Sample — Fictional Data Maximum Privacy

Ruth — Total Refusal

Refuses all blood products including fractions. Accepts only autologous procedures where blood remains in a continuous circuit. Maximum privacy — agent info encrypted.

7 refused 3 accepted
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Durable Power of Attorney

Blood-Related Medical Decisions

I, Ruth A. Thompson, born 1951-11-03, residing at 881 Peachtree St NE, Atlanta, GA 30309, being of sound mind, hereby declare:

1. Appointment of Healthcare Agent

I appoint David L. Thompson (Son) (phone: 555-0500) as my healthcare agent for all decisions relating to blood-based medical treatments.

If my agent is unable to serve, I appoint Grace Thompson-Bell (phone: 555-0520) 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. I accept autologous procedures (cell salvage, hemodilution, heart-lung bypass) provided the blood circuit remains continuous. Please use non-blood volume expanders, EPO, and iron therapy as alternatives.

4. Persons of Interest

Dr. William Harris — Primary Physician (phone: 555-0600)

Executed in Georgia, 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?

The most restrictive blood configuration. All donated blood products and fractions are refused. Only autologous procedures (using the patient's own blood in a continuous circuit) are accepted. This template also defaults to maximum privacy — the healthcare agent's contact information is encrypted and only visible with the passcode.

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. I accept autologous procedures (cell salvage, hemodilution, heart-lung bypass) provided the blood circuit remains continuous. Please use non-blood volume expanders, EPO, and iron therapy as alternatives.

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