______________________________________ Date: ________________
Witness 2: ______________________________________ Date: ________________
Signature:
Signature: ______________________________________ Date: ________________