Texas: Living Will and Advance Health-Care Instruction Requirements

Texas calls its treatment instruction a Directive to Physicians and Family or
Surrogates. It is governed by Subchapter B of the Texas Advance Directives Act,
separately from the medical power of attorney that appoints an agent and the
out-of-hospital DNR order that directs emergency resuscitation care.

Requirements one by one

Governing law and document

Section 166.031 defines a directive as an instruction "to administer, withhold, or
withdraw life-sustaining treatment in the event of a terminal or irreversible
condition." Section 166.033 prints a model Directive to Physicians, but its opening
words are permissive: a written directive "may be" in that form. Section 166.036
reinforces the point by barring a physician, facility, or professional from requiring
the person to use the provider's form.

Who may make an instruction

The two execution routes begin at different times. Under § 166.032(a), "[a] competent
adult may at any time execute a written directive." Under § 166.034(a), the nonwritten
route is narrower: it is available to "[a] competent qualified patient who is an
adult." A qualified patient already has a terminal or irreversible condition diagnosed
and certified in writing by the attending physician (§ 166.031(2)).

Oral, written, and signature form

A written directive is signed by the adult. Texas does not require one printed form,
and § 166.036 says the instrument remains effective without notarization when the
witness route is used. A nonwritten directive must be communicated in the attending
physician's presence with two qualified witnesses; the physician then records the
directive and the witnesses' names in the medical record (§ 166.034).

Texas also has a directive-specific electronic-signature rule. Section 166.011 permits
a digital or electronic signature only when it is verifiable, under the signer's sole
control, linked so a data change invalidates it, and persistent with the document. A
generic pasted image is not enough merely because it is electronic.

Witness, notary, and disqualifications

For the written route, § 166.032 gives an either/or choice. The adult may sign in the
presence of two witnesses, who also sign, or may instead sign and acknowledge the
signature before a notary. Both witnesses must be competent adults. At least one must
clear every § 166.003(2) disqualification: that witness cannot be the designated
decision-maker, a relative, an heir or estate claimant, the attending physician or that
physician's employee, or the specified direct-care, officer, director, partner, or
business-office employee of the treating facility.

The nonwritten route has no notary substitute. Section 166.034 requires the attending
physician and two qualified witnesses, including at least one witness who clears the
disinterested-witness list.

Covered conditions and trigger

The attending physician supplies the statutory condition finding. Section 166.040(a)
requires certification as a qualified patient when the physician diagnoses a terminal
or irreversible condition. "Terminal condition" means an incurable condition expected
to cause death within six months even with available life-sustaining treatment
(§ 166.002(13)). "Irreversible condition" includes a condition that is never cured,
leaves the person unable to care for or decide for themself, and is fatal without
life-sustaining treatment (§ 166.002(9)).

The paper does not displace a patient's present choice. Section 166.037 says the
qualified patient's desire supersedes the directive, and § 166.040(b) requires the
attending physician to check the proposed steps against both the statute and the
patient's existing desires before withholding or withdrawing treatment.

Treatment, nutrition, hydration, and comfort choices

The optional § 166.033 form separates two choices for each covered condition: stop or
withhold treatments other than those needed for comfort, or continue available
life-sustaining treatment. Its additional-instructions space specifically names
artificially administered nutrition and hydration as treatment that the adult may
address separately.

Section 166.002(10) supplies the boundary. "Life-sustaining treatment" includes
medications, mechanical breathing, dialysis, and artificially administered nutrition
and hydration. It excludes pain-management medication, procedures necessary for
comfort care, and other care that alleviates pain.

Pregnancy and other statutory limits

Texas states the pregnancy rule in one sentence. Section 166.049 provides: "A person
may not withdraw or withhold life-sustaining treatment under this subchapter from a
pregnant patient." This is a limit on withholding or withdrawal under the Directive
to Physicians subchapter; the page does not infer a medical outcome beyond that text.

Under § 166.050, the subchapter does not authorize mercy killing or an
affirmative or deliberate act or omission to end life, except to permit the natural
process of dying as the subchapter provides.

Revocation, notice, and registry

Section 166.042 lets the adult revoke "at any time without regard to the declarant's
mental state or competency." The methods are directed physical destruction, a signed
and dated written revocation, or an oral statement of intent. A written or oral
revocation becomes effective under the statute when the attending physician is notified
(or the writing is mailed to that physician). The physician records the time and date
and marks each chart copy VOID.

Texas does not make a patient registry filing part of execution. The registry in
§ 166.053 serves a different function: it lists providers and referral groups that may
help with a transfer under §§ 166.045 or 166.046.

Provider duties, recognition, and effect

After notice, the attending physician provides for qualified-patient certification and
checks that any proposed withholding or withdrawal complies with the subchapter and the
patient's existing desires (§ 166.040). Section 166.045 makes failure to effectuate a
qualified patient's directive subject to professional review and discipline. If the
attending physician refuses and does not use the § 166.046 procedure, life-sustaining
treatment continues only until the patient has a reasonable opportunity to transfer to
a willing physician or facility.

An advance directive validly executed in another jurisdiction receives the same effect
as a Texas directive under § 166.005, but it cannot authorize care that Texas law
otherwise prohibits.

What trips people up

• The notary and witness paths are alternatives. A written directive needs two
  qualifying witnesses or a notarial acknowledgment, not both (§ 166.032).
• A nonwritten directive has a narrower gateway. It is not a casual oral substitute
  for advance planning. The adult must already be a qualified patient, and the attending
  physician plus two qualified witnesses must be present (§§ 166.031, 166.034).
• The current patient's choice controls. A qualified patient's present desire
  supersedes the earlier directive (§ 166.037).
• Electronic execution has its own technical statute. Section 166.011 requires
  verification, signer control, tamper linkage, and persistence with the document.
• The pregnancy sentence is categorical within this subchapter. Section 166.049
  does not state a gestational-age, viability, or prognosis exception.

Common questions

Must I use the form printed in the Texas statute?
No. Section 166.033 offers a form, and § 166.036 bars a provider from requiring its own
form. A different document still must satisfy the applicable execution rules.

Can I state treatment wishes before I am ill?
Yes. A competent adult may execute a written directive "at any time" under § 166.032.
The narrower nonwritten route applies only after the adult is a qualified patient.

Does artificial nutrition and hydration count as life-sustaining treatment?
Yes. Section 166.002(10) includes artificially administered nutrition and hydration in
the definition, while excluding pain management and comfort care.

Will a directive signed in another state work in Texas?
Texas gives a directive validly executed elsewhere the same effect as a Texas directive,
subject to care that Texas law prohibits (§ 166.005).

Statutes and sources

All cited provisions were read in the Texas Legislative Council's current official
Health and Safety Code Chapter 166 text at
https://tcss.legis.texas.gov/resources/HS/htm/HS.166.htm (accessed 2026-07-30).

• Tex. Health & Safety Code § 166.002 — competence, terminal and irreversible
  conditions, life-sustaining treatment, nutrition and hydration, and comfort care.
• Tex. Health & Safety Code § 166.003 — witness qualifications.
• Tex. Health & Safety Code § 166.005 — directives executed elsewhere.
• Tex. Health & Safety Code § 166.011 — digital and electronic signatures.
• Tex. Health & Safety Code §§ 166.031–166.036 — the written and nonwritten
  Directive to Physicians routes and optional statutory form.
• Tex. Health & Safety Code §§ 166.037 and 166.040 — current desires,
  certification, and prerequisites for compliance.
• Tex. Health & Safety Code § 166.042 — revocation and medical-record notice.
• Tex. Health & Safety Code § 166.045 — failure to effectuate and transfer.
• Tex. Health & Safety Code §§ 166.049–166.050 — pregnancy and other limits.
• Tex. Health & Safety Code § 166.053 — provider-transfer registry.