Texas handles advance healthcare planning with two separate documents, and the distinction between them matters. The Medical Power of Attorney designates someone to make medical decisions on your behalf. The Directive to Physicians, which is Texas's living will, records your own instructions about life-sustaining treatment in defined end-of-life situations. Having one does not mean you have the other. A Texas resident with only a Medical Power of Attorney has a decision-maker but no documented treatment instructions. A Texas resident with only a Directive to Physicians has documented instructions but no named agent to advocate for them or handle every other medical situation that arises. Both documents together make up a complete Texas advance care plan.
The Medical Power of Attorney: designating your healthcare agent
The Texas Medical Power of Attorney, governed by Health and Safety Code Chapter 166, designates a person called the healthcare agent or healthcare proxy to make medical decisions on the principal's behalf when the principal lacks capacity. The agent's authority is broad: they can consent to or refuse treatment, access medical records, authorize transfers between facilities, and make the full range of healthcare decisions the principal would normally make in person.
The agent's authority activates when the principal's attending physician certifies that the principal lacks the capacity to make healthcare decisions. Unlike the financial power of attorney, which in Texas takes effect immediately upon signing, the Medical Power of Attorney is effectively a springing document whose triggering condition is incapacity. The agent cannot act under it while the principal has capacity.
Certain decisions fall outside the agent's authority under Texas law even with a valid Medical Power of Attorney. The agent cannot consent to voluntary inpatient mental health treatment, convulsive treatment, psychosurgery, or abortion. These decisions require either the principal's own consent or separate legal proceedings and cannot be delegated to a healthcare agent.
Texas requires the Medical Power of Attorney to be signed by the principal before either two qualified adult witnesses or a notary public. Witnesses cannot include the agent, the agent's relatives, the principal's healthcare provider or that provider's employees, or operators or employees of healthcare facilities where the principal receives care. The document must also include a specific disclosure statement explaining the nature and effect of the Medical Power of Attorney, which is set out in the statute.
The Directive to Physicians: Texas's living will
The Texas Directive to Physicians, also governed by Health and Safety Code Chapter 166, records the principal's own instructions about life-sustaining treatment in two defined circumstances: a terminal condition and an irreversible condition. These are the two qualifying situations under Texas law, and they have specific statutory definitions.
A terminal condition under Texas law 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. The six-month threshold is specific to Texas and differs from how other states define terminal illness.
An irreversible condition means a condition, injury, or illness that may be treated but is never cured or eliminated, that leaves the patient unable to care for or make decisions for themselves, and that without life-sustaining treatment provided over a long period will cause death. Persistent vegetative state is the most common example of an irreversible condition under this definition, but the category is broader.
For each condition, the Directive to Physicians asks the principal to choose one of two positions: that they want life-sustaining treatment provided and want to live as long as possible, or that they do not want life-sustaining treatment if it would only artificially prolong the dying process. The form also addresses comfort care separately, allowing the principal to request that comfort care and pain management be provided regardless of the decision about life-sustaining treatment.
Execution requirements for the Texas Directive to Physicians
The Directive to Physicians must be signed by the declarant before either two qualified adult witnesses or a notary public. The witness restrictions are the same as for the Medical Power of Attorney: no healthcare providers, no facility employees, no one who would inherit from the declarant, and no one who has a claim against the declarant's estate.
One of the two witnesses must be a person who is not a relative of the declarant by blood or marriage and who is not entitled to any portion of the declarant's estate. This is sometimes called the "independent witness" requirement. It is in addition to the general disqualification rules and means at least one witness must be entirely unconnected to the declarant's family and estate.
If the declarant is a patient in a healthcare facility at the time of signing, one of the two witnesses must be an individual designated by the facility as a patient advocate or ombudsman. This requirement mirrors California's skilled nursing facility rule and exists for the same reason: to protect patients who may be subject to pressure from facility staff or family members.
The 166 Procedure: when a Texas hospital disagrees with a directive
Texas has a unique and often misunderstood procedure that can override a patient's or agent's decision to withhold or withdraw life-sustaining treatment. Under Health and Safety Code Section 166.046, if a physician and hospital ethics committee determine that providing life-sustaining treatment would be medically inappropriate for a patient, they can issue a decision to discontinue treatment even if the patient or their surrogate objects. The patient or surrogate must be given 10 days' notice and an opportunity to transfer to another facility willing to provide the treatment.
This procedure works in the opposite direction of what most people assume: it allows a hospital to withdraw treatment the patient wants, not to override a directive requesting withdrawal. It is a relatively rare use of the statute, but it reflects Texas's distinctive approach to end-of-life decision-making: both the patient's wishes and the physician's medical judgment carry legal weight, and neither is entirely absolute.
For patients and families, the practical implication is that having a Texas Directive to Physicians does not guarantee unlimited continuation of life-sustaining treatment if the treating physicians consider it futile. Understanding this limitation is part of understanding what a Texas advance directive does and does not accomplish.
Texas Out-of-Hospital DNR: a third document for home and non-hospital settings
A Texas Directive to Physicians governs treatment decisions within a hospital or healthcare facility. For patients who want do-not-resuscitate instructions to apply outside of hospital settings, such as at home, in a nursing home, or in an ambulance, Texas has a separate document called the Out-of-Hospital Do Not Resuscitate Order (OOH DNR).
The OOH DNR must be signed by both the patient (or their legal representative) and the patient's attending physician. Emergency medical services personnel are legally required to honor a valid OOH DNR they encounter in a non-hospital setting. Without this document, EMS will typically attempt resuscitation regardless of what a Directive to Physicians says, because EMS personnel are not bound by hospital-based directives.
The OOH DNR is distinct from the Directive to Physicians and the Medical Power of Attorney. Patients who want their resuscitation preferences honored in all settings need all three documents.
Getting both Texas documents in order
Both the Medical Power of Attorney and the Directive to Physicians forms are available at no cost from the Texas Health and Human Services Commission website and the Texas Medical Association. For people who want a guided process that generates both documents alongside a financial power of attorney and will, Quicken WillMaker & Trust by Nolo produces both Texas healthcare documents with state-specific language updated annually to reflect current Health and Safety Code requirements.
The most common failure in Texas advance care planning is having one document but not the other. A Medical Power of Attorney without a Directive to Physicians leaves the agent to make end-of-life decisions without documented guidance from the principal. A Directive to Physicians without a Medical Power of Attorney documents your wishes but leaves no one with formal authority to advocate for them across all the medical situations a hospitalization involves. Both are needed.
A real-world example
Bob and Carol, both 67, live in Austin and execute both Texas documents in the same afternoon. Bob's Medical Power of Attorney names Carol as his agent and his adult daughter as successor. His Directive to Physicians states that he does not want life-sustaining treatment in a terminal condition or irreversible condition if it would only prolong dying, and that he wants aggressive comfort care. Carol's documents name Bob as her agent and the same daughter as successor, with identical treatment preferences. Both documents are signed before a notary. Bob provides copies of his Medical Power of Attorney to their family physician and to the local hospital's patient records department. Both directives are filed with the Texas advance directives registry. Two years later, Bob is hospitalized with a serious but non-terminal condition. Carol uses the Medical Power of Attorney to communicate with his medical team and authorize treatment. The Directive to Physicians is not triggered because the condition does not meet the terminal or irreversible threshold. Bob recovers. Both documents served their purpose.
Frequently Asked Questions
Does Texas have an advance directive registry?
Yes. Texas Health and Human Services maintains an Advance Directives Registry where residents can register their Directive to Physicians. Registration is voluntary and free. A registered directive can be accessed by healthcare providers statewide, which is useful if you are treated at a facility that does not already have a copy. The Medical Power of Attorney is not part of the registry, though some healthcare systems maintain their own records of both documents when patients provide them.
Can my Texas healthcare agent override my Directive to Physicians?
No, not for the situations the Directive specifically addresses. The agent's role is to make decisions consistent with the principal's documented wishes. If the Directive states that the principal does not want life-sustaining treatment in a terminal condition, the agent cannot authorize it over that instruction. For situations the Directive does not address, the agent exercises judgment guided by their knowledge of the principal's values. The principal's documented instructions always take precedence over the agent's personal preferences for the specific circumstances the Directive covers.
What is the difference between a terminal condition and an irreversible condition in Texas?
A terminal condition produces death within six months even with treatment. An irreversible condition is one that can be treated but never cured, that leaves the patient unable to care for themselves, and that will cause death without long-term life-sustaining treatment. The practical distinction is that a terminal condition has a relatively near-term end point regardless of treatment, while an irreversible condition like a persistent vegetative state could be maintained indefinitely with life-sustaining treatment. Your Directive can address each condition separately or apply the same instructions to both.
Does my Texas advance directive apply if I am treated in another state?
Most states recognize advance directives from other states if they were validly executed under the originating state's law. A Texas Directive to Physicians executed correctly under Texas Health and Safety Code Chapter 166 should be recognized in other states under their interstate recognition provisions. In practice, out-of-state providers may be less familiar with Texas forms and may request additional documentation. If you spend significant time in another state, creating a directive using that state's form as a supplement reduces practical friction.
Can I change my Texas Directive to Physicians after I sign it?
Yes, at any time while you have capacity. You can revoke the Directive verbally in the presence of a witness, in writing, or by destroying the document. You can also execute a new Directive that supersedes the old one. Texas law requires that your attending physician be notified of a revocation and that it be noted in your medical record. If your Directive is registered with the Texas advance directives registry, updating or revoking the registration is also advisable so that providers who access the registry see current information.