Sample — Fictional Data Faith-Based

Maria — Faith-Based Refusal

Refuses all primary blood components. Blood fractions (albumin, immunoglobulins, clotting factors) are a matter of personal conscience. Accepts all autologous procedures.

4 refused 3 personal 3 accepted
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Durable Power of Attorney

Blood-Related Medical Decisions

I, Maria R. Doe, born 1990-05-18, residing at 1847 Desert Bloom Dr, Phoenix, AZ 85004, being of sound mind, hereby declare:

1. Appointment of Healthcare Agent

I appoint Robert A. Doe (Spouse) (phone: 555-0142) as my healthcare agent for all decisions relating to blood-based medical treatments.

If my agent is unable to serve, I appoint Elena M. Reyes (phone: 555-0199) 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 PERSONAL DECISION
Immunoglobulins PERSONAL DECISION
Clotting factors PERSONAL DECISION
Cell salvage ACCEPT
Hemodilution ACCEPT
Heart-lung bypass ACCEPT

3. Special Instructions

I direct that I receive the best possible medical care that does not involve the use of allogeneic blood transfusions. I accept non-blood alternatives including volume expanders (saline, Ringer's lactate, dextran, hetastarch), recombinant erythropoietin (EPO), and surgical techniques that minimize blood loss. For blood fractions (albumin, immunoglobulins, clotting factors), please consult my healthcare agent — these are a matter of personal conscience for me.

4. Persons of Interest

Dr. Sarah Chen — Primary Physician (phone: 555-0200)

Elena M. Reyes — Mother (phone: 555-0199)

Executed in Arizona, 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 is the most common configuration for patients whose faith or conscience leads them to refuse primary blood components. The distinction between primary components and fractions reflects the view that fractions are a personal decision rather than a clear-cut refusal. Autologous procedures (using one's own blood) are generally accepted because no donated blood is involved.

Blood choices breakdown

Primary Blood Components

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

Blood Fractions

Albumin PERSONAL DECISION
Immunoglobulins PERSONAL DECISION
Clotting factors PERSONAL DECISION

Autologous Procedures

Cell salvage ACCEPT
Hemodilution ACCEPT
Heart-lung bypass ACCEPT

Suggested special instructions

I direct that I receive the best possible medical care that does not involve the use of allogeneic blood transfusions. I accept non-blood alternatives including volume expanders (saline, Ringer's lactate, dextran, hetastarch), recombinant erythropoietin (EPO), and surgical techniques that minimize blood loss. For blood fractions (albumin, immunoglobulins, clotting factors), please consult my healthcare agent — these are a matter of personal conscience for me.

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