⚠ EMERGENCY MEDICAL DIRECTIVE
DURABLE POWER OF ATTORNEY FOR HEALTH CARE · SIGNED 09/07/2023
NO BLOOD TRANSFUSIONS
This individual has legally refused whole blood, red cells,
white cells, platelets, and plasma under any circumstances.
I, Kenneth Adams, have filled out this document to set forth my treatment instructions and to appoint a health-care agent in case of my incapacity.
I am one of Jehovah's Witnesses, and I direct that NO TRANSFUSIONS of whole blood, red cells, white cells, platelets, or plasma be given me under any circumstances, even if health-care providers believe that such are necessary to preserve my life. (Acts 15:28, 29)
I refuse to predonate and store my blood for later infusion.
The following choice has been initialled (KA):
Option (b) — prolonging life on machines — was not selected.
No additional instructions recorded at the time of signing. Please refer to the signed paper document for the most current directives.
I give no one (including my agent) any authority to disregard or override my instructions set forth herein. Family members, relatives, or friends may disagree with me, but any such disagreement does not diminish the strength or substance of my refusal of blood or other instructions.
Apart from the matters covered above, I appoint the person named herein as my agent to make health-care decisions for me. I give my agent full power and authority to consent to or to refuse treatment (including artificial nutrition and hydration) on my behalf, to consult with my doctors and receive copies of my medical records, and to take legal action to ensure that my wishes are honoured.
If my first appointed agent is unavailable, unable, or unwilling to serve, I appoint an alternate agent herein to serve with the same power and authority.
⚖ This directive was executed on 09 July 2023 and witnessed by two adults, both of sound mind, who confirmed the principal signed freely and without duress, fraud, or undue influence.
The person who signed this document did so in the presence of the witnesses below. He or she appears to be of sound mind and free from duress, fraud, or undue influence. Both witnesses are 18 years of age or older and are not the health-care agent or alternate agent appointed in this document.
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Signed original document is held by the card owner.
Document reference: dpa E 1/16 · Executed 09/07/2023
This digital record is provided for emergency reference only.
It does not replace the original signed legal document.