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 - XML Representation

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    <CarePlan xmlns="http://hl7.org/fhir">
      <id value="Example-Smith-Johnson-PreferenceCarePlan3"/>
      <meta>
        <profile
                 value="http://hl7.org/fhir/us/pacio-adi/StructureDefinition/ADI-PreferenceCarePlan"/>
      </meta>
      <text>
        <status value="generated"/>
        <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>
      </text>
      <status value="active"/>
      <intent value="proposal"/>
      <category>
        <coding>
          <system value="http://loinc.org"/>
          <code value="81378-2"/>
          <display
                   value="Goals, preferences, and priorities under certain health conditions Narrative - Reported"/>
        </coding>
      </category>
      <title
             value="Care Plan for Terminal illness, lack of meaningful interaction"/>
      <subject>🔗
        <reference value="Patient/Example-Smith-Johnson-Patient1"/>
      </subject>
      <addresses>
        <display value="Terminal illness, lack of meaningful interaction"/>
      </addresses>
      <supportingInfo>🔗
        <reference
                   value="Observation/Example-Smith-Johnson-CareExperiencePreference1"/>
      </supportingInfo>
      <supportingInfo>🔗
        <reference
                   value="Observation/Example-Smith-Johnson-CareExperiencePreference2"/>
      </supportingInfo>
      <supportingInfo>🔗
        <reference
                   value="Observation/Example-Smith-Johnson-CareExperiencePreference3"/>
      </supportingInfo>
      <supportingInfo>🔗
        <reference
                   value="Observation/Example-Smith-Johnson-CareExperiencePreference4"/>
      </supportingInfo>
      <supportingInfo>🔗
        <reference
                   value="Observation/Example-Smith-Johnson-CareExperiencePreference5"/>
      </supportingInfo>
      <supportingInfo>🔗
        <reference
                   value="Observation/Example-Smith-Johnson-CareExperiencePreference7"/>
      </supportingInfo>
    </CarePlan>