Understanding the Texas Advance Directives Act (TADA) and Its Revisions

The Texas Advance Directives Act (TADA) clarified and amended existing Texas laws regarding a patient’s advance directives and the processes related to end-of-life care. Advance directives are legal documents that allow patients to communicate their wishes for their end-of-life care. The TADA ( part of the Texas Health and Safety Code, Chapter 166, and passed as Senate Bill 1260 by the Seventy-sixth Texas Legislature) was signed into law by Governor George W. Bush in 1999. Its purview included medical futility, the appropriate use of life-saving treatment, and the practical definition of the Hippocratic Oath and its tenet to “do no harm.” Originally introduced by Texas legislators Senator Mike Moncrief (D) and Representative Garnett Coleman (D) in 1997, the original version of the TADA was vetoed by Governor Bush due to a lack of controls on the ability of a physician to determine the appropriate end-of-life measure. Two years later, a provision was added to satisfy lawmakers that held these concerns: the ethics committee. Each medical facility for whom TADA was relevant was required to have an ethics committee that would be tasked with evaluating a physician’s decision to end treatment. Patients were to be informed of such a meeting at least forty-eight hours in advance and had to be given both the opportunity to attend the review and receive a written explanation of the decision reached by the ethics committee.

The legislation detailed significant guidelines for patients and health care facilities regarding end-of-life care. The procedure surrounding do-not-resuscitate (DNR) orders was standardized across a variety of health care facility settings, ensuring consistent application of DNR orders. An ethics committee was mandated at each hospital to overview cases in which an attending physician deemed that ending treatment, despite the wishes of the patient, was medically appropriate. Physicians were obligated to make a “reasonable effort” to transfer patients to another facility if they were unwilling to comply with the patient’s advance directive. TADA also contained provisions to shield health care professionals from liability when they act in accordance with a patient’s advance directive, whether that be in relation to life-sustaining treatment or a DNR order. Penalties were established for intentionally damaging, falsifying, or tampering with a patient’s directive or DNR order.

One component of the TADA that was controversial since its establishment was the “10-Day Rule,” an informal name given to the ten-day window that patients were given to find an alternate medical facility in the event that an ethics committee determined that further life-sustaining treatment was futile. Many of the activist organizations involved in the initial formation of TADA, such as Texas Right to Life, pushed for a six-month window, during which physicians would be required to provide life-sustaining treatment. Lawmakers and health care providers on the opposite side of the aisle, however, argued that such an extended period would likely just prolong the suffering and misery of patients, their families, and the health care providers that would be forced to provide futile care for months on end.

In 2023 House Bill 3162 passed as a revision to the TADA following the closure of the Tinslee Lewis case, a case in which what proved to be a premature invocation of the “10-Day Rule” resulted in challenges to the constitutionality of the TADA. The new measure extended the ten-day provision to twenty-five days and allowed for patients and their representatives to receive notice of an ethics committee review seven days in advance instead of forty-eight hours. H.B. 3162 also resulted in changes to the procedure surrounding ethics committees, the reporting requirements of health care facilities, and the rules surrounding DNR orders.

In passing this original TADA, Texas stood out as one of the few states where physicians could terminate a patient’s treatment against the wishes of the family. Since 1999 there have been continuous calls in nearly every legislative session for reform to TADA from all sides of the aisle. Although H.B. 3162 succeeded in replacing the TADA as Texas state law and brought about significant reforms in how advanced directives, DNR orders, and life-sustaining treatment are practiced in the state, the legacy of the original TADA was still the subject of much debate and further calls for reform in the 2020s.