Faith-Based: Refuse Primary, Conscience on Fractions

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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 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, recombinant erythropoietin (EPO), and surgical techniques that minimize blood loss. For blood fractions, please consult my healthcare agent — these are a matter of personal conscience.

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 is the most widely used configuration among patients with faith-based convictions regarding blood. The four primary components (whole blood, red cells, plasma, platelets) are clearly refused. Blood fractions — which are smaller derivatives of primary components — are treated as a personal conscience decision, recognizing that individuals may draw the line differently. All autologous procedures are accepted because they use the patient's own blood.

Blood choices breakdown

Primary Blood Components