Fill and Sign the Physicians on Behalf of a Minor Form

- 1 - NOTICE OF CONFIDENTIALITY RIGHTS: IF YOU ARE A NATURAL PERSON, YOU MAY REMOVE OR STRIKE ANY OF THE FOLLOWING INFORMATION FROM THIS INSTRUMENT BEFORE IT IS FILED FOR RECORD IN THE PUBLIC RECORDS: YOUR SOCIAL SECURITY NUMBER OR YOUR DRIVER’S LICENSE NUMBER DIRECTIVE TO PHYSICIANS ON BEHALF OF A MINOR (Texas Health and Safety Code § 166.033. Also see § 166.035) Instructions for completing this document: This is an important legal document known as an Advance Directive. It is designed to help you, the patient’s spouse (if the spouse is an adult); the patient’s parents; or the patient’s legal guardian, to communicate your wishes about medical treatment on behalf of the minor patient. 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 the minor patient were seriously ill.You are encouraged to discuss your values and wishes with your family, as well as the minor patient’s physician. That 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 this directive to the physician, usual hospital, and family. 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 the physician, family, hospital representative, or other advisers. You may also wish to complete a directive related to the donation of organs and tissues. - 2 - DIRECTIVE I, ______________________________________________, am the Check one: ________ spouse (if the spouse is an adult) ________ parent ________ guardian of ______________________________________________ a minor under the age of eighteen (18) years. I recognize that the best health care is based upon a partnership of trust and communication with the physician. The physician and I will make health care decisions together on behalf of the minor patient. I direct that the following treatment preferences be honored: If, in the judgment of the physician, the minor patient is suffering with a terminal condition from which he/she is 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 the minor patient comfortable be discontinued or withheld and the physician allow the minor patient to die as gently as possible; OR__________ I request that the minor patient 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, the minor patient is suffering with an irreversible condition so that he/she cannot care for himself/herself, and he/she is 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 the minor patient comfortable be discontinued or withheld and that the physician allow the minor patient to die as gently as possible; OR - 3 - __________ I request that the minor patient 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 the physician, you may wish to consider listing particular treatments in this space that you do or do not want to be used or administered in specific circumstances, such as artificial nutrition and fluids, intravenous antibiotics, etc. Be sure to state whether you do or do not want the physician to use the particular treatment.)________________________________________________________________________________________________________________________________________________________________________________________________________________________After signing this directive, I understand and agree that only those treatments needed to keep the minor patient comfortable would be provided and that he/she would not be given available life- sustaining treatments.Signed: _______________________________________________________________________Date: ____________________________________City, County, State of Residence: _______________________________________________I am the ________ spouse (if the spouse is an adult) ________ parent ________ guardian of _________________________________________, a minor under the age of eighteen years of age. 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 minor patient and may not be related to the minor 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 minor 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 - 4 - minor patient. This witness may not be an officer, director, partner, or business office employee of a health care facility in which the minor 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. - 5 - "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.