End-of-Life Documents and TADA
Advance Directives, Out-of-Hospital DNR, and Medical Powers
Three distinct document families carry different execution, capacity, scope, and clinical predicates under the Texas Advance Directives Act.
Structured Visual
Jurisdiction: TX; as of 2026-09-11; not legal advice; Render structure, refuse interpretation, cite, abstain, and hand off.
RENDER STRUCTURE · REFUSE INTERPRETATION · CITE · ABSTAIN · HAND-OFF: render structure, refuse interpretation, cite provenance, abstain when unsupported, and hand off to human review.
Scope and honesty note
Jurisdiction: Texas medical-practice statutes, as of 2026-09-11. This classroom page provides legal information, not legal or medical advice. It does not assess a patient, clinician, license, report, prescription, disclosure, privilege, disciplinary ground, offense, or outcome. Current statutes, agency rules, facts, procedure, and professional standards may differ. Render only pinned structure; refuse unsupported interpretation or action; cite, abstain, and hand off to qualified legal, medical, regulatory, or emergency professionals.
The rule in plain terms
The Act distinguishes a treatment directive, an out-of-hospital DNR order, and a medical power of attorney. A competent adult may execute a written directive under Section 166.032 using the qualified-witness route or the notarial alternative; the directive is communicated to the attending physician and made part of the medical record. An out-of-hospital DNR order has its own scope and execution rules, including the attending physician's signature and medical-record duties under Section 166.082(b), and different routes involving prior directives, designated proxies, or MPOA agents. A medical power of attorney is an authority document, not a finding of incapacity. Its agent may exercise authority only after the attending physician's written incapacity certification is filed in the medical record. Section 166.152 preserves the principal's objection, consultation and wishes/best-interests standards, prohibited consents, and qualified duration.
Chapter definitions
Advance directives, competence, terminal and irreversible conditions, and life-sustaining treatment are defined terms. Verbatim statutory text: “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) "Artificially administered 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 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 artificially administered 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 Medical Board; 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.” Legal citation: Tex. Health Safety Code § 166.002. Pinned source: https://www.neochart.com/catalog/texas/health_safety/chapter_166/section_166_002/tex_hs_166_002_ffd559a5cb42/tex_health_safety_code_sec_166_002_definitions_in_this_chapt_0001/index.html; data via neochart.com, snapshot 2026-09-11.
Witness qualifications
Required witnesses must meet the statutory qualification and disqualification rules. Verbatim statutory text: “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 health care or 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.” Legal citation: Tex. Health Safety Code § 166.003. Pinned source: https://www.neochart.com/catalog/texas/health_safety/chapter_166/section_166_003/tex_hs_166_003_585c8c70386b/tex_health_safety_code_sec_166_003_witnesses_in_any_circumst_0001/index.html; data via neochart.com, snapshot 2026-09-11.
Directive and qualified patient
The subchapter defines the directive's terminal-or-irreversible-condition setting and the attending physician's written qualified-patient certification. Verbatim statutory text: “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.” Legal citation: Tex. Health Safety Code § 166.031. Pinned source: https://www.neochart.com/catalog/texas/health_safety/chapter_166/section_166_031/tex_hs_166_031_7ace55face7a/tex_health_safety_code_sec_166_031_definitions_in_this_subch_0001/index.html; data via neochart.com, snapshot 2026-09-11.
Written treatment directive
A competent adult's written directive has witness or notarial execution paths, notification, and medical-record requirements. Verbatim statutory text: “(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 health care or 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.” Legal citation: Tex. Health Safety Code § 166.032. Pinned source: https://www.neochart.com/catalog/texas/health_safety/chapter_166/section_166_032/tex_hs_166_032_aa2dd0933dd9/tex_health_safety_code_sec_166_032_written_directive_by_comp_0001/index.html; data via neochart.com, snapshot 2026-09-11.
Out-of-hospital terminology
The statute defines the order, settings, and covered treatment for this distinct subchapter. Verbatim statutory text: “In this subchapter: (1) Repealed by Acts 2003, 78th Leg., ch. 1228, Sec. 8. (2) "DNR identification device" means an identification device specified by department rule 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 department rule 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 department rule 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 executive commissioner 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.” Legal citation: Tex. Health Safety Code § 166.081. Pinned source: https://www.neochart.com/catalog/texas/health_safety/chapter_166/section_166_081/tex_hs_166_081_dc836a7ab55a/tex_health_safety_code_sec_166_081_definitions_in_this_subch_0001/index.html; data via neochart.com, snapshot 2026-09-11.
Out-of-hospital DNR execution
This provision distinguishes the declarant, physician, witness/notary, prior-directive, proxy, and agent execution routes. Verbatim statutory text: “(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 department rule. (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 executive commissioner, 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.” Legal citation: Tex. Health Safety Code § 166.082. Pinned source: https://www.neochart.com/catalog/texas/health_safety/chapter_166/section_166_082/tex_hs_166_082_9ec42f448ff6/tex_health_safety_code_sec_166_082_out_of_hospital_dnr_order_0001/index.html; data via neochart.com, snapshot 2026-09-11.
MPOA scope and activation
The agent's scope, written incapacity certification, principal objection, decision standard, prohibited consents, and duration remain qualified. Verbatim statutory text: “(a) Subject to this subchapter or any express limitation on the authority of the agent contained in the medical power of attorney, the agent may make any health care decision on the principal's behalf that the principal could make if the principal were competent. (b) An agent may exercise authority only if the principal's attending physician certifies in writing and files the certification in the principal's medical record that, based on the attending physician's reasonable medical judgment, the principal is incompetent. (c) Notwithstanding any other provisions of this subchapter, treatment may not be given to or withheld from the principal if the principal objects regardless of whether, at the time of the objection: (1) a medical power of attorney is in effect; or (2) the principal is competent. (d) The principal's attending physician shall make reasonable efforts to inform the principal of any proposed treatment or of any proposal to withdraw or withhold treatment before implementing an agent's advance directive. (e) After consultation with the attending physician and other health care providers, the agent shall make a health care decision: (1) according to the agent's knowledge of the principal's wishes, including the principal's religious and moral beliefs; or (2) if the agent does not know the principal's wishes, according to the agent's assessment of the principal's best interests. (f) Notwithstanding any other provision of this subchapter, an agent may not consent to: (1) voluntary inpatient mental health services; (2) convulsive treatment; (3) psychosurgery; (4) abortion; or (5) neglect of the principal through the omission of care primarily intended to provide for the comfort of the principal. (g) The power of attorney is effective indefinitely on execution as provided by this subchapter and delivery of the document to the agent, unless it is revoked as provided by this subchapter or the principal becomes competent. If the medical power of attorney includes an expiration date and on that date the principal is incompetent, the power of attorney continues to be effective until the principal becomes competent unless it is revoked as provided by this subchapter.” Legal citation: Tex. Health Safety Code § 166.152. Pinned source: https://www.neochart.com/catalog/texas/health_safety/chapter_166/section_166_152/tex_hs_166_152_4d1cbf0dea17/tex_health_safety_code_sec_166_152_scope_and_duration_of_aut_0001/index.html; data via neochart.com, snapshot 2026-09-11.
MPOA execution
Witness or notarial execution and the physically-unable-to-sign provision have their own statutory conditions. Verbatim statutory text: “(a) Except as provided by Subsection (b), the medical power of attorney must be signed by the principal 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 document. (b) The principal, in lieu of signing in the presence of the witnesses, may sign the medical power of attorney and have the signature acknowledged before a notary public. (c) If the principal is physically unable to sign, another person may sign the medical power of attorney with the principal's name in the principal's presence and at the principal's express direction. The person may use a digital or electronic signature authorized under Section 166.011.” Legal citation: Tex. Health Safety Code § 166.154. Pinned source: https://www.neochart.com/catalog/texas/health_safety/chapter_166/section_166_154/tex_hs_166_154_c4e5c55ad1e4/tex_health_safety_code_sec_166_154_execution_0001/index.html; data via neochart.com, snapshot 2026-09-11.
Work the pinned classroom record
A synthetic chart contains a signed treatment directive, a separate purported out-of-hospital DNR order, and a medical power of attorney. The review identifies each instrument separately, checks its execution and applicable setting, records any necessary physician signature or certification, and preserves expressed patient wishes and objections. A physician's written incapacity certification in the MPOA record is not substituted for the qualified-patient certification required by another subchapter. The model does not treat an uploaded form, an agent's request, or a family relationship as sufficient to authorize any treatment decision.
Limits and authored cross-references
Witness eligibility must be checked against Section 166.003, and each instrument retains its own statutory exceptions and execution paths. The order's out-of-hospital setting is a defined term, not a geographic guess. Life-sustaining treatment and pain/comfort care are distinguished by the source definitions. This overview does not reproduce usable clinical forms or supply treatment instructions. Conflicting documents, revocation, superseding wishes, pregnancy-related questions, current rules, and actual clinical implementation require the full applicable provisions and qualified review; no unpinned substantive rule is supplied for them. The separate surrogate page covers its no-directive conditions, and the TADA page covers its qualified disagreement procedure.
Read the glanceable structure
The four-node overview separates document families. Execution, capacity, patient wishes, physician participation, and implementation remain explicit source-and-record questions in the prose. The diagram contains 4 deliberately limited nodes. It is a navigation aid, not law or advice; the words and pinned sources below control the classroom explanation.
Jurisdiction: TX; as of 2026-09-11; not legal advice; Render structure, refuse interpretation, cite, abstain, and hand off.
RENDER STRUCTURE · REFUSE INTERPRETATION · CITE · ABSTAIN · HAND-OFF: render structure, refuse interpretation, cite provenance, abstain when unsupported, and hand off to human review.
Narrow summary
Classify the instrument, verify its own formalities and prerequisites, preserve patient wishes and objections, and route actual care or authority questions to qualified legal and clinical review.