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

## Example CarePlan: Care Plan for Unconscious, vegetative state, coma for Smith-Johnson

Page standards status: Informative

status: active

intent: proposal

category: Advance care plan

subject: Betsy Smith-Johnson ; BetsySJ@example.com; gender: female; birthDate: 1950-11-15

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:

- Goals, preferences, and priorities under certain health conditions - Reported; 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
- 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 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.
- Religious or cultural affiliation contact to notify - Reported; Please attempt to notify someone from my religion at the following phone number: If I have included one: Catholic
- Religious or cultural beliefs - Reported; 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.
- Decision to inform doctors and nurses about the role religion, faith, culture, or spirituality play in my life - Reported; 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.