While the original development and spread of Advance Directives was motivated by concern over physician-driven overtreatment, an innovative approach to medical decisions in Texas was conceived by worries about patient- driven overtreatment at the end of life. After a decade of debate over the dilemma of “futile” or “inappropriate” care, an ad hoc group representing healthcare facilities in Houston innovated an unprecedented “process-based approach” to patient-driven overtreatment. This approach was bolstered by the editor of the Journal of the American Medical Association recommending similar policies be adopted throughout the country. The Houston hospitals adopted the experimental policy that developed into an unprecedented state law passed in 1999. This paper provides anecdotal evidence, from first-hand experience as a patient advocate, of how the process has led to, as politically intended, the involuntary removal of life-sustaining treatment from countless patients in Texas. After 17 years of debate, analysis, and practice, there is ample justification to conclude that the Texas ‘process-based approach’ crafted to resolve disputes over life-sustaining treatment is unethical. Initially, this paper describes the codified process-based approach and surveys the few similar mechanisms that have significant legal differences. Next, this paper establishes how the concept of respect for patient autonomy applies to decisions about life-sustaining treatment towards the end of life. Then the possible exceptions or caveats to the principle and ideal of shared decision-making are examined. This paper pays particular attention to whether various notions of medical futility or concerns of respecting a physician’s conscientious objection are justified reasons for this dispute resolution mechanism. Lastly, after affirming that the disputes over life-sustaining treatments are problematic on both clinical and academic levels, the paper outlines possible policy solutions that have a better likelihood of resolving conflict and upholding indispensable bioethical principles.