This form was developed to clearly document agreements resulting from the advance care planning (ACP) process. It is NOT a checklist. It can only be completed by a healthcare provider after a professional and nuanced conversation. For advice on conducting these conversations, please refer to the guideline for proactive care planning in the palliative phase and Palliaweb, see https://palliaweb.nl/zorgpraktijk/proactieve-zorgplanning. Enter 'unknown' if a topic is not discussed or if the patient does not (yet) have an opinion.When transferring to a long-term care setting, consider adding conversation records about advance care planning (ACP) to the transfer documents.

A living will is a verbal or written description of the patient’s wishes with regard to future medical action or end of their life. A living will is mainly used for situations in which the patient is no longer able to speak about these decisions with their healthcare provider.

A person not being a healthcare professional who is involved in the patient’s care, such as family members, caregivers, mental caretakers, guardians and legal representatives. Based on nl-core-ContactPerson and HCIM ContactPerson.

Any interaction, regardless of the situation, between a patient and the healthcare provider, in which the healthcare provider has primary responsibility for diagnosing, evaluating and treating the patient’s condition and informing the patient. These can be visits, appointments or non face-to-face interactions. Based on nl-core-Encounter and HCIM Encounter.

A person who is authorized to perform actions in the field of individual healthcare. Based on nl-core-HealthProfessionalPractitioner and HCIM HealthProfessional.

The specialty of a person who is authorized to perform actions in the field of individual healthcare. Based on nl-core-HealthProfessionalPractitionerRole and HCIM HealthProfessional.

Communication events that have taken place in context of Advance Care Planning. Based on Communication resource.

The primary, agreed-upon goal of a patient's medical treatment policy. Based on Goal resource.

Any internally implanted and external devices and/or aids used by the patient (in the past) to reduce the effects of functional limitations in organ systems or to facilitate the treatment of a disease. In the context of ACP, this profile is used to declare the use of an implantable cardioverter defibrillator (ICD). Based on nl-core-MedicalDevice and HCIM MedicalDevice.

The medical device (internally or externally). In the context of ACP, this profile is used to capture information on a patient's implantable cardioverter defibrillator (ICD). Based on nl-core-MedicalDeviceProduct and HCIM MedicalDevice.

Observation capturing whether the patient's organ donation choice is recorded in the donor register as reported by the patient. It is intended to track the administrative status of the decision rather than the clinical or legal specifics of the donation choice itself. This information is exchanged so the next caregiver knows whether the topic requires attention in future ACP conversations. Based on Observation resource.

A person who receives medical, psychological, paramedical, or nursing care. Based on nl-core-Patient and HCIM Patient.

The patient's position regarding euthanasia. Based on Observation resource.

The preferred place of death. This is the place where the patient prefers to die, if possible. The preferred place of death can be a home, a hospital, a nursing home, hospice or another location. Based on Observation resource.

Advance Care Planning procedure. Based on nl-core-Procedure-event profile and HCIM Procedure.

Observation capturing the patient's sense of purpose and other important information in the context of Advance Care Planning. While the primary concept is 'sense of purpose' (SNOMED 247751003), this profile serves as a container in the ACP dataset for capturing additional relevant information that may influence care decisions. Based on Observation resource.

The patient's wishes and expectations concerning their treatment, as an answer to the questions: 'What, according to the patient, should healthcare providers know to provide good care? Does this patient have specific wishes regarding their care (including cultural, religious, social, and spiritual aspects)?' Based on Observation resource.

This profile specifies verified treatment directives. A treatment directive contains a joint decision between a health professional (for example a general practitioner) and a patient or his representative(s) about the desirability of performing a certain treatment, such as resuscitation, before this treatment becomes (acute) necessary.

An extension to indicate the patient's legal capability regarding medical treatment decisions, and to provide a comment on this capability.

ValueSet for Position Regarding Euthanasia, representing the the patient's position regarding euthanasia and information on the presence of a euthanasia statement.

ICD product code for MedicalDevice ProductType.

ValueSet for Medical Policy Goal, representing the primary agreed-upon goal of a patient's medical treatment policy.

ValueSet for Preferred Place of Death, representing the place where the patient prefers to die, if possible.

ValueSet representing 'Yes, No, Unknown' answers.

ValueSet that extends the BehandelingToegestaan code list by adding an 'Unknown' option. It provides the codes representing the possible answers: 'Yes', 'No', 'Yes with restrictions', and 'Unknown'.