Texas Living Will Template
This Living Will is created in accordance with the Texas Health and Safety Code, Chapter 166, Subchapter D. It allows individuals to specify their medical treatment preferences in the event they are unable to communicate their wishes.
Personal Information:
- Name: ______________________________
- Date of Birth: ______________________
- Address: _____________________________
- City: ______________________________
- State: ____________ Zip Code: ________
- Phone Number: ______________________
Declaration:
I, the undersigned, being of sound mind, voluntarily make this declaration. If at any time I am diagnosed with a terminal condition, or if I am in an irreversible condition, I wish to make my healthcare preferences known. My wishes are as follows:
- If I am unable to communicate, I do not wish to receive:
- Artificial nutrition and hydration
- Cardiopulmonary resuscitation (CPR)
- Mechanical ventilation
- If I am in a terminal condition, I request the following treatment options:
- Comfort care only
- Palliative care to relieve suffering
Revocation of Previous Living Wills:
This document revokes any previous Living Wills I may have executed.
Signatures:
By signing below, I confirm that I understand the contents of this Living Will and that it reflects my desires regarding medical treatment.
Signature: ______________________________ Date: ____________
Witness 1 Name: ________________________ Signature: __________________________
Date: ____________
Witness 2 Name: ________________________ Signature: __________________________
Date: ____________
This document must be signed in the presence of two adult witnesses who are not related to you by blood or marriage, and who will not benefit financially from your death.