Texas Advance Directives, Medical Power of Attorney & Out-of-Hospital DNR for San Antonio Seniors (2026 Guide)

By San Antonio Senior Advisor Care Team · October 31, 2026

Texas Advance Directives for San Antonio Seniors: The Three Documents That Matter

Before a parent moves into assisted living or memory care in San Antonio, almost every admissions director will ask the same question: does your loved one have a Texas advance directive on file? In Texas, "advance directive" is an umbrella term defined in Chapter 166 of the Texas Health and Safety Code, the Advance Directives Act. For most Bexar County families, three documents do the real work. The Directive to Physicians and Family or Surrogates (often called a living will) records what treatment your parent wants or refuses if they have a terminal or irreversible condition. The Medical Power of Attorney names an agent who can make health care decisions when your parent can no longer make them. The Out-of-Hospital Do-Not-Resuscitate Order (OOH-DNR) tells EMS crews, emergency department staff and facility caregivers not to start CPR outside a hospital setting. Each document has its own form, its own signing rules and its own job, and none of them substitutes for the others.

These documents matter more in San Antonio than many families expect because of how care actually happens here. A resident of a Type A or Type B assisted living facility licensed under Chapter 247 who collapses at 2 a.m. will be met by San Antonio Fire Department EMS or a county ESD crew, not by their own physician. Without a valid OOH-DNR in hand, those paramedics are required to begin resuscitation. Without a Medical Power of Attorney, the hospitalist at Methodist Hospital, Baptist Medical Center or University Hospital may have to fall back on the Texas surrogate-consent rules in Chapter 313 of the Health and Safety Code, which can create conflict when siblings disagree.

How to Complete a Texas Medical Power of Attorney and Directive to Physicians

The Texas Medical Power of Attorney uses the statutory form in Section 166.164. Your parent names an agent and, ideally, one or more alternates, and the agent's authority begins only when the attending physician certifies in writing that your parent lacks the capacity to make health care decisions. The Directive to Physicians uses the form in Section 166.033 and lets your parent state in their own words what they want regarding life-sustaining treatment, artificial nutrition and hydration, and comfort care. Both documents must be signed by your parent while they have capacity, and both must be either signed in front of two qualified adult witnesses or acknowledged before a notary public. At least one witness cannot be the named agent, a relative by blood or marriage, someone entitled to inherit, the attending physician, or an employee of the facility or health care provider directly caring for your parent, so plan witnesses carefully if you are signing inside a facility.

In practice, many San Antonio families complete these forms at the kitchen table with a notary from a local bank branch, or during an elder-law consultation. Free statutory forms are available through Texas Health and Human Services and from the hospital systems themselves; Methodist, Baptist and University Health all offer advance-care-planning packets. Spanish-language versions of the Texas forms exist and are widely used across the South Side and West Side. If your parent is more comfortable in Spanish, have them sign the Spanish version so there is no question they understood it: la directiva anticipada y el poder notarial médico deben reflejar sus propios deseos. Keep the originals somewhere easy to reach, give copies to the agent and the primary care physician, and ask the assisted living community to scan them into the resident record.

Out-of-Hospital DNR Orders in San Antonio Assisted Living and Memory Care

The Texas Out-of-Hospital DNR Order is a standardized state form published by the Department of State Health Services' EMS and Trauma Systems office. Unlike the living will, it is a physician order: it must be signed by your parent (or their legally authorized representative) and by the attending physician, and it requires two qualified witnesses or a notary for the patient's signature. Once completed, the original or a copy should travel with your parent. Texas also allows an approved OOH-DNR identification device, such as a bracelet or necklace, which is helpful for residents who go on outings or to dialysis or day programs. EMS crews in Bexar County are trained to look for the form or device and honor it, but they cannot honor a document they cannot find.

For assisted living residents, the practical rule is simple: the facility should keep the OOH-DNR in a place staff can grab instantly, often a red folder inside the apartment door or at the nurse's station, and should note DNR status on the resident service plan. Memory care communities in Alamo Heights, Stone Oak and the Medical Center area usually have their own internal code-status forms as well, but those internal forms do not bind EMS. Only the state OOH-DNR does. Families should also know that a person can revoke an OOH-DNR at any time, including verbally, and that a pregnant patient's DNR is not honored under Texas law. Review the order after every hospitalization, because hospital DNR orders written at discharge from Christus Santa Rosa or St. Luke's Baptist do not automatically convert into a valid out-of-hospital order.

What Happens Without an Advance Directive in Texas

If your parent has no Medical Power of Attorney and can no longer communicate, Texas law sets a priority list of surrogates who may consent to medical treatment: a court-appointed guardian, then the spouse, then a majority of reasonably available adult children, then the parents, then the nearest living relative. For end-of-life decisions under Chapter 166, a similar ladder applies, and a physician and a surrogate together can make a decision to withhold or withdraw life-sustaining treatment. That sounds workable on paper, but in a family with four adult children spread from Helotes to Houston, "a majority of reasonably available adult children" can mean frantic phone calls from a hospital hallway at Brooke Army Medical Center or University Hospital.

The worst-case scenario is guardianship. If no one has authority and the family cannot agree, someone may need to file in the Bexar County Probate Courts for a guardianship of the person, which costs thousands of dollars in attorney and court fees and can take weeks. A properly signed Medical Power of Attorney avoids nearly all of that. Families comparing tools can read our earlier guide on guardianship versus power of attorney in Texas, and anyone worried about a parent being pressured to sign documents should know that Adult Protective Services and the long-term care ombudsman program both investigate concerns about undue influence in facilities.

Free Help Completing Texas Advance Directives in Bexar County

You do not need to pay a lawyer to complete the statutory forms, although an elder-law attorney is worth the cost when your parent also needs a durable financial power of attorney, a Medicaid plan or a Miller trust. For free help, start with AACOG, the Alamo Area Council of Governments, which runs the Area Agency on Aging for Bexar and the surrounding counties. Call (210) 362-5200 or visit aacog.com and ask for benefits counseling or legal assistance for adults 60 and older; their benefits counselors can explain the forms and refer you to the legal aid programs that serve the region. Texas RioGrande Legal Aid also serves low-income seniors in Bexar County. Veterans receiving care through the Audie L. Murphy VA Medical Center can complete VA Form 10-0137, the VA advance directive, through their primary care team or social work office.

Hospital chaplaincy and social work departments are another overlooked resource. Methodist Healthcare, Baptist Health System, University Health and Christus Santa Rosa all have staff who will walk a patient through advance care planning during an admission, often with bilingual staff available. Hospice and palliative care programs in San Antonio also routinely help patients complete the OOH-DNR with their physician. Whatever route you take, confirm the final documents are signed, dated, witnessed or notarized, and copied to the right people before move-in day. When you tour communities, ask how they store advance directives, how they communicate code status to EMS, and how often they review directives with residents and families.

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Common questions

Does an assisted living facility in San Antonio require a Texas advance directive before move-in?

Texas does not require a resident to have an advance directive as a condition of admission, and a Chapter 247 licensed assisted living facility cannot refuse care simply because a resident declines to sign one. What facilities are required to do is ask about advance directives, provide written information about the resident's right to make them, and document the answer in the resident record. In practice, most San Antonio communities strongly encourage residents to bring a Medical Power of Attorney, a Directive to Physicians and, where appropriate, an Out-of-Hospital DNR order to the admission appointment. Memory care communities in particular want a named agent on file because residents with advancing dementia may not be able to consent to treatment later. Bring copies, not originals, and ask the director of nursing or wellness director where the documents will be kept and how night staff will find them during an emergency.

Is a hospital DNR from Methodist or Baptist valid after my parent returns to assisted living?

No. A do-not-resuscitate order written inside Methodist Hospital, Baptist Medical Center, University Hospital, BAMC or any other hospital is an inpatient order and generally applies only while your parent is a patient there. Once your parent is discharged back to an assisted living community in Bexar County, EMS crews will look for the state Out-of-Hospital DNR Order form or an approved OOH-DNR identification device. If neither is present, paramedics are expected to begin resuscitation. Ask the hospital discharge planner or case manager, before discharge, to have the attending physician sign a Texas OOH-DNR form if that reflects your parent's wishes. Many San Antonio hospitals keep blank state forms on hand. Then make sure the signed original travels home with your parent and that the assisted living community records the change in the service plan.

Who can be a witness for a Texas medical power of attorney in a nursing home or assisted living?

Texas allows the Medical Power of Attorney and the Directive to Physicians to be either acknowledged before a notary public or signed in front of two competent adult witnesses. The rules on who may serve as a witness are strict. Neither witness may be the person named as agent. At least one witness must not be related to your parent by blood or marriage, must not be entitled to any part of their estate, must not be their attending physician or an employee of that physician, must not be an employee of the health care facility where your parent is a patient or resident if that employee is involved in their direct care, and must not have a claim against the estate. Because of these limits, families signing documents inside a San Antonio assisted living or nursing facility often find it simpler to bring in a mobile notary, many of whom offer bilingual English and Spanish service.

Can my parent with early dementia still sign a Texas advance directive?

Often, yes. A diagnosis of Alzheimer's disease or another dementia does not automatically mean a person lacks capacity to sign a Medical Power of Attorney or Directive to Physicians. The question is whether, at the time of signing, your parent understands the nature of the document, who they are appointing and what decisions that person will be able to make. Many San Antonio elder-law attorneys recommend completing advance directives as soon as possible after a diagnosis, ideally with a recent note from the treating physician or a neurologist at UT Health San Antonio documenting capacity. If your parent can no longer understand the documents, a Medical Power of Attorney is no longer an option and the family may need to rely on the Texas surrogate-consent ladder or pursue guardianship through the Bexar County Probate Courts. AACOG benefits counselors at (210) 362-5200 can help families find low-cost legal assistance for these situations.