Advance Medical Directive/Release (1999)

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ADVANCE MEDICAL DIRECTIVE/RELEASE

I, make this advance directive as a formal statement of my wishes. These instructions reflect my resolute and informed decision.

I direct that no blood transfusions (whole blood, red cells, cells, platelets, or blood plasma) be given to me under any circumstances, even if physicians deem such necessary to preserve my life or health. I will accept nonblood volume expanders (such as dextran, saline or Ringer's solution, or hematast) and other nonblood management.

This legal directive is an exercise of my right to accept or to refuse medical treatment in accord with my deeply held values and convictions. I am one of Jehovah's Witnesses, and I make this directive out of obedience to commands in the Bible, such as "Keep abstaining . . . from blood." (Acts 15:28, 29) This is, and has been, my unwavering religious stand for years. I am years old.

I also know that there are various dangers associated with blood transfusions. So I have decided to avoid such dangers and, instead, to

accept whatever risks may seem to be involved in my choice of alternative nonhlood management.

I release physicians, anesthesiologists, and hospitals and their personnel from liability for any damages that might be caused by my refusal of blood, despite their otherwise competent care.

I authorize the person(s) named on the reverse to see that my instructions set forth in this directive are upheld and to answer any questions about my absolute refusal of blood.

Signature

Address

Date

Telephone

Witness

Witness

md 3/78

Founded in U.S.A.