PACIO Advance Healthcare Directive Interoperability Implementation Guide
2.0.0-ballot - STU 2 – Ballot

PACIO Advance Healthcare Directive Interoperability Implementation Guide, published by HL7 International / Patient Empowerment. This guide is not an authorized publication; it is the continuous build for version 2.0.0-ballot built by the FHIR (HL7® FHIR® Standard) CI Build. This version is based on the current content of https://github.com/HL7/pacio-adi/ and changes regularly. See the Directory of published versions

## : Care Plan for Terminal illness, lack of meaningful interaction - JSON Representation

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    {
      "resourceType" : "CarePlan",
      "id" : "Example-Smith-Johnson-PreferenceCarePlan3",
      "meta" : {
        "profile" : [
          🔗 "http://hl7.org/fhir/us/pacio-adi/StructureDefinition/ADI-PreferenceCarePlan"
        ]
      },
      "text" : {
        "status" : "generated",
        "div" : "<div xmlns=\"http://www.w3.org/1999/xhtml\"><p><b>status</b>: active</p><p><b>intent</b>: proposal</p><p><b>category</b>: <span title=\"Codes: {http://snomed.info/sct 736366004}\">Advance care plan</span></p><p><b>subject</b>: <a href=\"Patient-Example-Smith-Johnson-Patient1.html\">Betsy Smith-Johnson</a> ; BetsySJ@example.com; gender: female; birthDate: 1950-11-15</p><p><b>addresses</b>: <span>Terminal illness, lack of meaningful interaction</span></p><p><b>goal</b>:</p><ul><li><a href=\"Goal-Example-Smith-Johnson-PersonalGoal1.html\"><span title=\"Codes: {http://loinc.org 81378-2}\">Goals, preferences, and priorities under certain health conditions - Reported</span></a>; <span title=\"Codes: \">If I am so sick or seriously injured that I cannot express my own medical treatment preferences, and if I am not expected to live without additional treatment for my illness, disease, condition or injury, then I want my medical care team to know that these are the things that are most important to me: Avoiding prolonged dependence on machines, Not being a physical burden to my family, Dying at home</span></li><li><a href=\"Observation-Example-Smith-Johnson-CareExperiencePreference1.html\"><span title=\"Codes: {http://loinc.org 75775-7}\">Decision to inform doctors and nurses about the role religion, faith, culture, or spirituality play in my life - Reported</span></a>; <span title=\"Codes: \">Here are some thoughts that I would like for my medical care team and my healthcare agent(s) to know about the role that religion, faith or spirituality play in my life: I am Catholic, please call Father Mark at Saint Catherine's on Main Street.</span></li><li><a href=\"Observation-Example-Smith-Johnson-CareExperiencePreference2.html\"><span title=\"Codes: {http://loinc.org 81360-0}\">My likes and joys - Reported</span></a>; <span title=\"Codes: \">Here are some examples of the things that I would like to have near me, music that I’d like to hear, and other details of my care that would help to keep me happy and relaxed: I love the smell of lavender and the feeling of sunshine on my face.</span></li><li><a href=\"Observation-Example-Smith-Johnson-CareExperiencePreference3.html\"><span title=\"Codes: {http://loinc.org 81362-6}\">My dislikes and fears - Reported</span></a>; <span title=\"Codes: \">Here is a list of things that I would like to avoid if at all possible, people that I don’t wish to see, and concerns I have about particular family members, pets, and so on: I do not like my feet to be cold.</span></li><li><a href=\"Observation-Example-Smith-Johnson-CareExperiencePreference4.html\"><span title=\"Codes: {http://loinc.org 81380-8}\">Goals, preferences, and priorities for care experience - Reported</span></a>; <span title=\"Codes: \">How to care for me: If I become incapacitated and cannot express myself, here is what I would like to tell my healthcare agent, family and friends about how I would like for them to care for me: I want photos of my family where I can see them.</span></li><li><a href=\"Observation-Example-Smith-Johnson-CareExperiencePreference5.html\"><span title=\"Codes: {http://loinc.org 81364-2}\">Religious or cultural beliefs - Reported</span></a>; <span title=\"Codes: \">If I appear to be approaching the end of my life, here are some things that I would like for my caregivers to know about my faith and my religion. Please call Father Mark if my condition warrants the services of a priest.</span></li><li><a href=\"Observation-Example-Smith-Johnson-CareExperiencePreference7.html\"><span title=\"Codes: {http://loinc.org 81366-7}\">Unfinished business - Reported</span></a>; <span title=\"Codes: \">If it appears that I am approaching the end of my life, and I cannot communicate with persons around me, I would want my doctors and nurses, my family, and my friends to know about some unfinished business that I need to address: I want my sister and I to talk again, and miss her. I wish we hadn't disagreed all those years ago and regret the time it has cost us. I'd like to see her face if I were very ill and needed the comfort of family at my side.</span></li><li><a href=\"Observation-Example-Smith-Johnson-PersonalInterventionPreference1.html\"><span title=\"Codes: {http://loinc.org 75776-5}\">Preference on consulting a supportive and palliative care team to help treat physical, emotional, and spiritual discomfort and support family - Reported</span></a>; <span title=\"Codes: \">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.</span></li><li><a href=\"Observation-Example-Smith-Johnson-PersonalInterventionPreference3.html\"><span title=\"Codes: {http://loinc.org 75778-1}\">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</span></a>; <span title=\"Codes: \">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 would like for them to keep trying life-sustaining treatments until my healthcare agent decides it is time to stop and such treatments and let me die gently.</span></li><li><a href=\"Observation-Example-Smith-Johnson-PersonalInterventionPreference5.html\"><span title=\"Codes: {http://loinc.org 75780-7}\">Preferred location to spend final days if possible to choose - Reported</span></a>; <span title=\"Codes: \">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.</span></li></ul></div>"
      },
      "status" : "active",
      "intent" : "proposal",
      "category" : [
        {
          "coding" : [
            {
              "system" : "http://loinc.org",
              "code" : "81378-2",
              "display" : "Goals, preferences, and priorities under certain health conditions Narrative - Reported"
            }
          ]
        }
      ],
      "title" : "Care Plan for Terminal illness, lack of meaningful interaction",
      "subject" : {
        🔗 "reference" : "Patient/Example-Smith-Johnson-Patient1"
      },
      "addresses" : [
        {
          "display" : "Terminal illness, lack of meaningful interaction"
        }
      ],
      "supportingInfo" : [
        {
          🔗 "reference" : "Observation/Example-Smith-Johnson-CareExperiencePreference1"
        },
        {
          🔗 "reference" : "Observation/Example-Smith-Johnson-CareExperiencePreference2"
        },
        {
          🔗 "reference" : "Observation/Example-Smith-Johnson-CareExperiencePreference3"
        },
        {
          🔗 "reference" : "Observation/Example-Smith-Johnson-CareExperiencePreference4"
        },
        {
          🔗 "reference" : "Observation/Example-Smith-Johnson-CareExperiencePreference5"
        },
        {
          🔗 "reference" : "Observation/Example-Smith-Johnson-CareExperiencePreference7"
        }
      ]
    }