Sample — Fictional Data Evidence-Based

Sarah — Evidence-Based PBM

Refuses donor blood but accepts all fractions and autologous procedures. Based on Patient Blood Management evidence for an elective orthopedic surgery.

4 refused 6 accepted
bloodless.org

Durable Power of Attorney

Blood-Related Medical Decisions

I, Sarah J. Kim, born 1998-01-22, residing at 2204 Congress Ave, Austin, TX 78701, being of sound mind, hereby declare:

1. Appointment of Healthcare Agent

I appoint Michael Torres (Partner) (phone: 555-0310) as my healthcare agent for all decisions relating to blood-based medical treatments.

If my agent is unable to serve, I appoint Dr. Yuna Kim (phone: 555-0320) 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

I am undergoing planned orthopedic surgery and prefer bloodless surgical techniques based on Patient Blood Management evidence. I accept all autologous procedures and blood fractions. I refuse allogeneic (donor) whole blood and primary components. Please use cell salvage, tranexamic acid, and EPO as appropriate. My surgeon, Dr. Park, is aware of these decisions.

4. Persons of Interest

Dr. James Park — Orthopedic Surgeon (phone: 555-0400)

Dr. Yuna Kim — Mother (physician) (phone: 555-0320)

Executed in Texas, United States.

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 reflects a medical evidence-based approach rather than a faith-based one. The patient refuses donor (allogeneic) blood products based on clinical evidence that Patient Blood Management often produces equal or better outcomes. All fractions and autologous procedures are accepted, giving surgeons maximum flexibility within the bloodless 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

I am undergoing planned orthopedic surgery and prefer bloodless surgical techniques based on Patient Blood Management evidence. I accept all autologous procedures and blood fractions. I refuse allogeneic (donor) whole blood and primary components. Please use cell salvage, tranexamic acid, and EPO as appropriate. My surgeon, Dr. Park, is aware of these decisions.

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