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Complete Home and Office Legal Guide (Chestnut) (1993).ISO
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1993-08-01
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DIRECTIVE TO PHYSICIANS AS PROVIDED BY TEXAS NATURAL DEATH ACT
SECTION 3
DIRECTIVE TO PHYSICIANS
Directive made this _________________ day of ___________. I Robyn
Fitzpatrick, 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utilized, I direct that such procedures be withheld or withdrawn,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 Joseph Poole, M.D., whose
address is Austin, Texas.
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 _________________________________________________
Robyn Fitzpatrick
City of residence: Austin
County of residence: Oil
State of residence: Texas
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 Robyn Fitzpatrick, _________________________________ 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 Robyn Fitzpartick 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:
___________________________________________________________
Robyn Fitzpatrick
Subscribed and acknowledged before me by the said Declarant Robyn
Fitzpatrick and by the said witnesses ___________________________
and _____________________________ on This ______________ day of
___________________________________________, 19______.
______________________________________________
Notary Public in and for
___________________________ County, Texas