Working Caregiver- Caregiver Articles

**Only for Patients In a Nursing Home or Hospital**

Surrogate Decision that does not include withholding or withdrawing life sustaining treatment

Name of Patient:

__________________________________________

This consent is not related to withholding or withdrawing life-sustaining procedures and would be used for an adult patient:

• who has no formal guardian or health care agent under a medical power of attorney; and
• who's care decisions are NOT related to the withholding or withdrawing of life-sustaining procedures.

A surrogate-decision maker may not consent to:

• voluntary inpatient mental health services;
• electro-convulsive treatment; or
• the appointment of another surrogate decision-maker.

If an adult patient in a nursing home or hospital is comatose, incapacitated, or otherwise mentally or physically incapable of communication, an adult surrogate from the following list, in order of priority, who has decision-making capacity, is available after a reasonably diligent inquiry, and is willing to consent to medical treatment on behalf of the patient, may consent to medical treatment on behalf of the patient:

the patient's spouse;

• an adult child of the patient who has the waiver and consent of all other qualified adult children
• if the patient to act on behalf of the patient as the sole decision-maker;
• a majority of the patient's reasonably available adult children;
• the patient's parents;
• the individual clearly identified to act for the patient by the patient before the patient became incapacitated,
• the patient's nearest living relative, or a member of the clergy

PHYSICIAN DOCUMENTATION:

1) Describe the patient's comatose state, incapacity, or other mental or physical inability to communicate

2) Proposed medical treatment

3) How is it known that this decision is based on knowledge of what the patient would desire?

4) Attempts to contact persons eligible to serve as surrogate decision-maker:

____________________

Physician Signature Date of Signature

Reprinted with permission by Office of Attorney General of Texas