Advance Medical Directive: Sample Form

Medical Author: Maude B. Hecht, RN
Medical Editor: William C. Shiel, Jr. MD, FACP, FACR and Barbara K. Hecht, Ph.D.

The current case of Terri Schiavo has focussed the spotlight on the issue of advance medical directives. An advance directive, through a living will or the designation of a health care proxy, prevents the involvement of the courts "in virtually all cases," according to George J. Annas, J.D., M.P.H writing in an article published online by The New England Journal of Medicine on March 22, 2005.

Here is an example of an Advance Medical Directive. It is a real one. It happens to have been prepared (and signed) by a 36-year-old woman who lives in the State of Texas. Points 1-6 (below) are, as required, in accord with the Texas Health Code. Point 7 was added to specify further her wishes.

Remember that this is just an example. Your Advance Medical Directive should reflect your own personal wishes.

Directive to Physicians

Directive made this __th day of ____ in the year ____.

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 in this directive.

1. If at any time I should have an incurable or irreversible condition caused by injury, disease, or illness certified to be a terminal condition by two physicians, and if the application of life-sustaining procedures would serve only to artificially postpone the moment of my death, and if my attending physician determines that my death is imminent or will result within a relatively short time without the application of life-sustaining procedures. I direct that those procedures be withheld or withdrawn, and that I be permitted to die naturally.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 those life-sustaining procedures, it is my intention that this directive be honored by my family and physicians as the final expression of my legal right to refuse medical or surgical treatment and accept the consequences form that refusal.
3. If I have been diagnosed as pregnant and that diagnosis is known to my physician, this directive has no effect during my pregnancy.
4. This directive is in effect until it is revoked.
5. I understand the full import of this directive and I am emotionally and mentally competent to make this directive.
6. I understand that I may revoke this directive as any time.
7. I request that only comfort care be provided to me, no antibiotics, no artificial nutrition, no mechanical ventilation, and no hydration. It is my strong preference to be allowed to die outside of a care facility if possible, even if that preference is determined by my physician to shorten my period of dying. The only condition under which I desire these preferences for end of life care to be altered is in the case of possible organ and tissue donation. I request that any and all organs and tissue that may be salvaged be provided for transplant. My remains may then be cremated.

Signed ______________ in the City of ____________etc.

I am not a person designated by the declarant to make a treatment decision. I am not related to the declarant by blood or marriage. I would not be entitled to any portion of the declarant's estate on the declarant's death. I am not the attending physician of the declarant or an employee of the attending physician. I have no claim in against any portion of the declarant's estate on the declarant's death. Furthermore, if I am an employee of the health care facility in which the declarant is a patient, I am not involved in providing direct patient care to the declarant and am not an officer, director, partner, or business office employee of the heath care facility or of any parent organization of the health care facility.

Witness ______________

Witness ______________

For more information, please read the Advance Medical Directives article.

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Reference: Texas Health and Safety Code, Chapter 166

Last Editorial Review: 3/23/2005