DIRECTIVE TO PHYSICIANS ON BEHALF OF A MINOR
(Texas Health and Safety Code, § 166.033.  Also see § 166.035)

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 for your spouse, child, or ward (who is under 18 years of age) and who is suffering from a terminal condition (a terminal or irreversible condition that has been diagnosed and certified in writing by the attending physician) at some time in the future if you are unable to make your wishes known. 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 your spouse, child, or ward were seriously ill.

You are encouraged to discuss your values and wishes with your family or chosen spokesperson, as well as your spouse's, child's or ward's physician. That 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 this directive to the physician, usual hospital, and family.

You may also wish to complete a directive related to the donation of organs and tissues.

DIRECTIVE

I, ___________________________________________________________________________, am the _____ spouse _____ parent _____ guardian of __________________________________ __________________________________________________ a minor under the age of eighteen (18) years. I am making this Directive on behalf of my _____ spouse _____child _____ward. I recognize that the best health care is based upon a partnership of trust and communication between a patient and his/her physician. My _____ spouse's _____child's _____ward's physician and I will make health care decisions together which we believe to be in the best interests of my _____ spouse _____child _____ward. Keeping in mind that I have consulted with the physician, I direct that the following treatment preferences be honored:

If, in the judgment of the physician, my _____ spouse _____child _____ward is suffering with a terminal condition from which he/she is expected to die within six months, even with available life-sustaining treatment provided in accordance with prevailing standards of medical care: __________ I request that all treatments other than those needed to keep my _____ spouse _____child _____ward comfortable be discontinued or withheld and the physician allow my _____ spouse _____child _____ward to die as gently as possible; OR __________ I request that my _____ spouse _____child _____ward be kept alive in this terminal condition using available life-sustaining treatment. (THIS SELECTION DOES NOT APPLY TO HOSPICE CARE.)

If, in the judgment of my physician, my _____ spouse _____child _____ward is suffering with an irreversible condition so that he/she cannot care for himself/herself, and he/she is expected to die without life-sustaining treatment provided in accordance with prevailing standards of care: __________ I request that all treatments other than those needed to keep my _____ spouse _____child _____ward comfortable be discontinued or withheld and that the physician allow _____ spouse _____child _____ward to die as gently as possible; OR __________ I request that my _____ spouse _____child _____ward be kept alive in this irreversible condition using available life-sustaining treatment. (THIS SELECTION DOES NOT APPLY TO HOSPICE CARE.)

Additional requests:

(After discussion with the physician, you may wish to consider listing particular treatments in this space that you do or do not want to be used or administered in specific circumstances, such as artificial nutrition and fluids, intravenous antibiotics, etc. Be sure to state whether you do or do not want the physician to use the particular treatment.)
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I understand and agree that only those treatments needed to keep my _____ spouse _____child _____ward comfortable would be provided and that he/she would not be given available lifesustaining treatments.

Signed: _______________________________________________________________________

Date: _________________________________________________________________________

City, County, State of Residence: __________________________________________________
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I am the _____ spouse _____ parent _____ guardian of _________________________________ ______________________________________________________________, a minor under the age of eighteen years of age.

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 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:

"Artificial 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 stomach (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 lifesustaining 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 lifesustaining medications and artificial life support such as mechanical breathing machines, kidney dialysis treatment, and artificial hydration and nutrition. 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.