Official Faith-Based

Faith-Based: Refuse All Blood Products

Refuses all primary components and all fractions. Only autologous procedures (own blood, continuous circuit) are accepted.

7 refused 3 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 REFUSE
Immunoglobulins REFUSE
Clotting factors REFUSE
Cell salvage ACCEPT
Hemodilution ACCEPT
Heart-lung bypass ACCEPT

3. Special Instructions

I refuse all blood products — both primary components and fractions derived from donated blood. I accept autologous procedures (cell salvage, hemodilution, heart-lung bypass) provided my blood remains in a continuous extracorporeal circuit. Please use non-blood volume expanders, EPO, iron therapy, and tranexamic acid as alternatives.

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?

A more restrictive configuration where both primary blood components and all fractions are refused. This reflects the position that fractions, being derived from donated blood, are equivalent to the primary components. Autologous procedures remain acceptable because they involve only the patient's own blood.

Blood choices breakdown

Primary Blood Components

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

Blood Fractions

Albumin REFUSE
Immunoglobulins REFUSE
Clotting factors REFUSE

Autologous Procedures

Cell salvage ACCEPT
Hemodilution ACCEPT
Heart-lung bypass ACCEPT

Suggested special instructions

I refuse all blood products — both primary components and fractions derived from donated blood. I accept autologous procedures (cell salvage, hemodilution, heart-lung bypass) provided my blood remains in a continuous extracorporeal circuit. Please use non-blood volume expanders, EPO, iron therapy, and tranexamic acid as alternatives.

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