CHAPTER 166. ADVANCE DIRECTIVES - Texas Statutes

HEALTH AND SAFETY CODE

TITLE 2. HEALTH

SUBTITLE H. PUBLIC HEALTH PROVISIONS

CHAPTER 166. ADVANCE DIRECTIVES

SUBCHAPTER A. GENERAL PROVISIONS

Sec. 166.001. SHORT TITLE. This chapter may be cited as the

Advance Directives Act.

Added by Acts 1999, 76th Leg., ch. 450, Sec. 1.02, eff. Sept. 1,

1999.

Sec. 166.002. DEFINITIONS. In this chapter:

(1) "Advance directive" means:

(A) a directive, as that term is defined by Section 166.031;

(B) an out-of-hospital DNR order, as that term is defined by

Section 166.081; or

(C) a medical power of attorney under Subchapter D.

(2) "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).

(3) "Attending physician" means a physician selected by or

assigned to a patient who has primary responsibility for a

patient's treatment and care.

(4) "Competent" means possessing the ability, based on

reasonable medical judgment, to understand and appreciate the

nature and consequences of a treatment decision, including the

significant benefits and harms of and reasonable alternatives to

a proposed treatment decision.

(5) "Declarant" means a person who has executed or issued a

directive under this chapter.

(5-a) "Digital signature" means an electronic identifier

intended by the person using it to have the same force and effect

as the use of a manual signature.

(5-b) "Electronic signature" means a facsimile, scan, uploaded

image, computer-generated image, or other electronic

representation of a manual signature that is intended by the

person using it to have the same force and effect of law as a

manual signature.

(6) "Ethics or medical committee" means a committee established

under Sections 161.031-161.033.

(7) "Health care or treatment decision" means consent, refusal

to consent, or withdrawal of consent to health care, treatment,

service, or a procedure to maintain, diagnose, or treat an

individual's physical or mental condition, including such a

decision on behalf of a minor.

(8) "Incompetent" means lacking the ability, based on reasonable

medical judgment, to understand and appreciate the nature and

consequences of a treatment decision, including the significant

benefits and harms of and reasonable alternatives to a proposed

treatment decision.

(9) "Irreversible condition" means a condition, injury, or

illness:

(A) that may be treated but is never cured or eliminated;

(B) that leaves a person unable to care for or make decisions

for the person's own self; and

(C) that, without life-sustaining treatment provided in

accordance with the prevailing standard of medical care, is

fatal.

(10) "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

life-sustaining medications and artificial life support, such as

mechanical breathing machines, kidney dialysis treatment, and

artificial nutrition and hydration. The term does not include the

administration of pain management medication or the performance

of a medical procedure considered to be necessary to provide

comfort care, or any other medical care provided to alleviate a

patient's pain.

(11) "Medical power of attorney" means a document delegating to

an agent authority to make health care decisions executed or

issued under Subchapter D.

(12) "Physician" means:

(A) a physician licensed by the Texas State Board of Medical

Examiners; or

(B) a properly credentialed physician who holds a commission in

the uniformed services of the United States and who is serving on

active duty in this state.

(13) "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. A patient who has been

admitted to a program under which the person receives hospice

services provided by a home and community support services agency

licensed under Chapter 142 is presumed to have a terminal

condition for purposes of this chapter.

(14) "Witness" means a person who may serve as a witness under

Section 166.003.

(15) "Cardiopulmonary resuscitation" means any medical

intervention used to restore circulatory or respiratory function

that has ceased.

Added by Acts 1999, 76th Leg., ch. 450, Sec. 1.02, eff. Sept. 1,

1999. Amended by Acts 2003, 78th Leg., ch. 1228, Sec. 1, eff.

June 20, 2003.

Amended by:

Acts 2009, 81st Leg., R.S., Ch.

461, Sec. 1, eff. September 1, 2009.

Sec. 166.003. WITNESSES. In any circumstance in which this

chapter requires the execution of an advance directive or the

issuance of a nonwritten advance directive to be witnessed:

(1) each witness must be a competent adult; and

(2) at least one of the witnesses must be a person who is not:

(A) a person designated by the declarant to make a treatment

decision;

(B) a person related to the declarant by blood or marriage;

(C) a person entitled to any part of the declarant's estate

after the declarant's death under a will or codicil executed by

the declarant or by operation of law;

(D) the attending physician;

(E) an employee of the attending physician;

(F) an employee of a health care facility in which the declarant

is a patient if the employee is providing direct patient care to

the declarant or is an officer, director, partner, or business

office employee of the health care facility or of any parent

organization of the health care facility; or

(G) a person who, at the time the written advance directive is

executed or, if the directive is a nonwritten directive issued

under this chapter, at the time the nonwritten directive is

issued, has a claim against any part of the declarant's estate

after the declarant's death.

Added by Acts 1999, 76th Leg., ch. 450, Sec. 1.02, eff. Sept. 1,

1999.

Sec. 166.004. STATEMENT RELATING TO ADVANCE DIRECTIVE. (a) In

this section, "health care provider" means:

(1) a hospital;

(2) an institution licensed under Chapter 242, including a

skilled nursing facility;

(3) a home and community support services agency;

(4) a personal care facility; and

(5) a special care facility.

(b) A health care provider shall maintain written policies

regarding the implementation of advance directives. The policies

must include a clear and precise statement of any procedure the

health care provider is unwilling or unable to provide or

withhold in accordance with an advance directive.

(c) Except as provided by Subsection (g), the health care

provider shall provide written notice to an individual of the

written policies described by Subsection (b). The notice must be

provided at the earlier of:

(1) the time the individual is admitted to receive services from

the health care provider; or

(2) the time the health care provider begins providing care to

the individual.

(d) If, at the time notice is to be provided under Subsection

(c), the individual is incompetent or otherwise incapacitated and

unable to receive the notice required by this section, the

provider shall provide the required written notice, in the

following order of preference, to:

(1) the individual's legal guardian;

(2) a person responsible for the health care decisions of the

individual;

(3) the individual's spouse;

(4) the individual's adult child;

(5) the individual's parent; or

(6) the person admitting the individual.

(e) If Subsection (d) applies and except as provided by

Subsection (f), if a health care provider is unable, after

diligent search, to locate an individual listed by Subsection

(d), the health care provider is not required to provide the

notice.

(f) If an individual who was incompetent or otherwise

incapacitated and unable to receive the notice required by this

section at the time notice was to be provided under Subsection

(c) later becomes able to receive the notice, the health care

provider shall provide the written notice at the time the

individual becomes able to receive the notice.

(g) This section does not apply to outpatient hospital services,

including emergency services.

Added by Acts 1999, 76th Leg., ch. 450, Sec. 1.02, eff. Sept. 1,

1999.

Sec. 166.005. ENFORCEABILITY OF ADVANCE DIRECTIVES EXECUTED IN

ANOTHER JURISDICTION. An advance directive or similar instrument

validly executed in another state or jurisdiction shall be given

the same effect as an advance directive validly executed under

the law of this state. This section does not authorize the

administration, withholding, or withdrawal of health care

otherwise prohibited by the laws of this state.

Added by Acts 1999, 76th Leg., ch. 450, Sec. 1.02, eff. Sept. 1,

1999.

Sec. 166.006. EFFECT OF ADVANCE DIRECTIVE ON INSURANCE POLICY

AND PREMIUMS. (a) The fact that a person has executed or issued

an advance directive does not:

(1) restrict, inhibit, or impair in any manner the sale,

procurement, or issuance of a life insurance policy to that

person; or

(2) modify the terms of an existing life insurance policy.

(b) Notwithstanding the terms of any life insurance policy, the

fact that life-sustaining treatment is withheld or withdrawn from

an insured qualified patient under this chapter does not legally

impair or invalidate that person's life insurance policy and may

not be a factor for the purpose of determining, under the life

insurance policy, whether benefits are payable or the cause of

death.

(c) The fact that a person has executed or issued or failed to

execute or issue an advance directive may not be considered in

any way in establishing insurance premiums.

Added by Acts 1999, 76th Leg., ch. 450, Sec. 1.02, eff. Sept. 1,

1999.

Sec. 166.007. EXECUTION OF ADVANCE DIRECTIVE MAY NOT BE

REQUIRED. A physician, health facility, health care provider,

insurer, or health care service plan may not require a person to

execute or issue an advance directive as a condition for

obtaining insurance for health care services or receiving health

care services.

Added by Acts 1999, 76th Leg., ch. 450, Sec. 1.02, eff. Sept. 1,

1999.

Sec. 166.008. CONFLICT BETWEEN ADVANCE DIRECTIVES. To the

extent that a treatment decision or an advance directive validly

executed or issued under this chapter conflicts with another

treatment decision or an advance directive executed or issued

under this chapter, the treatment decision made or instrument

executed later in time controls.

Added by Acts 1999, 76th Leg., ch. 450, Sec. 1.02, eff. Sept. 1,

1999.

Sec. 166.009. CERTAIN LIFE-SUSTAINING TREATMENT NOT REQUIRED.

This chapter may not be construed to require the provision of

life-sustaining treatment that cannot be provided to a patient

without denying the same treatment to another patient.

Added by Acts 1999, 76th Leg., ch. 450, Sec. 1.02, eff. Sept. 1,

1999.

Sec. 166.010. APPLICABILITY OF FEDERAL LAW RELATING TO CHILD

ABUSE AND NEGLECT. This chapter is subject to applicable federal

law and regulations relating to child abuse and neglect to the

extent applicable to the state based on its receipt of federal

funds.

Added by Acts 2003, 78th Leg., ch. 1228, Sec. 2, eff. June 20,

2003.

Sec. 166.011. DIGITAL OR ELECTRONIC SIGNATURE. (a) For an

advance directive in which a signature by a declarant, witness,

or notary public is required or used, the declarant, witness, or

notary public may sign the directive or a written revocation of

the directive using:

(1) a digital signature that:

(A) uses an algorithm approved by the department;

(B) is unique to the person using it;

(C) is capable of verification;

(D) is under the sole control of the person using it;

(E) is linked to data in a manner that invalidates the digital

signature if the data is changed;

(F) persists with the document and not by association in

separate files; and

(G) is bound to a digital certificate; or

(2) an electronic signature that:

(A) is capable of verification;

(B) is under the sole control of the person using it;

(C) is linked to data in a manner that invalidates the

electronic signature if the data is changed; and

(D) persists with the document and not by association in

separate files.

(b) In approving an algorithm for purposes of Subsection

(a)(1)(A), the department may consider an algorithm approved by

the National Institute of Standards and Technology.

(c) The executive commissioner of the Health and Human Services

Commission by rule shall modify the advance directive forms

required under this chapter as necessary to provide for the use

of a digital or electronic signature that complies with the

requirements of this section.

Added by Acts 2009, 81st Leg., R.S., Ch.

461, Sec. 2, eff. September 1, 2009.

SUBCHAPTER B. DIRECTIVE TO PHYSICIANS

Sec. 166.031. DEFINITIONS. In this subchapter:

(1) "Directive" means an instruction made under Section 166.032,

166.034, or 166.035 to administer, withhold, or withdraw

life-sustaining treatment in the event of a terminal or

irreversible condition.

(2) "Qualified patient" means a patient with a terminal or

irreversible condition that has been diagnosed and certified in

writing by the attending physician.

Acts 1989, 71st Leg., ch. 678, Sec. 1, eff. Sept. 1, 1989.

Amended by Acts 1991, 72nd Leg., ch. 14, Sec. 208, eff. Sept. 1,

1991; Acts 1993, 73rd Leg., ch. 107, Sec. 5.04, eff. Aug. 30,

1993. Renumbered from Sec. 672.002 and amended by Acts 1999, 76th

Leg., ch. 450, Sec. 1.03, eff. Sept. 1, 1999.

Sec. 166.032. WRITTEN DIRECTIVE BY COMPETENT ADULT; NOTICE TO

PHYSICIAN. (a) A competent adult may at any time execute a

written directive.

(b) Except as provided by Subsection (b-1), the declarant must

sign the directive in the presence of two witnesses who qualify

under Section 166.003, at least one of whom must be a witness who

qualifies under Section 166.003(2). The witnesses must sign the

directive.

(b-1) The declarant, in lieu of signing in the presence of

witnesses, may sign the directive and have the signature

acknowledged before a notary public.

(c) A declarant may include in a directive directions other than

those provided by Section 166.033 and may designate in a

directive a person to make a treatment decision for the declarant

in the event the declarant becomes incompetent or otherwise

mentally or physically incapable of communication.

(d) A declarant shall notify the attending physician of the

existence of a written directive. If the declarant is incompetent

or otherwise mentally or physically incapable of communication,

another person may notify the attending physician of the

existence of the written directive. The attending physician shall

make the directive a part of the declarant's medical record.

Acts 1989, 71st Leg., ch. 678, Sec. 1, eff. Sept. 1, 1989.

Amended by Acts 1991, 72nd Leg., ch. 14, Sec. 209, eff. Sept. 1,

1991; Acts 1997, 75th Leg., ch. 291, Sec. 1, eff. Jan. 1, 1998.

Renumbered from Sec. 672.003 and amended by Acts 1999, 76th Leg.,

ch. 450, Sec. 1.03, eff. Sept. 1, 1999.

Amended by:

Acts 2009, 81st Leg., R.S., Ch.

461, Sec. 3, eff. September 1, 2009.

Sec. 166.033. FORM OF WRITTEN DIRECTIVE. A written directive

may be in the following form:

DIRECTIVE TO PHYSICIANS AND FAMILY OR SURROGATES

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 at some time in the future when you are

unable to make your wishes known because of illness or injury.

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 you were seriously ill.

You are encouraged to discuss your values and wishes with your

family or chosen spokesperson, as well as your physician. Your

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 your directive to your physician, usual

hospital, and family or spokesperson. Consider a periodic review

of this document. By periodic review, you can best assure that

the directive reflects your preferences.

In addition to this advance directive, Texas law provides for two

other types of directives that can be important during a serious

illness. These are the Medical Power of Attorney and the

Out-of-Hospital Do-Not-Resuscitate Order. You may wish to discuss

these with your physician, family, hospital representative, or

other advisers. You may also wish to complete a directive related

to the donation of organs and tissues.

DIRECTIVE

I, __________, recognize that the best health care is based upon

a partnership of trust and communication with my physician. My

physician and I will make health care decisions together as long

as I am of sound mind and able to make my wishes known. If there

comes a time that I am unable to make medical decisions about

myself because of illness or injury, I direct that the following

treatment preferences be honored:

If, in the judgment of my physician, I am suffering with a

terminal condition from which I am 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 me comfortable be discontinued or withheld and my

physician allow me to die as gently as possible; OR

__________

I request that I 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, I am suffering with an

irreversible condition so that I cannot care for myself or make

decisions for myself and am 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 me comfortable be discontinued or withheld and my

physician allow me to die as gently as possible; OR

__________

I request that I 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 your physician, you

may wish to consider listing particular treatments in this space

that you do or do not want in specific circumstances, such as

artificial nutrition and fluids, intravenous antibiotics, etc. Be

sure to state whether you do or do not want the particular

treatment.)

________________________________________________________________

________________________________________________________________

________________________________________________________________

After signing this directive, if my representative or I elect

hospice care, I understand and agree that only those treatments

needed to keep me comfortable would be provided and I would not

be given available life-sustaining treatments.

If I do not have a Medical Power of Attorney, and I am unable to

make my wishes known, I designate the following person(s) to make

treatment decisions with my physician compatible with my personal

values:

1. __________

2. __________

(If a Medical Power of Attorney has been executed, then an agent

already has been named and you should not list additional names

in this document.)

If the above persons are not available, or if I have not

designated a spokesperson, I understand that a spokesperson will

be chosen for me following standards specified in the laws of

Texas. If, in the judgment of my physician, my death is imminent

within minutes to hours, even with the use of all available

medical treatment provided within the prevailing standard of

care, I acknowledge that all treatments may be withheld or

removed except those needed to maintain my comfort. I understand

that under Texas law this directive has no effect if I have been

diagnosed as pregnant. This directive will remain in effect until

I revoke it. No other person may do so.

Signed__________ Date__________ City, County, State of Residence

__________

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

life-sustaining 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

life-sustaining 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.

Acts 1989, 71st Leg., ch. 678, Sec. 1, eff. Sept. 1, 1989.

Amended by Acts 1991, 72nd Leg., ch. 14, Sec. 209, eff. Sept. 1,

1991; Acts 1997, 75th Leg., ch. 291, Sec. 2, eff. Jan. 1, 1998.

Renumbered from Sec. 672.004 and amended by Acts 1999, 76th Leg.,

ch. 450, Sec. 1.03, eff. Sept. 1, 1999.

Sec. 166.034. ISSUANCE OF NONWRITTEN DIRECTIVE BY COMPETENT

ADULT QUALIFIED PATIENT. (a) A competent qualified patient who

is an adult may issue a directive by a nonwritten means of

communication.

(b) A declarant must issue the nonwritten directive in the

presence of the attending physician and two witnesses who qualify

under Section 166.003, at least one of whom must be a witness who

qualifies under Section 166.003(2).

(c) The physician shall make the fact of the existence of the

directive a part of the declarant's medical record, and the names

of the witnesses shall be entered in the medical record.

Acts 1989, 71st Leg., ch. 678, Sec. 1, eff. Sept. 1, 1989.

Renumbered from Sec. 672.005 and amended by Acts 1999, 76th Leg.,

ch. 450, Sec. 1.03, eff. Sept. 1, 1999.

Sec. 166.035. EXECUTION OF DIRECTIVE ON BEHALF OF PATIENT

YOUNGER THAN 18 YEARS OF AGE. The following persons may execute

a directive on behalf of a qualified patient who is younger than

18 years of age:

(1) the patient's spouse, if the spouse is an adult;

(2) the patient's parents; or

(3) the patient's legal guardian.

Acts 1989, 71st Leg., ch. 678, Sec. 1, eff. Sept. 1, 1989.

Renumbered from Sec. 672.006 by Acts 1999, 76th Leg., ch. 450,

Sec. 1.03, eff. Sept. 1, 1999.

Sec. 166.036. NOTARIZED DOCUMENT NOT REQUIRED; REQUIREMENT OF

SPECIFIC FORM PROHIBITED. (a) Except as provided by Section

166.032(b-1), a written directive executed under Section 166.033

or 166.035 is effective without regard to whether the document

has been notarized.

(b) A physician, health care facility, or health care

professional may not require that:

(1) a directive be notarized; or

(2) a person use a form provided by the physician, health care

facility, or health care professional.

Added by Acts 1999, 76th Leg., ch. 450, Sec. 1.03, eff. Sept. 1,

1999.

Amended by:

Acts 2009, 81st Leg., R.S., Ch.

461, Sec. 4, eff. September 1, 2009.

Sec. 166.037. PATIENT DESIRE SUPERSEDES DIRECTIVE. The desire

of a qualified patient, including a qualified patient younger

than 18 years of age, supersedes the effect of a directive.

Acts 1989, 71st Leg., ch. 678, Sec. 1, eff. Sept. 1, 1989.

Renumbered from Sec. 672.007 and amended by Acts 1999, 76th Leg.,

ch. 450, Sec. 1.03, eff. Sept. 1, 1999.

Sec. 166.038. PROCEDURE WHEN DECLARANT IS INCOMPETENT OR

INCAPABLE OF COMMUNICATION. (a) This section applies when an

adult qualified patient has executed or issued a directive and is

incompetent or otherwise mentally or physically incapable of

communication.

(b) If the adult qualified patient has designated a person to

make a treatment decision as authorized by Section 166.032(c),

the attending physician and the designated person may make a

treatment decision in accordance with the declarant's directions.

(c) If the adult qualified patient has not designated a person

to make a treatment decision, the attending physician shall

comply with the directive unless the physician believes that the

directive does not reflect the patient's present desire.

Acts 1989, 71st Leg., ch. 678, Sec. 1, eff. Sept. 1, 1989.

Renumbered from 672.008 and amended by Acts 1999, 76th Leg., ch.

450, Sec. 1.03, eff. Sept. 1, 1999.

Sec. 166.039. PROCEDURE WHEN PERSON HAS NOT EXECUTED OR ISSUED A

DIRECTIVE AND IS INCOMPETENT OR INCAPABLE OF COMMUNICATION. (a)

If an adult qualified patient has not executed or issued a

directive and is incompetent or otherwise mentally or physically

incapable of communication, the attending physician and the

patient's legal guardian or an agent under a medical power of

attorney may make a treatment decision that may include a

decision to withhold or withdraw life-sustaining treatment from

the patient.

(b) If the patient does not have a legal guardian or an agent

under a medical power of attorney, the attending physician and

one person, if available, from one of the following categories,

in the following priority, may make a treatment decision that may

include a decision to withhold or withdraw life-sustaining

treatment:

(1) the patient's spouse;

(2) the patient's reasonably available adult children;

(3) the patient's parents; or

(4) the patient's nearest living relative.

(c) A treatment decision made under Subsection (a) or (b) must

be based on knowledge of what the patient would desire, if known.

(d) A treatment decision made under Subsection (b) must be

documented in the patient's medical record and signed by the

attending physician.

(e) If the patient does not have a legal guardian and a person

listed in Subsection (b) is not available, a treatment decision

made under Subsection (b) must be concurred in by another

physician who is not involved in the treatment of the patient or

who is a representative of an ethics or medical committee of the

health care facility in which the person is a patient.

(f) The fact that an adult qualified patient has not executed or

issued a directive does not create a presumption that the patient

does not want a treatment decision to be made to withhold or

withdraw life-sustaining treatment.

(g) A person listed in Subsection (b) who wishes to challenge a

treatment decision made under this section must apply for

temporary guardianship under Section 875, Texas Probate Code. The

court may waive applicable fees in that proceeding.

Acts 1989, 71st Leg., ch. 678, Sec. 1, eff. Sept. 1, 1989.

Amended by Acts 1997, 75th Leg., ch. 291, Sec. 3, eff. Jan. 1,

1998. Renumbered from Sec. 672.009 and amended by Acts 1999, 76th

Leg., ch. 450, Sec. 1.03, eff. Sept. 1, 1999.

Sec. 166.040. PATIENT CERTIFICATION AND PREREQUISITES FOR

COMPLYING WITH DIRECTIVE. (a) An attending physician who has

been notified of the existence of a directive shall provide for

the declarant's certification as a qualified patient on diagnosis

of a terminal or irreversible condition.

(b) Before withholding or withdrawing life-sustaining treatment

from a qualified patient under this subchapter, the attending

physician must determine that the steps proposed to be taken are

in accord with this subchapter and the patient's existing

desires.

Acts 1989, 71st Leg., ch. 678, Sec. 1, eff. Sept. 1, 1989.

Amended by Acts 1991, 72nd Leg., 1st C.S., ch. 14, Sec. 6.01,

eff. Nov. 12, 1991. Renumbered from Sec. 672.010 and amended by

Acts 1999, 76th Leg., ch. 450, Sec. 1.03, eff. Sept. 1, 1999.

Sec. 166.041. DURATION OF DIRECTIVE. A directive is effective

until it is revoked as prescribed by Section 166.042.

Acts 1989, 71st Leg., ch. 678, Sec. 1, eff. Sept. 1, 1989.

Renumbered from Sec. 672.011 and amended by Acts 1999, 76th Leg.,

ch. 450, Sec. 1.03, eff. Sept. 1, 1999.

Sec. 166.042. REVOCATION OF DIRECTIVE. (a) A declarant may

revoke a directive at any time without regard to the declarant's

mental state or competency. A directive may be revoked by:

(1) the declarant or someone in the declarant's presence and at

the declarant's direction canceling, defacing, obliterating,

burning, tearing, or otherwise destroying the directive;

(2) the declarant signing and dating a written revocation that

expresses the declarant's intent to revoke the directive; or

(3) the declarant orally stating the declarant's intent to

revoke the directive.

(b) A written revocation executed as prescribed by Subsection

(a)(2) takes effect only when the declarant or a person acting on

behalf of the declarant notifies the attending physician of its

existence or mails the revocation to the attending physician. The

attending physician or the physician's designee shall record in

the patient's medical record the time and date when the physician

received notice of the written revocation and shall enter the

word "VOID" on each page of the copy of the directive in the

patient's medical record.

(c) An oral revocation issued as prescribed by Subsection (a)(3)

takes effect only when the declarant or a person acting on behalf

of the declarant notifies the attending physician of the

revocation. The attending physician or the physician's designee

shall record in the patient's medical record the time, date, and

place of the revocation, and, if different, the time, date, and

place that the physician received notice of the revocation. The

attending physician or the physician's designees shall also enter

the word "VOID" on each page of the copy of the directive in the

patient's medical record.

(d) Except as otherwise provided by this subchapter, a person is

not civilly or criminally liable for failure to act on a

revocation made under this section unless the person has actual

knowledge of the revocation.

Acts 1989, 71st Leg., ch. 678, Sec. 1, eff. Sept. 1, 1989.

Renumbered from Sec. 672.012 and amended by Acts 1999, 76th Leg.,

ch. 450, Sec. 1.03, eff. Sept. 1, 1999.

Sec. 166.043. REEXECUTION OF DIRECTIVE. A declarant may at any

time reexecute a directive in accordance with the procedures

prescribed by Section 166.032, including reexecution after the

declarant is diagnosed as having a terminal or irreversible

condition.

Acts 1989, 71st Leg., ch. 678, Sec. 1, eff. Sept. 1, 1989.

Renumbered from Sec. 672.013 and amended by Acts 1999, 76th Leg.,

ch. 450, Sec. 1.03, eff. Sept. 1, 1999.

Sec. 166.044. LIMITATION OF LIABILITY FOR WITHHOLDING OR

WITHDRAWING LIFE-SUSTAINING PROCEDURES. (a) A physician or

health care facility that causes life-sustaining treatment to be

withheld or withdrawn from a qualified patient in accordance with

this subchapter is not civilly liable for that action unless the

physician or health care facility fails to exercise reasonable

care when applying the patient's advance directive.

(b) A health professional, acting under the direction of a

physician, who participates in withholding or withdrawing

life-sustaining treatment from a qualified patient in accordance

with this subchapter is not civilly liable for that action unless

the health professional fails to exercise reasonable care when

applying the patient's advance directive.

(c) A physician, or a health professional acting under the

direction of a physician, who participates in withholding or

withdrawing life-sustaining treatment from a qualified patient in

accordance with this subchapter is not criminally liable or

guilty of unprofessional conduct as a result of that action

unless the physician or health professional fails to exercise

reasonable care when applying the patient's advance directive.

(d) The standard of care that a physician, health care facility,

or health care professional shall exercise under this section is

that degree of care that a physician, health care facility, or

health care professional, as applicable, of ordinary prudence and

skill would have exercised under the same or similar

circumstances in the same or a similar community.

Acts 1989, 71st Leg., ch. 678, Sec. 1, eff. Sept. 1, 1989.

Renumbered from Sec. 672.015 and amended by Acts 1999, 76th Leg.,

ch. 450, Sec. 1.03, eff. Sept. 1, 1999.

Sec. 166.045. LIABILITY FOR FAILURE TO EFFECTUATE DIRECTIVE.

(a) A physician, health care facility, or health care

professional who has no knowledge of a directive is not civilly

or criminally liable for failing to act in accordance with the

directive.

(b) A physician, or a health professional acting under the

direction of a physician, is subject to review and disciplinary

action by the appropriate licensing board for failing to

effectuate a qualified patient's directive in violation of this

subchapter or other laws of this state. This subsection does not

limit remedies available under other laws of this state.

(c) If an attending physician refuses to comply with a directive

or treatment decision and does not wish to follow the procedure

established under Section 166.046, life-sustaining treatment

shall be provided to the patient, but only until a reasonable

opportunity has been afforded for the transfer of the patient to

another physician or health care facility willing to comply with

the directive or treatment decision.

(d) A physician, health professional acting under the direction

of a physician, or health care facility is not civilly or

criminally liable or subject to review or disciplinary action by

the person's appropriate licensing board if the person has

complied with the procedures outlined in Section 166.046.

Acts 1989, 71st Leg., ch. 678, Sec. 1, eff. Sept. 1, 1989.

Renumbered from Sec. 672.016 and amended by Acts 1999, 76th Leg.,

ch. 450, Sec. 1.03, eff. Sept. 1, 1999.

Sec. 166.046. PROCEDURE IF NOT EFFECTUATING A DIRECTIVE OR

TREATMENT DECISION. (a) If an attending physician refuses to

honor a patient's advance directive or a health care or treatment

decision made by or on behalf of a patient, the physician's

refusal shall be reviewed by an ethics or medical committee. The

attending physician may not be a member of that committee. The

patient shall be given life-sustaining treatment during the

review.

(b) The patient or the person responsible for the health care

decisions of the individual who has made the decision regarding

the directive or treatment decision:

(1) may be given a written description of the ethics or medical

committee review process and any other policies and procedures

related to this section adopted by the health care facility;

(2) shall be informed of the committee review process not less

than 48 hours before the meeting called to discuss the patient's

directive, unless the time period is waived by mutual agreement;

(3) at the time of being so informed, shall be provided:

(A) a copy of the appropriate statement set forth in Section

166.052; and

(B) a copy of the registry list of health care providers and

referral groups that have volunteered their readiness to consider

accepting transfer or to assist in locating a provider willing to

accept transfer that is posted on the website maintained by the

Texas Health Care Information Council under Section 166.053; and

(4) is entitled to:

(A) attend the meeting; and

(B) receive a written explanation of the decision reached during

the review process.

(c) The written explanation required by Subsection (b)(2)(B)

must be included in the patient's medical record.

(d) If the attending physician, the patient, or the person

responsible for the health care decisions of the individual does

not agree with the decision reached during the review process

under Subsection (b), the physician shall make a reasonable

effort to transfer the patient to a physician who is willing to

comply with the directive. If the patient is a patient in a

health care facility, the facility's personnel shall assist the

physician in arranging the patient's transfer to:

(1) another physician;

(2) an alternative care setting within that facility; or

(3) another facility.

(e) If the patient or the person responsible for the health care

decisions of the patient is requesting life-sustaining treatment

that the attending physician has decided and the review process

has affirmed is inappropriate treatment, the patient shall be

given available life-sustaining treatment pending transfer under

Subsection (d). The patient is responsible for any costs incurred

in transferring the patient to another facility. The physician

and the health care facility are not obligated to provide

life-sustaining treatment after the 10th day after the written

decision required under Subsection (b) is provided to the patient

or the person responsible for the health care decisions of the

patient unless ordered to do so under Subsection (g).

(e-1) If during a previous admission to a facility a patient's

attending physician and the review process under Subsection (b)

have determined that life-sustaining treatment is inappropriate,

and the patient is readmitted to the same facility within six

months from the date of the decision reached during the review

process conducted upon the previous admission, Subsections (b)

through (e) need not be followed if the patient's attending

physician and a consulting physician who is a member of the

ethics or medical committee of the facility document on the

patient's readmission that the patient's condition either has not

improved or has deteriorated since the review process was

conducted.

(f) Life-sustaining treatment under this section may not be

entered in the patient's medical record as medically unnecessary

treatment until the time period provided under Subsection (e) has

expired.

(g) At the request of the patient or the person responsible for

the health care decisions of the patient, the appropriate

district or county court shall extend the time period provided

under Subsection (e) only if the court finds, by a preponderance

of the evidence, that there is a reasonable expectation that a

physician or health care facility that will honor the patient's

directive will be found if the time extension is granted.

(h) This section may not be construed to impose an obligation on

a facility or a home and community support services agency

licensed under Chapter 142 or similar organization that is beyond

the scope of the services or resources of the facility or agency.

This section does not apply to hospice services provided by a

home and community support services agency licensed under Chapter

142.

Added by Acts 1999, 76th Leg., ch. 450, Sec. 1.03, eff. Sept. 1,

1999. Amended by Acts 2003, 78th Leg., ch. 1228, Sec. 3, 4, eff.

June 20, 2003.

Sec. 166.047. HONORING DIRECTIVE DOES NOT CONSTITUTE OFFENSE OF

AIDING SUICIDE. A person does not commit an offense under

Section 22.08, Penal Code, by withholding or withdrawing

life-sustaining treatment from a qualified patient in accordance

with this subchapter.

Acts 1989, 71st Leg., ch. 678, Sec. 1, eff. Sept. 1, 1989.

Renumbered from Sec. 672.017 and amended by Acts 1999, 76th Leg.,

ch. 450, Sec. 1.03, eff. Sept. 1, 1999.

Sec. 166.048. CRIMINAL PENALTY; PROSECUTION. (a) A person

commits an offense if the person intentionally conceals, cancels,

defaces, obliterates, or damages another person's directive

without that person's consent. An offense under this subsection

is a Class A misdemeanor.

(b) A person is subject to prosecution for criminal homicide

under Chapter 19, Penal Code, if the person, with the intent to

cause life-sustaining treatment to be withheld or withdrawn from

another person contrary to the other person's desires, falsifies

or forges a directive or intentionally conceals or withholds

personal knowledge of a revocation and thereby directly causes

life-sustaining treatment to be withheld or withdrawn from the

other person with the result that the other person's death is

hastened.

Acts 1989, 71st Leg., ch. 678, Sec. 1, eff. Sept. 1, 1989.

Renumbered from Sec. 672.018 and amended by Acts 1999, 76th Leg.,

ch. 450, Sec. 1.03, eff. Sept. 1, 1999.

Sec. 166.049. PREGNANT PATIENTS. A person may not withdraw or

withhold life-sustaining treatment under this subchapter from a

pregnant patient.

Acts 1989, 71st Leg., ch. 678, Sec. 1, eff. Sept. 1, 1989.

Renumbered from Sec. 672.019 and amended by Acts 1999, 76th Leg.,

ch. 450, Sec. 1.03, eff. Sept. 1, 1999.

Sec. 166.050. MERCY KILLING NOT CONDONED. This subchapter does

not condone, authorize, or approve mercy killing or permit an

affirmative or deliberate act or omission to end life except to

permit the natural process of dying as provided by this

subchapter.

Acts 1989, 71st Leg., ch. 678, Sec. 1, eff. Sept. 1, 1989.

Renumbered from Sec. 672.020 and amended by Acts 1999, 76th Leg.,

ch. 450, Sec. 1.03, eff. Sept. 1, 1999.

Sec. 166.051. LEGAL RIGHT OR RESPONSIBILITY NOT AFFECTED. This

subchapter does not impair or supersede any legal right or

responsibility a person may have to effect the withholding or

withdrawal of life-sustaining treatment in a lawful manner,

provided that if an attending physician or health care facility

is unwilling to honor a patient's advance directive or a

treatment decision to provide life-sustaining treatment,

life-sustaining treatment is required to be provided the patient,

but only until a reasonable opportunity has been afforded for

transfer of the patient to another physician or health care

facility willing to comply with the advance directive or

treatment decision.

Acts 1989, 71st Leg., ch. 678, Sec. 1, eff. Sept. 1, 1989.

Renumbered from Sec. 672.021 and amended by Acts 1999, 76th Leg.,

ch. 450, Sec. 1.03, eff. Sept. 1, 1999.

Sec. 166.052. STATEMENTS EXPLAINING PATIENT'S RIGHT TO TRANSFER.

(a) In cases in which the attending physician refuses to honor

an advance directive or treatment decision requesting the

provision of life-sustaining treatment, the statement required by

Section 166.046(b)(2)(A) shall be in substantially the following

form:

When There Is A Disagreement About Medical Treatment: The

Physician Recommends Against Life-Sustaining Treatment That You

Wish To Continue

You have been given this information because you have requested

life-sustaining treatment,* which the attending physician

believes is not appropriate. This information is being provided

to help you understand state law, your rights, and the resources

available to you in such circumstances. It outlines the process

for resolving disagreements about treatment among patients,

families, and physicians. It is based upon Section 166.046 of the

Texas Advance Directives Act, codified in Chapter 166 of the

Texas Health and Safety Code.

When an attending physician refuses to comply with an advance

directive or other request for life-sustaining treatment because

of the physician's judgment that the treatment would be

inappropriate, the case will be reviewed by an ethics or medical

committee. Life-sustaining treatment will be provided through the

review.

You will receive notification of this review at least 48 hours

before a meeting of the committee related to your case. You are

entitled to attend the meeting. With your agreement, the meeting

may be held sooner than 48 hours, if possible.

You are entitled to receive a written explanation of the decision

reached during the review process.

If after this review process both the attending physician and the

ethics or medical committee conclude that life-sustaining

treatment is inappropriate and yet you continue to request such

treatment, then the following procedure will occur:

1. The physician, with the help of the health care facility, will

assist you in trying to find a physician and facility willing to

provide the requested treatment.

2. You are being given a list of health care providers and

referral groups that have volunteered their readiness to consider

accepting transfer, or to assist in locating a provider willing

to accept transfer, maintained by the Texas Health Care

Information Council. You may wish to contact providers or

referral groups on the list or others of your choice to get help

in arranging a transfer.

3. The patient will continue to be given life-sustaining

treatment until he or she can be transferred to a willing

provider for up to 10 days from the time you were given the

committee's written decision that life-sustaining treatment is

not appropriate.

4. If a transfer can be arranged, the patient will be responsible

for the costs of the transfer.

5. If a provider cannot be found willing to give the requested

treatment within 10 days, life-sustaining treatment may be

withdrawn unless a court of law has granted an extension.

6. You may ask the appropriate district or county court to extend

the 10-day period if the court finds that there is a reasonable

expectation that a physician or health care facility willing to

provide life-sustaining treatment will be found if the extension

is granted.

*"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

life-sustaining medications and artificial life support, such as

mechanical breathing machines, kidney dialysis treatment, and

artificial nutrition and hydration. The term does not include the

administration of pain management medication or the performance

of a medical procedure considered to be necessary to provide

comfort care, or any other medical care provided to alleviate a

patient's pain.

(b) In cases in which the attending physician refuses to comply

with an advance directive or treatment decision requesting the

withholding or withdrawal of life-sustaining treatment, the

statement required by Section 166.046(b)(3)(A) shall be in

substantially the following form:

When There Is A Disagreement About Medical Treatment: The

Physician Recommends Life-Sustaining Treatment That You Wish To

Stop

You have been given this information because you have requested

the withdrawal or withholding of life-sustaining treatment* and

the attending physician refuses to comply with that request. The

information is being provided to help you understand state law,

your rights, and the resources available to you in such

circumstances. It outlines the process for resolving

disagreements about treatment among patients, families, and

physicians. It is based upon Section 166.046 of the Texas Advance

Directives Act, codified in Chapter 166 of the Texas Health and

Safety Code.

When an attending physician refuses to comply with an advance

directive or other request for withdrawal or withholding of

life-sustaining treatment for any reason, the case will be

reviewed by an ethics or medical committee. Life-sustaining

treatment will be provided through the review.

You will receive notification of this review at least 48 hours

before a meeting of the committee related to your case. You are

entitled to attend the meeting. With your agreement, the meeting

may be held sooner than 48 hours, if possible.

You are entitled to receive a written explanation of the decision

reached during the review process.

If you or the attending physician do not agree with the decision

reached during the review process, and the attending physician

still refuses to comply with your request to withhold or withdraw

life-sustaining treatment, then the following procedure will

occur:

1. The physician, with the help of the health care facility, will

assist you in trying to find a physician and facility willing to

withdraw or withhold the life-sustaining treatment.

2. You are being given a list of health care providers and

referral groups that have volunteered their readiness to consider

accepting transfer, or to assist in locating a provider willing

to accept transfer, maintained by the Texas Health Care

Information Council. You may wish to contact providers or

referral groups on the list or others of your choice to get help

in arranging a transfer.

*"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

life-sustaining medications and artificial life support, such as

mechanical breathing machines, kidney dialysis treatment, and

artificial nutrition and hydration. The term does not include the

administration of pain management medication or the performance

of a medical procedure considered to be necessary to provide

comfort care, or any other medical care provided to alleviate a

patient's pain.

(c) An attending physician or health care facility may, if it

chooses, include any additional information concerning the

physician's or facility's policy, perspective, experience, or

review procedure.

Added by Acts 2003, 78th Leg., ch. 1228, Sec. 5, eff. June 20,

2003.

Sec. 166.053. REGISTRY TO ASSIST TRANSFERS. (a) The Texas

Health Care Information Council shall maintain a registry listing

the identity of and contact information for health care providers

and referral groups, situated inside and outside this state, that

have voluntarily notified the council they may consider accepting

or may assist in locating a provider willing to accept transfer

of a patient under Section 166.045 or 166.046.

(b) The listing of a provider or referral group in the registry

described in this section does not obligate the provider or group

to accept transfer of or provide services to any particular

patient.

(c) The Texas Health Care Information Council shall post the

current registry list on its website in a form appropriate for

easy comprehension by patients and persons responsible for the

health care decisions of patients and shall provide a clearly

identifiable link from its home page to the registry page. The

list shall separately indicate those providers and groups that

have indicated their interest in assisting the transfer of:

(1) those patients on whose behalf life-sustaining treatment is

being sought;

(2) those patients on whose behalf the withholding or withdrawal

of life-sustaining treatment is being sought; and

(3) patients described in both Subdivisions (1) and (2).

(d) The registry list described in this section shall include

the following disclaimer:

"This registry lists providers and groups that have indicated to

the Texas Health Care Information Council their interest in

assisting the transfer of patients in the circumstances

described, and is provided for information purposes only. Neither

the Texas Health Care Information Council nor the State of Texas

endorses or assumes any responsibility for any representation,

claim, or act of the listed providers or groups."

Added by Acts 2003, 78th Leg., ch. 1228, Sec. 5, eff. June 20,

2003.

SUBCHAPTER C. OUT-OF-HOSPITAL DO-NOT-RESUSCITATE ORDERS

Sec. 166.081. DEFINITIONS. In this subchapter:

(1) Repealed by Acts 2003, 78th Leg., ch. 1228, Sec. 8.

(2) "DNR identification device" means an identification device

specified by the board under Section 166.101 that is worn for the

purpose of identifying a person who has executed or issued an

out-of-hospital DNR order or on whose behalf an out-of-hospital

DNR order has been executed or issued under this subchapter.

(3) "Emergency medical services" has the meaning assigned by

Section 773.003.

(4) "Emergency medical services personnel" has the meaning

assigned by Section 773.003.

(5) "Health care professionals" means physicians, physician

assistants, nurses, and emergency medical services personnel and,

unless the context requires otherwise, includes hospital

emergency personnel.

(6) "Out-of-hospital DNR order":

(A) means a legally binding out-of-hospital do-not-resuscitate

order, in the form specified by the board under Section 166.083,

prepared and signed by the attending physician of a person, that

documents the instructions of a person or the person's legally

authorized representative and directs health care professionals

acting in an out-of-hospital setting not to initiate or continue

the following life-sustaining treatment:

(i) cardiopulmonary resuscitation;

(ii) advanced airway management;

(iii) artificial ventilation;

(iv) defibrillation;

(v) transcutaneous cardiac pacing; and

(vi) other life-sustaining treatment specified by the board

under Section 166.101(a); and

(B) does not include authorization to withhold medical

interventions or therapies considered necessary to provide

comfort care or to alleviate pain or to provide water or

nutrition.

(7) "Out-of-hospital setting" means a location in which health

care professionals are called for assistance, including long-term

care facilities, in-patient hospice facilities, private homes,

hospital outpatient or emergency departments, physician's

offices, and vehicles during transport.

(8) "Proxy" means a person designated and authorized by a

directive executed or issued in accordance with Subchapter B to

make a treatment decision for another person in the event the

other person becomes incompetent or otherwise mentally or

physically incapable of communication.

(9) "Qualified relatives" means those persons authorized to

execute or issue an out-of-hospital DNR order on behalf of a

person who is incompetent or otherwise mentally or physically

incapable of communication under Section 166.088.

(10) "Statewide out-of-hospital DNR protocol" means a set of

statewide standardized procedures adopted by the board under

Section 166.101(a) for withholding cardiopulmonary resuscitation

and certain other life-sustaining treatment by health care

professionals acting in out-of-hospital settings.

Added by Acts 1995, 74th Leg., ch. 965, Sec. 10, eff. June 16,

1995. Renumbered from Sec. 674.001 and amended by Acts 1999, 76th

Leg., ch. 450, Sec. 1.04, eff. Sept. 1, 1999; Acts 2003, 78th

Leg., ch. 1228, Sec. 8, eff. June 20, 2003.

Sec. 166.082. OUT-OF-HOSPITAL DNR ORDER; DIRECTIVE TO

PHYSICIANS. (a) A competent person may at any time execute a

written out-of-hospital DNR order directing health care

professionals acting in an out-of-hospital setting to withhold

cardiopulmonary resuscitation and certain other life-sustaining

treatment designated by the board.

(b) Except as provided by this subsection, the declarant must

sign the out-of-hospital DNR order in the presence of two

witnesses who qualify under Section 166.003, at least one of whom

must be a witness who qualifies under Section 166.003(2). The

witnesses must sign the order. The attending physician of the

declarant must sign the order and shall make the fact of the

existence of the order and the reasons for execution of the order

a part of the declarant's medical record. The declarant, in lieu

of signing in the presence of witnesses, may sign the

out-of-hospital DNR order and have the signature acknowledged

before a notary public.

(c) If the person is incompetent but previously executed or

issued a directive to physicians in accordance with Subchapter B,

the physician may rely on the directive as the person's

instructions to issue an out-of-hospital DNR order and shall

place a copy of the directive in the person's medical record.

The physician shall sign the order in lieu of the person signing

under Subsection (b) and may use a digital or electronic

signature authorized under Section 166.011.

(d) If the person is incompetent but previously executed or

issued a directive to physicians in accordance with Subchapter B

designating a proxy, the proxy may make any decisions required of

the designating person as to an out-of-hospital DNR order and

shall sign the order in lieu of the person signing under

Subsection (b).

(e) If the person is now incompetent but previously executed or

issued a medical power of attorney designating an agent, the

agent may make any decisions required of the designating person

as to an out-of-hospital DNR order and shall sign the order in

lieu of the person signing under Subsection (b).

(f) The board, on the recommendation of the department, shall by

rule adopt procedures for the disposition and maintenance of

records of an original out-of-hospital DNR order and any copies

of the order.

(g) An out-of-hospital DNR order is effective on its execution.

Added by Acts 1995, 74th Leg., ch. 965, Sec. 10, eff. June 16,

1995. Renumbered from Sec. 674.0