PACIO Advance Directive Interoperability Implementation Guide
2.1.0 - STU 2 United States of America flag

PACIO Advance Directive Interoperability Implementation Guide, published by HL7 International / Patient Empowerment. This guide is not an authorized publication; it is the continuous build for version 2.1.0 built by the FHIR (HL7® FHIR® Standard) CI Build. This version is based on the current content of https://github.com/HL7/fhir-pacio-adi/ and changes regularly. See the Directory of published versions

Example Bundle: Example-Smith-Johnson-Bundle1

Document Details

Generated Narrative: Bundle Personal Advance Care Plan

Document Subject

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Document Content

Appointment of a Primary Healthcare Agent and Alternate Healthcare Agents

IF THIS PART OF THE uADD™ IS LEFT BLANK, I DO NOT WANT TO DESIGNATE A HEALTHCARE AGENT AT THIS TIME, AND I DO NOT WANT A DEFAULT HEALTHCARE AGENT DESIGNATED FOR ME UNDER APPLICABLE LAW. I TRUST THE DOCTORS AND NURSES TREATING ME TO MAKE MEDICAL TREATMENT DECISIONS REGARDING MY TREATMENT AND CARE.

I am appointing the person or persons below as my healthcare agent and, if applicable, as my alternate healthcare agent(s), and I am granting to each of them the legal authority to make medical treatment decisions on my behalf and to consult with my physician and others. The power to make medical treatment decisions that I am granting to my healthcare agent(s) is expressly subject to, and limited by, the choices that I have expressed elsewhere in my uADD. If my medical treatment choices are not clear, I am authorizing and directing my healthcare agent to make decisions in my best interests and based on what is known of my wishes.

Primary Healthcare Agent

The person I choose as my Primary Healthcare Agent is:

Charles Johnson

(Son)

CharlesSJ@example.com

[SELECTED to act as a healthcare agent on 3/29/2021, at 2:25 PM CDT]

[ACCEPTED to act as a healthcare agent on 4/1/2021, at 3:39 PM CDT]

First Alternate Healthcare Agent

If this healthcare agent is unable or unwilling to make medical treatment decisions for me, or if my spouse is designated as my primary healthcare agent and our marriage is annulled, or we are divorced or legally separated, then my next choice for a healthcare agent is:

Debra Johnson

(Daughter)

DebraSJ@example.com

[SELECTED to act as a healthcare agent on 3/29/2021, at 2:25 PM CDT]

[As of 4/1/2021, at 3:40 PM CDT, a response is still PENDING]

My Healthcare Agent’s General Authority

Subject to my medical treatment choices expressed elsewhere in this uADD™ and applicable law that requires otherwise, I grant to my healthcare agent the power to make all choices and medical treatment decisions for me.

If I cannot express my own wishes for medical treatment,

I would like the doctors treating me, as well as my healthcare agent if I have chosen one, to make decisions based as much as possible and appropriate on my instructions below.

If at some point in the future I am declared incompetent,

I DO NOT want to be allowed to override these preferences. I want my doctors to follow the preferences I express in this document.

Unless I have stated otherwise somewhere else in this uADD™, I understand that my healthcare agent may reconsider my medical treatment choices expressed above in light of my other instructions contained elsewhere in this uADD™ or new medical information.

Primary Healthcare Agent Consent

status: active

scope: Powers granted to healthcare agent [Reported]

category: Advance Directive

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

dateTime: 2020-08-03

Policies

-AuthorityUri
*https://www.michigan.gov/http://www.legislature.mi.gov/(S(tpnclc1ofteerx2x2dppcmdz))/mileg.aspx?page=GetObject&objectname=mcl-386-1998-V-5

provision

type: permit

actor

role: Primary healthcare agent [Reported]

reference: natural son; Charles Johnson ; CharlesSJ@example.com

actor

role: First alternate healthcare agent [Reported]

reference: First alternate healthcare agent [Reported], natural daughter; Debra Johnson ; DebraSJ@example.com

action: Advance directive - request for intubation, Advance directive - request for tube feeding, Advance directive - request for life support, Advance directive - request for IV fluid and support, Advance directive - request for antibiotics, Advance directive - request for resuscitation that differs from cardiopulmonary resuscitation

purpose: power of attorney

Patient Goals, Preferences, and Priorities for Care Experience

MyDirectives® offers people a list of optional questions that can be answered by typing text in a text box or by uploading a video or audio file for each question. Only those questions answered by Betsy Smith-Johnson appear here. For a complete list of questions in My Thoughts, please visit www.MyDirectives.com.

In case I’m being cared for by a person(s) who doesn't know me very well, I’d like my following thoughts to be known.

My likes / joys:

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.

My dislikes / fears:

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.

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.

My religion:

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.

Please attempt to notify someone from my religion at the following phone number:

If I have included one

Catholic

My unfinished business:

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.

Laughter:

These are some of my fondest memories from life that have always brought a smile to my face or made me laugh:

My dogs make me laugh when they play together, and my grandchildren make me laugh when they put on plays for me. They bring me great joy.

Patient Goals, preferences, and priorities under certain conditions

Care Plan 1

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:

Care Plan 2

status: active

intent: proposal

category: Advance care plan

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

addresses: Permanent, severe brain damage and I am unable to recognize my family and friends

goal:

Care Plan 3

status: active

intent: proposal

category: Advance care plan

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

addresses: Terminal illness, lack of meaningful interaction

goal:

Goals, Preferences and Priorities Upon Death

Consent to Donate

I consent to donate all organs and tissues.

Autopsy

I want an autopsy

only if there are questions about my death.

Here are my thoughts on funeral or burial plans:

If I were to pass away:

Please call Jim Houston, my lawyer, for arrangements I have already made.

Additional Documentation

PMOLST Order Observation

Order Exists: available here

Witnesses and Notary

I am emotionally and mentally competent to make this uADD. I understand the purpose and effect of this uADD, I agree with everything that is written in this uADD, and I have made this uADD knowingly, willingly and after careful deliberation.

Signature:Betsy Smith-Johnson
Date:3/29/2021

Statement of Witnesses

I declare that the person who signed this uADD, or who asked another to sign this uADD on his/her behalf, is the individual identified in the document, and he/she did so in my presence or otherwise provided satisfactory proof to me of his/her identity. I believe him/her to be of sound mind and at least 18 years of age. I personally witnessed him/her sign this document or ask the person indicated to do so, or I received proof of his/her identity that I believe is adequate, and I believe that he/she did so voluntarily. By signing this document as a witness, I certify that I am:

  • At least 18 years of age.
  • Not related to the person signing this document by blood, marriage or adoption.
  • Not a healthcare agent appointed by the person signing this document.
  • Not directly financially responsible for that person’s healthcare.
  • Not a healthcare provider directly serving the person at this time.
  • Not an employee (other than a social worker or chaplain), officer, director, or partner of a healthcare provider (or any parent organization of such healthcare provider) directly serving the person at this time.
  • Not aware that I am entitled to or have a claim against the person’s estate.

Witness Number:
Signature:
Date:

Additional Resources Included in Document

Entry 1 - fullUrl = http://www.example.org/fhir/Composition/Example-Smith-Johnson-PACPComposition1

Resource Composition:

Generated Narrative: Composition Example-Smith-Johnson-PACPComposition1

Language: en-US

Profile: ADI PtAuthored Composition

Composition Version Number: 9f94d9de-a514-4e10-9c23-dc8c87f0c6fc

Jurisdiction: Michigan (United States)

Data Enterer: Smith-Johnson, Betsy Female, DoB: 1950-11-15 ( http://hl7.org/fhir/sid/us-medicare#United States Medicare Number#10A3D58WH1600)

Effective Date: 2021-03-29 14:25:34-0500 --> (ongoing)

identifier: urn:oid:2.16.840.1.113883.4.823.1.7124/0-87f37989294a408897aacd1fc5d8fd16

status: Final

type: Patient Personal advance care plan

category: Advance directives

date: 2021-03-29 14:25:34-0500

author: Smith-Johnson, Betsy Female, DoB: 1950-11-15 ( http://hl7.org/fhir/sid/us-medicare#United States Medicare Number#10A3D58WH1600)

title: Personal Advance Care Plan

custodian: Organization MyDirectives.com

Entry 2 - fullUrl = http://www.example.org/fhir/Patient/Example-Smith-Johnson-Patient1

Resource Patient:

Generated Narrative: Patient Example-Smith-Johnson-Patient1

Last updated: 2021-03-29 14:25:34-0500; Language: en-US

Profile: US Core Patient Profile

Smith-Johnson, Betsy Female, DoB: 1950-11-15 ( http://hl7.org/fhir/sid/us-medicare#United States Medicare Number#10A3D58WH1600)

Active:trueMarital Status:unknown
Other Id:Medical Record Number/1032702 (use: usual, )
Contact Detail
Language:English (preferred)
son:
  • Charles Johnson
  • 111 Maple Ct, Grand Rapids, MI 49503
  • ph: (210) 222-3333
daughter:
  • Debra Johnson
  • 333 W. Camden St., Baltimore, MD 21201
  • ph: (410) 444-5555
US Core Race Extension:
  • ombCategory: CDC Race and Ethnicity 2106-3: White
  • text: White

Entry 3 - fullUrl = http://www.example.org/fhir/RelatedPerson/Example-Smith-Johnson-Notary1

Resource RelatedPerson:

Notary

Charles Xavier

Entry 4 - fullUrl = http://www.example.org/fhir/RelatedPerson/Example-Smith-Johnson-HealthcareAgent1

Resource RelatedPerson:

Primary Healthcare Agent

The person I choose as my Primary Healthcare Agent is:

Charles Johnson

(Son)

CharlesSJ@example.com

[SELECTED to act as a healthcare agent on 3/29/2021, at 2:25 PM CDT]

[ACCEPTED to act as a healthcare agent on 4/1/2021, at 3:39 PM CDT]

Entry 5 - fullUrl = http://www.example.org/fhir/RelatedPerson/Example-Smith-Johnson-HealthcareAgent2

Resource RelatedPerson:

First Alternate Healthcare Agent

If this healthcare agent is unable or unwilling to make medical treatment decisions for me, or if my spouse is designated as my primary healthcare agent and our marriage is annulled, or we are divorced or legally separated, then my next choice for a healthcare agent is:

Debra Johnson

(Daughter)

DebraSJ@example.com

[SELECTED to act as a healthcare agent on 3/29/2021, at 2:25 PM CDT]

[As of 4/1/2021, at 3:40 PM CDT, a response is still PENDING]

Entry 6 - fullUrl = http://www.example.org/fhir/Consent/Example-Smith-Johnson-HealthcareAgentConsent

Resource Consent:

status: active

scope: Powers granted to healthcare agent [Reported]

category: Advance Directive

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

dateTime: 2020-08-03

Policies

-AuthorityUri
*https://www.michigan.gov/http://www.legislature.mi.gov/(S(tpnclc1ofteerx2x2dppcmdz))/mileg.aspx?page=GetObject&objectname=mcl-386-1998-V-5

provision

type: permit

actor

role: Primary healthcare agent [Reported]

reference: natural son; Charles Johnson ; CharlesSJ@example.com

actor

role: First alternate healthcare agent [Reported]

reference: First alternate healthcare agent [Reported], natural daughter; Debra Johnson ; DebraSJ@example.com

action: Advance directive - request for intubation, Advance directive - request for tube feeding, Advance directive - request for life support, Advance directive - request for IV fluid and support, Advance directive - request for antibiotics, Advance directive - request for resuscitation that differs from cardiopulmonary resuscitation

purpose: power of attorney

Entry 7 - fullUrl = http://www.example.org/fhir/CarePlan/Example-Smith-Johnson-PreferenceCarePlan1

Resource CarePlan:

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:

Entry 8 - fullUrl = http://www.example.org/fhir/CarePlan/Example-Smith-Johnson-PreferenceCarePlan2

Resource CarePlan:

status: active

intent: proposal

category: Advance care plan

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

addresses: Permanent, severe brain damage and I am unable to recognize my family and friends

goal:

Entry 9 - fullUrl = http://www.example.org/fhir/CarePlan/Example-Smith-Johnson-PreferenceCarePlan3

Resource CarePlan:

status: active

intent: proposal

category: Advance care plan

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

addresses: Terminal illness, lack of meaningful interaction

goal:

Entry 10 - fullUrl = http://www.example.org/fhir/Observation/Example-Smith-Johnson-CareExperiencePreference1

Resource Observation:

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.

Entry 11 - fullUrl = http://www.example.org/fhir/Observation/Example-Smith-Johnson-CareExperiencePreference2

Resource Observation:

My likes / joys:

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.

Entry 12 - fullUrl = http://www.example.org/fhir/Observation/Example-Smith-Johnson-CareExperiencePreference3

Resource Observation:

My dislikes / fears:

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.

Entry 13 - fullUrl = http://www.example.org/fhir/Observation/Example-Smith-Johnson-CareExperiencePreference4

Resource Observation:

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.

Entry 14 - fullUrl = http://www.example.org/fhir/Observation/Example-Smith-Johnson-CareExperiencePreference5

Resource Observation:

My religion:

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.

Entry 15 - fullUrl = http://www.example.org/fhir/Observation/Example-Smith-Johnson-CareExperiencePreference6

Resource Observation:

Please attempt to notify someone from my religion at the following phone number:

If I have included one

Catholic

Entry 16 - fullUrl = http://www.example.org/fhir/Observation/Example-Smith-Johnson-CareExperiencePreference7

Resource Observation:

My unfinished business:

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.

Entry 17 - fullUrl = http://www.example.org/fhir/Observation/Example-Smith-Johnson-CareExperiencePreference8

Resource Observation:

Laughter:

These are some of my fondest memories from life that have always brought a smile to my face or made me laugh:

My dogs make me laugh when they play together, and my grandchildren make me laugh when they put on plays for me. They bring me great joy.

Entry 18 - fullUrl = http://www.example.org/fhir/Observation/Example-Smith-Johnson-PersonalInterventionPreference1

Resource Observation:

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.

Entry 19 - fullUrl = http://www.example.org/fhir/Observation/Example-Smith-Johnson-PersonalInterventionPreference3

Resource Observation:

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.

Entry 20 - fullUrl = http://www.example.org/fhir/Observation/Example-Smith-Johnson-PersonalInterventionPreference5

Resource Observation:

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.

Entry 21 - fullUrl = http://www.example.org/fhir/Observation/Example-Smith-Johnson-PersonalInterventionPreference6

Resource Observation:

Here are my thoughts on funeral or burial plans:

If I were to pass away:

Please call Jim Houston, my lawyer, for arrangements I have already made.

Entry 22 - fullUrl = http://www.example.org/fhir/Goal/Example-Smith-Johnson-PersonalGoal1

Resource Goal:

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

Entry 23 - fullUrl = http://www.example.org/fhir/Observation/Example-Smith-Johnson-OrganDonationObservation1

Resource Observation:

Consent to Donate

I consent to donate all organs and tissues.

Entry 24 - fullUrl = http://www.example.org/fhir/Observation/Example-Smith-Johnson-AutopsyObservation1

Resource Observation:

Autopsy

I want an autopsy

only if there are questions about my death.

Entry 25 - fullUrl = http://www.example.org/fhir/Observation/Example-Smith-Johnson-DocumentationObservation1

Resource Observation:

PMOLST Order Observation

Order Exists: available here

Entry 26 - fullUrl = http://www.example.org/fhir/Organization/Example-Smith-Johnson-OrganizationCustodian1

Resource Organization:

Generated Narrative: Organization Example-Smith-Johnson-OrganizationCustodian1

identifier: United States National Provider Identifier/1234567893

active: true

name: MyDirectives.com

Contacts

-TelecomAddress
*+1(202)776-7700740 E. Campbell Rd. Suite 825 Richardson TX 75081 US