Official Evidence-Based

Patient Blood Management: Selective

Evidence-based approach: refuses donor blood, accepts all fractions and autologous procedures. Maximum surgical flexibility within a bloodless framework.

4 refused 6 accepted
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Durable Power of Attorney

Blood-Related Medical Decisions

I, [Your Name], born [Date of Birth], residing at [Your Address], being of sound mind, hereby declare:

1. Appointment of Healthcare Agent

I appoint [Agent Name] ([Relationship]) (phone: [Phone]) as my healthcare agent for all decisions relating to blood-based medical treatments.

If my agent is unable to serve, I appoint [Alternate Agent Name] (phone: [Phone]) as successor.

2. Blood-Related Directives

I hereby direct that the following blood products and procedures be handled as specified:

Whole blood transfusions REFUSE
Packed red blood cells REFUSE
Plasma REFUSE
Platelets REFUSE
Albumin ACCEPT
Immunoglobulins ACCEPT
Clotting factors ACCEPT
Cell salvage ACCEPT
Hemodilution ACCEPT
Heart-lung bypass ACCEPT

3. Special Instructions

Based on Patient Blood Management evidence, I decline allogeneic (donor) whole blood and primary components. I accept all blood fractions and all autologous procedures. Please employ PBM best practices: preoperative optimization (iron, EPO), intraoperative cell salvage, controlled hypotension, and antifibrinolytics as clinically indicated.

Executed in [State], [Country].

Signature / date
Witness 1
Witness 2 / Notary
Generated by bloodless.org for informational purposes only. Not legal advice. Verify execution requirements in your jurisdiction before signing.

Why this configuration?

This configuration is driven by clinical evidence rather than faith. Patient Blood Management (PBM) research — endorsed by the WHO — shows that avoiding unnecessary transfusions often improves outcomes. By accepting fractions and autologous procedures while refusing donor whole blood, patients give their surgical team maximum flexibility within a bloodless care framework.

Blood choices breakdown

Primary Blood Components

Whole blood transfusions REFUSE
Packed red blood cells REFUSE
Plasma REFUSE
Platelets REFUSE

Blood Fractions

Albumin ACCEPT
Immunoglobulins ACCEPT
Clotting factors ACCEPT

Autologous Procedures

Cell salvage ACCEPT
Hemodilution ACCEPT
Heart-lung bypass ACCEPT

Suggested special instructions

Based on Patient Blood Management evidence, I decline allogeneic (donor) whole blood and primary components. I accept all blood fractions and all autologous procedures. Please employ PBM best practices: preoperative optimization (iron, EPO), intraoperative cell salvage, controlled hypotension, and antifibrinolytics as clinically indicated.

Copies blood choices and instructions into the editor. All personal fields start blank.