DIRECTIVE TO PHYSICIANS AS PROVIDED BY TEXAS NATURAL DEATH ACT

SECTION 3

DIRECTIVE TO PHYSICIANS

Directive made this _________________ day of ___________. I

____________, being of sound mind, willfully and voluntarily make

known my desire that my life shall not be artificially prolonged

under the circumstances set forth below, and do hereby declare:

1. If at any time I should have an incurable 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 prolong the moment of

my death and where my attending physician determines that my death

is imminent whether or not life-sustaining procedures are

utilized, I direct that such procedures be withheld or withdrawn,

and that I be permitted to die naturally.

2. In the absence of my ability to give directions regarding the

use of such life-sustaining procedures, it is my intention that

this directive shall be honored by my family and physician(s) 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 that diagnosis is

known to my physician, this directive shall have no force or

effect during the course of my pregnancy.

4. I have been diagnosed and notified at least 14 days ago as

having a terminal condition by _________________, M.D., whose

address is ____________, ________.

I understand that if I have not filed in the physician's name and

address, it shall be presumed that I did not have a terminal

condition when I made out this directive.

5. This directive shall be in effect until revoked.

6. I understand the full import of this directive and I am

emotionally and mentally competent to make this directive.

7. I understand that I may revoke this directive at any time.

Signed _________________________________________________

City of residence: _______________

County of residence: _____________

State of residence: ______________

The declarant has been personally known to me and I believe him

or her to be of sound mind. I am not related to the declarant by

blood or marriage, nor would I be entitled to any portion of the

declarant's estate on his decease, nor am I the attending

physician of declarant or an employee of the attending physician

or a health 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 decease.

Witness:

__________________________________________________

Witness:

__________________________________________________

Witness:

__________________________________________________

STATE OF TEXAS

COUNTY OF _______________________

Before me, the undersigned authority, on this day personally

appeared ________________________, __________________________ and

__________________________ and _________________________________

known to me to be the declarant and witnesses whose names are

subscribed to the foregoing instrument in their respective

capacities, and, all of said persons being by me duly sworn, the

declarant _________________ declared to me and to the said

witnesses in my presence that the said instrument is his Directive

to Physicians, and that he willingly and voluntarily made and

executed it as his free act and deed for the purposes therein

expressed.

Declarant:

___________________________________________________________

Subscribed and acknowledged before me by the said Declarant

_____________ and by the said witnesses ________________________

and _____________________________ on This ______________ day of

___________________________________________, 19______.

______________________________________________

Notary Public in and for

___________________________ County, Texas