PACIO Advance Directive Interoperability Implementation Guide, published by HL7 Patient Empowerment Working Group. This is not an authorized publication; it is the continuous build for version 0.1.0). This version is based on the current content of https://github.com/HL7/pacio-adi/ and changes regularly. See the Directory of published versions
Example CarePlan: Example-McBee-PreferenceCarePlan1
Generated Narrative
status: active
intent: proposal
category: Advance care plan
subject: Generated Summary: language: en-US; id: 047e62ccf09d4b39a8add708a69b7f38; active: true; Betsy Smith-Johnson ; BetsySJ@example.com; gender: female; birthDate: 1950-11-15; unknown
addresses:
- Unconscious, in a coma, or in a persistent vegetative state with little or no chance of recovery
- Persistent vegetative state (SNOMED CT 24473007)
- Irreversible coma (SNOMED CT 73453007)
goal:
- Generated Summary: lifecycleStatus: proposed; Preference on consulting a supportive and palliative care team to help treat physical, emotional, and spiritual discomfort and support family [Reported]; If I am having significant pain or suffering, I would like my doctors to consult a Supportive and Palliative Care Team to help treat my physical, emotional and spiritual discomfort, and to support my family.
- Generated Summary: lifecycleStatus: proposed; Information to tell doctors if my health deteriorates due to a terminal illness and I am unable to interact meaningfully with family, friends, or surroundings [Reported]; If my health ever deteriorates due to a terminal illness, and my doctors believe I will not be able to interact meaningfully with my family, friends, or surroundings, I prefer that they stop all life-sustaining treatments and let me die as gently as possible. I realize that I will not receive life-sustaining treatments including but not limited to breathing machines, blood transfusions, dialysis, heart machines, and IV drugs to keep my heart working. I also realize that medical personnel will not attempt cardiopulmonary resuscitation (CPR), and they will allow me to die naturally.
- Generated Summary: lifecycleStatus: proposed; Thoughts on artificial nutrition and hydration [Reported]; If my response above indicates that I do not want life-sustaining treatments, I expressly authorize my attending physician to withhold or withdraw artificial nutrition and hydration and instruct my healthcare agent (or, if I have not designated a healthcare agent, my default surrogate), my family and the doctors and nurses who are taking care of me to respect this request.
- Generated Summary: lifecycleStatus: proposed; Information to tell doctors if I have a severe, irreversible brain injury or illness and can't dress, feed, or bathe myself, or communicate my medical wishes, but can be kept alive [Reported]; If I have a severe, irreversible brain injury or illness and can’t dress, feed, or bathe myself, or communicate my medical wishes, but doctors can keep me alive in this condition for a long period of time, I would like for them to keep trying life-sustaining treatments for 2 months.
- Generated Summary: lifecycleStatus: proposed; Thoughts on cardiopulmonary resuscitation (CPR) [Reported]; Although I understand that, depending on the situation and circumstances, medical personnel may not be able to follow my wishes, here are my general thoughts on cardiopulmonary resuscitation (CPR): I do not want CPR attempted.
- Generated Summary: lifecycleStatus: proposed; Thoughts on cardiopulmonary resuscitation (CPR) [Reported]; Although I understand that, depending on the situation and circumstances, medical personnel may not be able to follow my wishes, here are my general thoughts on cardiopulmonary resuscitation (CPR): I want my healthcare agent to make the decision, but if my chances are slim to none that I'll leave the hospital, even if they resuscitate me, then I absolutely do not want CPR.
- Generated Summary: lifecycleStatus: proposed; Preferred location to spend final days if possible to choose [Reported]; If it were possible to choose, here is where I would like to spend my final days: At home.I would like to receive hospice care at home if possible.
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Propose a change