Sample — Fictional Data Faith-Based

Maria — Faith-Based (Own Blood Only)

Refuses donor blood for primary components, accepts autologous (own) blood. Accepts all fractions and all autologous procedures.

10 accepted
bloodless.org

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 ACCEPT
Packed red blood cells ACCEPT
Plasma ACCEPT
Platelets ACCEPT
Albumin ACCEPT
Immunoglobulins ACCEPT
Clotting factors ACCEPT
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 my own blood (autologous) for primary components but refuse donor blood. I accept all fractions (albumin, immunoglobulins, clotting factors) and all autologous procedures. I accept non-blood alternatives including volume expanders (saline, Ringer's lactate, dextran, hetastarch), recombinant erythropoietin (EPO), and surgical techniques that minimize blood loss.

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 a common configuration for patients whose faith or conscience leads them to refuse donor blood but accept their own blood (autologous). All fractions and autologous procedures are accepted, giving medical teams maximum flexibility within the bloodless framework.

Blood choices breakdown

Primary Blood Components

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

Blood Fractions

Albumin ACCEPT
Immunoglobulins ACCEPT
Clotting factors ACCEPT

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 my own blood (autologous) for primary components but refuse donor blood. I accept all fractions (albumin, immunoglobulins, clotting factors) and all autologous procedures. I accept non-blood alternatives including volume expanders (saline, Ringer's lactate, dextran, hetastarch), recombinant erythropoietin (EPO), and surgical techniques that minimize blood loss.

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