Official Surgery Prep

Cardiac Surgery: Bloodless Protocol

Specialized for cardiac procedures. Accepts heart-lung bypass, cell salvage, and fractions. Includes cardiac-specific preparation instructions.

4 refused 6 accepted
bloodless.org

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 ACCEPT
Immunoglobulins ACCEPT
Clotting factors ACCEPT
Cell salvage ACCEPT
Hemodilution ACCEPT
Heart-lung bypass ACCEPT

3. Special Instructions

I am undergoing cardiac surgery and request a bloodless surgical protocol. I accept heart-lung bypass (cardiopulmonary bypass), cell salvage, and acute normovolemic hemodilution. I accept all blood fractions. I refuse allogeneic whole blood and primary components. Please use miniaturized bypass circuits to reduce hemodilution, retrograde autologous priming (RAP), and modified ultrafiltration (MUF). Coordinate EPO and iron therapy preoperatively.

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?

Cardiac surgery presents unique challenges for bloodless patients because cardiopulmonary bypass inherently involves significant blood management. This template explicitly accepts heart-lung bypass and includes cardiac-specific techniques (miniaturized circuits, RAP, MUF) that reduce the need for transfusion. Many cardiac centers now offer established bloodless programs.

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 cardiac surgery and request a bloodless surgical protocol. I accept heart-lung bypass (cardiopulmonary bypass), cell salvage, and acute normovolemic hemodilution. I accept all blood fractions. I refuse allogeneic whole blood and primary components. Please use miniaturized bypass circuits to reduce hemodilution, retrograde autologous priming (RAP), and modified ultrafiltration (MUF). Coordinate EPO and iron therapy preoperatively.

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