Texas Futile Care Law: The 25-Day Rule and Hospital Ethics Disputes

Few people know about this until they're in the middle of it: a Texas physician can refuse to follow your advance directive if they believe the requested treatment is medically inappropriate. When that happens, the hospital must follow a structured dispute resolution process that was significantly reformed by House Bill 3162, effective September 1, 2023.

If you've heard of the "Texas 10-day rule," that rule no longer exists. HB 3162 replaced it with a 25-day transfer window and added important patient protections.

When a Physician Can Refuse

The dispute process activates when a physician believes that a patient or surrogate's treatment request — whether asking to continue life support or asking to withdraw it — is medically inappropriate. The physician cannot unilaterally override the directive. Instead, the case must go through the hospital's ethics or medical committee.

The HB 3162 Dispute Resolution Process

Step 1: Written Notice (7-Day Minimum)

The hospital must provide the patient or surrogate with written notice of the ethics committee review meeting at least seven calendar days before the meeting. Under the old law, this notice period was only 48 hours — barely enough time to find an advocate or attorney.

The patient or surrogate has the right to attend the committee meeting and present their case.

Step 2: Ethics Committee Review

The committee evaluates whether the physician's refusal is medically justified. HB 3162 imposed two critical restrictions on the committee's deliberation:

• No quality-of-life judgments. The committee cannot weigh the patient's quality of life as a factor in deciding whether treatment is appropriate.
• No disability discrimination. A patient's pre-existing disability cannot be considered in the evaluation.

These provisions were added specifically to address advocacy concerns that the prior law allowed subjective judgments about whether a patient's life was "worth" sustaining.

Step 3: The 25-Day Transfer Window

If the committee sides with the physician, the hospital must continue providing life-sustaining treatment for 25 calendar days while the patient or surrogate searches for a facility willing to accept the transfer.

During this 25-day period:

• The attending physician must perform any medical procedures necessary to facilitate the transfer
• Life-sustaining treatment cannot be withdrawn
• Comfort care and pain management must continue

This is a dramatic expansion from the old 10-day window, which families and advocates widely criticized as too short to arrange complex patient transfers — especially for patients on ventilators or requiring specialized care.

Step 4: After the 25-Day Window

If no transfer facility is found within 25 days, the physician may withdraw the disputed treatment. The patient or surrogate can seek a court extension, but the burden shifts to demonstrating that a transfer facility is likely to be found with additional time.

The Imminent Death Exception

HB 3162 also codified an exception: a physician can issue a DNR order if they determine that death is imminent (within minutes to hours), regardless of whether resuscitation is requested. This applies only when resuscitation would be futile, and the physician must not act with intent to hasten death.

What This Means for Your Planning

The dispute resolution process exists as a safety valve — it's not triggered in routine care. But knowing it exists matters for two reasons:

1. Your advance directive is not absolute. A physician can challenge it through the ethics committee process.
2. Having an MPOA agent matters enormously. A strong advocate who can attend the ethics committee meeting, push for transfer options, and escalate to court if needed is your best protection.

The Texas Advance Directive & Living Will Kit covers the dispute resolution process and includes a timeline showing what happens at each stage, so your designated agent knows exactly what to expect if a hospital challenges your documented wishes.

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