{"resourceType":"Composition","status":"preliminary","subject":{"display":"","reference":""},"date":"2024-05-19","author":[{"display":"","reference":""}],"title":"Continuity of Care Document","section":[{"reference":"Patient/Example-McBee-Patient1"},{"reference":"Patient/Example-McBee-Patient1"},{"reference":"CarePlan/Example-McBee-PreferenceCarePlan1"},{"reference":"CarePlan/Example-McBee-PreferenceCarePlan1"},{"reference":"Consent/Example-McBee-HealthcareAgentConsent"},{"reference":"Consent/Example-McBee-HealthcareAgentConsent"},{"reference":"List/Example-McBee-PersonalPrioritiesOrganizer1"},{"reference":"List/Example-McBee-PersonalPrioritiesOrganizer1"},{"reference":"Observation/Example-McBee-PersonalInterventionPreference8"},{"reference":"Observation/Example-McBee-PersonalInterventionPreference7"},{"reference":"Observation/Example-McBee-PersonalInterventionPreference6"},{"reference":"Observation/Example-McBee-PersonalInterventionPreference5"},{"reference":"Observation/Example-McBee-PersonalInterventionPreference4"},{"reference":"Observation/Example-McBee-PersonalInterventionPreference3"},{"reference":"Observation/Example-McBee-PersonalInterventionPreference2"},{"reference":"Observation/Example-McBee-PersonalInterventionPreference1"},{"reference":"Observation/Example-McBee-OrganDonationObservation1"},{"reference":"Observation/Example-McBee-CareExperiencePreference4"},{"reference":"Observation/Example-McBee-CareExperiencePreference3"},{"reference":"Observation/Example-McBee-CareExperiencePreference2"},{"reference":"Observation/Example-McBee-CareExperiencePreference1"},{"reference":"Observation/Example-McBee-AutopsyObservation1"},{"reference":"Observation/Example-McBee-CareExperiencePreference1"},{"reference":"Observation/Example-McBee-CareExperiencePreference2"},{"reference":"Observation/Example-McBee-CareExperiencePreference3"},{"reference":"Observation/Example-McBee-CareExperiencePreference4"},{"reference":"Observation/Example-McBee-PersonalInterventionPreference1"},{"reference":"Observation/Example-McBee-PersonalInterventionPreference2"},{"reference":"Observation/Example-McBee-PersonalInterventionPreference3"},{"reference":"Observation/Example-McBee-PersonalInterventionPreference4"},{"reference":"Observation/Example-McBee-PersonalInterventionPreference5"},{"reference":"Observation/Example-McBee-PersonalInterventionPreference6"},{"reference":"Observation/Example-McBee-PersonalInterventionPreference7"},{"reference":"Observation/Example-McBee-PersonalInterventionPreference8"},{"reference":"Observation/Example-McBee-OrganDonationObservation1"},{"reference":"Observation/Example-McBee-AutopsyObservation1"},{"reference":"Organization/Example-McBee-OrganizationCustodian1"},{"reference":"Organization/Example-McBee-OrganizationAssembler1"},{"reference":"Organization/Example-McBee-OrganizationCustodian1"},{"reference":"ValueSet/operation-outcome"},{"reference":"ValueSet/SDOHCC-ValueSetLOINCSNOMEDCT"},{"reference":"ValueSet/SDOHCC-ValueSetObservationDataAbsentReason"},{"reference":"ValueSet/SDOHCC-ValueSetObservationDerivedFromIdType"},{"reference":"ValueSet/SDOHCC-ValueSetObservationMethod"},{"reference":"ValueSet/SDOHCC-ValueSetObservationStatus"},{"reference":"ValueSet/SDOHCC-ValueSetOMBEthnicityCategories"},{"reference":"ValueSet/SDOHCC-ValueSetOMBRaceCategories"},{"reference":"ValueSet/SDOHCC-ValueSetPronounsValue"},{"reference":"ValueSet/SDOHCC-ValueSetSDOHCategory"},{"reference":"ValueSet/SDOHCC-ValueSetSDOHQuestionnaireCategory"},{"reference":"ValueSet/SDOHCC-ValueSetTaskCode"},{"reference":"ValueSet/SDOHCC-ValueSetTaskPriority"},{"reference":"ValueSet/SDOHCC-ValueSetTaskStatus"}]} {"resourceType":"DocumentManifest","status":"current"} {"resourceType":"Patient","id":"Example-McBee-Patient1","meta":{"lastUpdated":"2021-04-07T19:55:22+00:00","profile":["http://hl7.org/fhir/us/core/StructureDefinition/us-core-patient"]},"language":"en-US","text":{"status":"generated","div":"

McBee, Roger Rienman male, DoB: 1945-04-01 ( Social Beneficiary Identifier/555-12-1246)


Active:trueMarital Status:NoInformation
Other Id:Driver's License Number/33487
Contact Detail
"},"identifier":[{"type":{"coding":[{"system":"http://terminology.hl7.org/CodeSystem/v2-0203","code":"SB","display":"Social Beneficiary Identifier"}]},"system":"http://hl7.org/fhir/sid/us-ssn","value":"555-12-1246"},{"type":{"coding":[{"system":"http://terminology.hl7.org/CodeSystem/v2-0203","code":"DL","display":"Driver's License Number"}]},"system":"urn:oid:2.16.840.1.113883.4.3.12","value":"33487"}],"active":true,"name":[{"text":"McBee, Roger Rienman","family":"McBee","given":["Roger","Rienman"]}],"telecom":[{"system":"phone","value":"+1(469)238-2858","use":"home","rank":1},{"system":"phone","value":"+1(214)497-9529","use":"mobile","rank":2},{"system":"email","value":"rogerb@example.com","use":"mobile","rank":3}],"gender":"male","birthDate":"1945-04-01","address":[{"type":"physical","line":["12345 Main Street"],"city":"Orlando","state":"FL","postalCode":"75219","country":"US"}],"maritalStatus":{"coding":[{"system":"http://terminology.hl7.org/CodeSystem/v3-NullFlavor","code":"NI"}]},"_id":"xWpWsovmSEeBTmoH3"} {"resourceType":"Patient","id":"Example-McBee-Patient1","meta":{"lastUpdated":"2021-04-07T19:55:22+00:00","profile":["http://hl7.org/fhir/us/core/StructureDefinition/us-core-patient"]},"language":"en-US","text":{"status":"generated","div":"

Generated Narrative: Patient

Resource Patient "Example-McBee-Patient1" Updated "2021-04-07 19:55:22+0000" (Language "en-US")

Profile: US Core Patient Profile

identifier: Social Beneficiary Identifier/555-12-1246, Driver's License Number/33487

active: true

name: McBee, Roger Rienman

telecom: +1(469)238-2858, +1(214)497-9529, rogerb@example.com

gender: male

birthDate: 1945-04-01

address: 12345 Main Street Orlando FL 75219 US

maritalStatus: NoInformation (NullFlavor#NI)

"},"identifier":[{"type":{"coding":[{"system":"http://terminology.hl7.org/CodeSystem/v2-0203","code":"SB","display":"Social Beneficiary Identifier"}]},"system":"http://hl7.org/fhir/sid/us-ssn","value":"555-12-1246"},{"type":{"coding":[{"system":"http://terminology.hl7.org/CodeSystem/v2-0203","code":"DL","display":"Driver's License Number"}]},"system":"urn:oid:2.16.840.1.113883.4.3.12","value":"33487"}],"active":true,"name":[{"text":"McBee, Roger Rienman","family":"McBee","given":["Roger","Rienman"]}],"telecom":[{"system":"phone","value":"+1(469)238-2858","use":"home","rank":1},{"system":"phone","value":"+1(214)497-9529","use":"mobile","rank":2},{"system":"email","value":"rogerb@example.com","use":"mobile","rank":3}],"gender":"male","birthDate":"1945-04-01","address":[{"type":"physical","line":["12345 Main Street"],"city":"Orlando","state":"FL","postalCode":"75219","country":"US"}],"maritalStatus":{"coding":[{"system":"http://terminology.hl7.org/CodeSystem/v3-NullFlavor","code":"NI"}]},"_id":"2DbBkyvTi2LpQAGkN"} {"resourceType":"CarePlan","id":"Example-McBee-PreferenceCarePlan1","meta":{"profile":["http://hl7.org/fhir/us/pacio-adi/StructureDefinition/ADI-PreferenceCarePlan"]},"text":{"status":"generated","div":"

Generated Narrative: CarePlan

Resource CarePlan "Example-McBee-PreferenceCarePlan1"

Profile: ADI Preference Care Plan

status: active

intent: proposal

category: Assessment and Plan of Treatment (US Core CarePlan Category Extension Codes#assess-plan), Goals, preferences, and priorities under certain health conditions [Reported] (LOINC#81378-2)

title: Care Plan for Unconscious, vegetative state, coma for McBee

subject: Patient/Example-McBee-Patient1 " MCBEE"

addresses:

supportingInfo:

"},"status":"active","intent":"proposal","category":[{"coding":[{"system":"http://hl7.org/fhir/us/core/CodeSystem/careplan-category","code":"assess-plan"}]},{"coding":[{"system":"http://loinc.org","code":"81378-2","display":"Goals, preferences, and priorities under certain health conditions [Reported]"}]}],"title":"Care Plan for Unconscious, vegetative state, coma for McBee","subject":{"reference":"Patient/Example-McBee-Patient1"},"addresses":[{"display":"Unconscious, in a coma, or in a persistent vegetative state with little or no chance of recovery"},{"display":"Persistent vegetative state (SNOMED CT 24473007)"},{"display":"Irreversible coma (SNOMED CT 73453007)"}],"supportingInfo":[{"reference":"Observation/Example-McBee-PersonalInterventionPreference1"},{"reference":"Observation/Example-McBee-PersonalInterventionPreference2"},{"reference":"Observation/Example-McBee-PersonalInterventionPreference3"},{"reference":"Observation/Example-McBee-PersonalInterventionPreference4"},{"reference":"Observation/Example-McBee-PersonalInterventionPreference5"},{"reference":"Observation/Example-McBee-PersonalInterventionPreference6"},{"reference":"Observation/Example-McBee-PersonalInterventionPreference7"}],"_id":"LkNRz4sqRvuqPNCEM"} {"resourceType":"CarePlan","id":"Example-McBee-PreferenceCarePlan1","meta":{"profile":["http://hl7.org/fhir/us/pacio-adi/StructureDefinition/ADI-PreferenceCarePlan"]},"text":{"status":"generated","div":"

Generated Narrative: CarePlan

Resource CarePlan "Example-McBee-PreferenceCarePlan1"

Profile: ADI Preference Care Plan

status: active

intent: proposal

category: Assessment and Plan of Treatment (US Core CarePlan Category Extension Codes#assess-plan), Goals, preferences, and priorities under certain health conditions [Reported] (LOINC#81378-2)

title: Care Plan for Unconscious, vegetative state, coma for McBee

subject: See on this page: Patient/Example-McBee-Patient1

addresses:

supportingInfo:

"},"status":"active","intent":"proposal","category":[{"coding":[{"system":"http://hl7.org/fhir/us/core/CodeSystem/careplan-category","code":"assess-plan"}]},{"coding":[{"system":"http://loinc.org","code":"81378-2","display":"Goals, preferences, and priorities under certain health conditions [Reported]"}]}],"title":"Care Plan for Unconscious, vegetative state, coma for McBee","subject":{"reference":"Patient/Example-McBee-Patient1"},"addresses":[{"display":"Unconscious, in a coma, or in a persistent vegetative state with little or no chance of recovery"},{"display":"Persistent vegetative state (SNOMED CT 24473007)"},{"display":"Irreversible coma (SNOMED CT 73453007)"}],"supportingInfo":[{"reference":"Observation/Example-McBee-PersonalInterventionPreference1"},{"reference":"Observation/Example-McBee-PersonalInterventionPreference2"},{"reference":"Observation/Example-McBee-PersonalInterventionPreference3"},{"reference":"Observation/Example-McBee-PersonalInterventionPreference4"},{"reference":"Observation/Example-McBee-PersonalInterventionPreference5"},{"reference":"Observation/Example-McBee-PersonalInterventionPreference6"},{"reference":"Observation/Example-McBee-PersonalInterventionPreference7"}],"_id":"NuF88ugeZwaG79Mc9"} {"resourceType":"Consent","id":"Example-McBee-HealthcareAgentConsent","meta":{"profile":["http://hl7.org/fhir/us/pacio-adi/StructureDefinition/ADI-ParticipantConsent"]},"text":{"status":"additional","div":"

status: active

scope: Powers granted to healthcare agent [Reported]

category: Advance Directive

patient: Social Beneficiary Identifier: 555-12-1246, Roger Rienman McBee; Phone: +1(469)238-2858, Phone: +1(214)497-9529, rogerb@example.com; gender: male; birthDate: 1945-04-01

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: Bobbins Sally ; SallyBobbins@example.com

actor

role: First alternate healthcare agent [Reported]

reference: unrelated friend; Susskind S. Leonard ; ssuskind@example.com

action: Advance directive - request for intubation, Advance directive - request for tube feeding, Advance directive - request for life support

purpose: power of attorney

"},"status":"active","scope":{"coding":[{"system":"http://loinc.org","code":"75786-4","display":"Powers granted to healthcare agent [Reported]"}]},"category":[{"coding":[{"system":"http://terminology.hl7.org/CodeSystem/consentcategorycodes","code":"acd","display":"Advance Directive"}]}],"patient":{"reference":"Patient/Example-McBee-Patient1"},"dateTime":"2020-08-03","policy":[{"authority":"https://www.michigan.gov/","uri":"http://www.legislature.mi.gov/(S(tpnclc1ofteerx2x2dppcmdz))/mileg.aspx?page=GetObject&objectname=mcl-386-1998-V-5"}],"provision":{"type":"permit","actor":[{"role":{"coding":[{"system":"http://loinc.org","code":"75783-1","display":"Primary healthcare agent [Reported]"}]},"reference":{"reference":"RelatedPerson/Example-McBee-HealthcareAgent1"}},{"role":{"coding":[{"system":"http://loinc.org","code":"75784-9","display":"First alternate healthcare agent [Reported]"}]},"reference":{"reference":"RelatedPerson/Example-McBee-HealthcareAgent2"}}],"action":[{"coding":[{"system":"http://hl7.org/fhir/us/pacio-adi/CodeSystem/ADIHCADecisionsCS","code":"intubation","display":"Intubation"}]},{"coding":[{"system":"http://hl7.org/fhir/us/pacio-adi/CodeSystem/ADIHCADecisionsCS","code":"tube-feeding","display":"Tube feeding"}]},{"coding":[{"system":"http://hl7.org/fhir/us/pacio-adi/CodeSystem/ADIHCADecisionsCS","code":"life-support","display":"Life support"}]}],"purpose":[{"system":"http://terminology.hl7.org/CodeSystem/v3-ActReason","code":"PWATRNY"}]},"_id":"fbNf5xoWWYgR5Fktc"} {"resourceType":"Consent","id":"Example-McBee-HealthcareAgentConsent","meta":{"profile":["http://hl7.org/fhir/us/pacio-adi/StructureDefinition/ADI-ParticipantConsent"]},"text":{"status":"additional","div":"

status: active

scope: Powers granted to healthcare agent [Reported]

category: Advance Directive

patient: Social Beneficiary Identifier: 555-12-1246, Roger Rienman McBee; Phone: +1(469)238-2858, Phone: +1(214)497-9529, rogerb@example.com; gender: male; birthDate: 1945-04-01

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: Bobbins Sally ; SallyBobbins@example.com

actor

role: First alternate healthcare agent [Reported]

reference: unrelated friend; Susskind S. Leonard ; ssuskind@example.com

action: Advance directive - request for intubation, Advance directive - request for tube feeding, Advance directive - request for life support

purpose: power of attorney

"},"status":"active","scope":{"coding":[{"system":"http://loinc.org","code":"75786-4","display":"Powers granted to healthcare agent [Reported]"}]},"category":[{"coding":[{"system":"http://terminology.hl7.org/CodeSystem/consentcategorycodes","code":"acd","display":"Advance Directive"}]}],"patient":{"reference":"Patient/Example-McBee-Patient1"},"dateTime":"2020-08-03","policy":[{"authority":"https://www.michigan.gov/","uri":"http://www.legislature.mi.gov/(S(tpnclc1ofteerx2x2dppcmdz))/mileg.aspx?page=GetObject&objectname=mcl-386-1998-V-5"}],"provision":{"type":"permit","actor":[{"role":{"coding":[{"system":"http://loinc.org","code":"75783-1","display":"Primary healthcare agent [Reported]"}]},"reference":{"reference":"RelatedPerson/Example-McBee-HealthcareAgent1"}},{"role":{"coding":[{"system":"http://loinc.org","code":"75784-9","display":"First alternate healthcare agent [Reported]"}]},"reference":{"reference":"RelatedPerson/Example-McBee-HealthcareAgent2"}}],"action":[{"coding":[{"system":"http://hl7.org/fhir/us/pacio-adi/CodeSystem/ADIHCADecisionsCS","code":"intubation","display":"Intubation"}]},{"coding":[{"system":"http://hl7.org/fhir/us/pacio-adi/CodeSystem/ADIHCADecisionsCS","code":"tube-feeding","display":"Tube feeding"}]},{"coding":[{"system":"http://hl7.org/fhir/us/pacio-adi/CodeSystem/ADIHCADecisionsCS","code":"life-support","display":"Life support"}]}],"purpose":[{"system":"http://terminology.hl7.org/CodeSystem/v3-ActReason","code":"PWATRNY"}]},"_id":"GofAk95hj3zR2YYM6"} {"resourceType":"List","id":"Example-McBee-PersonalPrioritiesOrganizer1","meta":{"profile":["http://hl7.org/fhir/us/pacio-adi/StructureDefinition/ADI-PersonalPrioritiesOrganizer"]},"text":{"status":"additional","div":"

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:

  1. Being at peace with my God
  2. Dying at home
  3. Being able to feed, bathe, and take care of myself
  4. Being free from pain
  5. Resolving conflicts
  6. Being with my family
  7. Not being a financial burden to my family
"},"status":"current","mode":"working","title":"My Advance Care Goals","code":{"coding":[{"system":"http://loinc.org","code":"81340-2","display":"Goals AndOr Preferences in Order of Priority [Reported]"}]},"subject":{"reference":"Patient/Example-McBee-Patient1"},"orderedBy":{"coding":[{"system":"http://terminology.hl7.org/CodeSystem/list-order","code":"priority"}]},"entry":[{"item":{"reference":"Goal/Example-McBee-PersonalGoal1"}},{"item":{"reference":"Goal/Example-McBee-PersonalGoal2"}},{"item":{"reference":"Goal/Example-McBee-PersonalGoal3"}},{"item":{"reference":"Goal/Example-McBee-PersonalGoal4"}},{"item":{"reference":"Goal/Example-McBee-PersonalGoal5"}},{"item":{"reference":"Goal/Example-McBee-PersonalGoal6"}},{"item":{"reference":"Goal/Example-McBee-PersonalGoal7"}}],"_id":"D2CZsCJc6vcoqvfhe"} {"resourceType":"List","id":"Example-McBee-PersonalPrioritiesOrganizer1","meta":{"profile":["http://hl7.org/fhir/us/pacio-adi/StructureDefinition/ADI-PersonalPrioritiesOrganizer"]},"text":{"status":"additional","div":"

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:

  1. Being at peace with my God
  2. Dying at home
  3. Being able to feed, bathe, and take care of myself
  4. Being free from pain
  5. Resolving conflicts
  6. Being with my family
  7. Not being a financial burden to my family
"},"status":"current","mode":"working","title":"My Advance Care Goals","code":{"coding":[{"system":"http://loinc.org","code":"81340-2","display":"Goals AndOr Preferences in Order of Priority [Reported]"}]},"subject":{"reference":"Patient/Example-McBee-Patient1"},"orderedBy":{"coding":[{"system":"http://terminology.hl7.org/CodeSystem/list-order","code":"priority"}]},"entry":[{"item":{"reference":"Goal/Example-McBee-PersonalGoal1"}},{"item":{"reference":"Goal/Example-McBee-PersonalGoal2"}},{"item":{"reference":"Goal/Example-McBee-PersonalGoal3"}},{"item":{"reference":"Goal/Example-McBee-PersonalGoal4"}},{"item":{"reference":"Goal/Example-McBee-PersonalGoal5"}},{"item":{"reference":"Goal/Example-McBee-PersonalGoal6"}},{"item":{"reference":"Goal/Example-McBee-PersonalGoal7"}}],"_id":"gNGjHTmcBkE3ypWoq"} {"resourceType":"Observation","id":"Example-McBee-PersonalInterventionPreference8","meta":{"profile":["http://hl7.org/fhir/us/pacio-adi/StructureDefinition/ADI-PersonalInterventionPreference"]},"text":{"status":"additional","div":"

Here are my thoughts on funeral or burial plans:

If I were to pass away: I have a plot. My wife has the details, also my secretary, Ms. Williams, will know.

"},"status":"final","category":[{"coding":[{"system":"http://hl7.org/fhir/us/pacio-adi/CodeSystem/ADIPreferenceCategoryCS","code":"intervention-preference","display":"Intervention preference"}]}],"code":{"coding":[{"system":"http://loinc.org","code":"81356-8","display":"Death arrangements [Reported]"}]},"subject":{"reference":"Patient/Example-McBee-Patient1"},"effectiveDateTime":"2016-05-18T22:33:22Z","performer":[{"reference":"Patient/Example-McBee-Patient1"}],"valueString":"Here are my thoughts on funeral or burial plans: If I were to pass away: I have a plot. My wife has the details, also my secretary, Ms. Williams, will know.","_id":"kQqAxbAGZPi5RzoGs"} {"resourceType":"Observation","id":"Example-McBee-PersonalInterventionPreference7","meta":{"profile":["http://hl7.org/fhir/us/pacio-adi/StructureDefinition/ADI-PersonalInterventionPreference"]},"text":{"status":"additional","div":"

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.

"},"status":"final","category":[{"coding":[{"system":"http://hl7.org/fhir/us/pacio-adi/CodeSystem/ADIPreferenceCategoryCS","code":"intervention-preference","display":"Intervention preference"}]}],"code":{"coding":[{"system":"http://loinc.org","code":"75780-7","display":"Preferred location to spend final days if possible to choose [Reported]"}]},"subject":{"reference":"Patient/Example-McBee-Patient1"},"effectiveDateTime":"2016-05-18T22:33:22Z","performer":[{"reference":"Patient/Example-McBee-Patient1"}],"valueString":"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.","_id":"cPsr56zn85uk9qSia"} {"resourceType":"Observation","id":"Example-McBee-PersonalInterventionPreference6","meta":{"profile":["http://hl7.org/fhir/us/pacio-adi/StructureDefinition/ADI-PersonalInterventionPreference"]},"text":{"status":"additional","div":"

Although I understand that, depending on the situation and circumstances, medical personnel may not be able to follow my wishes, here are my general thoughts on cardiopulmonary resuscitation (CPR):

I want my healthcare agent to make the decision, but if my chances are slim to none that I'll leave the hospital, even if they resuscitate me, then I absolutely do not want CPR.

"},"status":"final","category":[{"coding":[{"system":"http://hl7.org/fhir/us/pacio-adi/CodeSystem/ADIPreferenceCategoryCS","code":"intervention-preference","display":"Intervention preference"}]}],"code":{"coding":[{"system":"http://loinc.org","code":"75779-9","display":"Thoughts on cardiopulmonary resuscitation (CPR) [Reported]"}]},"subject":{"reference":"Patient/Example-McBee-Patient1"},"effectiveDateTime":"2016-05-18T22:33:22Z","performer":[{"reference":"Patient/Example-McBee-Patient1"}],"valueString":"Although I understand that, depending on the situation and circumstances, medical personnel may not be able to follow my wishes, here are my general thoughts on cardiopulmonary resuscitation (CPR): I want my healthcare agent to make the decision, but if my chances are slim to none that I'll leave the hospital, even if they resuscitate me, then I absolutely do not want CPR.","_id":"tZXjy9ct8MHPqZBpm"} {"resourceType":"Observation","id":"Example-McBee-PersonalInterventionPreference5","meta":{"profile":["http://hl7.org/fhir/us/pacio-adi/StructureDefinition/ADI-PersonalInterventionPreference"]},"text":{"status":"additional","div":"

Although I understand that, depending on the situation and circumstances, medical personnel may not be able to follow my wishes, here are my general thoughts on cardiopulmonary resuscitation (CPR):

I want my healthcare agent to make the decision, but if my chances are slim to none that I'll leave the hospital, even if they resuscitate me, then I absolutely do not want CPR.

"},"status":"final","category":[{"coding":[{"system":"http://hl7.org/fhir/us/pacio-adi/CodeSystem/ADIPreferenceCategoryCS","code":"intervention-preference","display":"Intervention preference"}]}],"code":{"coding":[{"system":"http://loinc.org","code":"75779-9","display":"Thoughts on cardiopulmonary resuscitation (CPR) [Reported]"}]},"subject":{"reference":"Patient/Example-McBee-Patient1"},"effectiveDateTime":"2016-05-18T22:33:22Z","performer":[{"reference":"Patient/Example-McBee-Patient1"}],"valueString":"Although I understand that, depending on the situation and circumstances, medical personnel may not be able to follow my wishes, here are my general thoughts on cardiopulmonary resuscitation (CPR): I do not want CPR attempted.","_id":"LyPQjo4Mg3A9CJzjs"} {"resourceType":"Observation","id":"Example-McBee-PersonalInterventionPreference4","meta":{"profile":["http://hl7.org/fhir/us/pacio-adi/StructureDefinition/ADI-PersonalInterventionPreference"]},"text":{"status":"additional","div":"

If I have a severe, irreversible brain injury or illness and can’t dress, feed, or bathe myself, or communicate my medical wishes, but doctors can keep me alive in this condition for a long period of time, I would like for them to keep trying life-sustaining treatments for 2 months.

"},"status":"final","category":[{"coding":[{"system":"http://hl7.org/fhir/us/pacio-adi/CodeSystem/ADIPreferenceCategoryCS","code":"intervention-preference","display":"Intervention preference"}]}],"code":{"coding":[{"system":"http://loinc.org","code":"75778-1","display":"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]"}]},"subject":{"reference":"Patient/Example-McBee-Patient1"},"effectiveDateTime":"2016-05-18T22:33:22Z","performer":[{"reference":"Patient/Example-McBee-Patient1"}],"valueString":"If I have a severe, irreversible brain injury or illness and can’t dress, feed, or bathe myself, or communicate my medical wishes, but doctors can keep me alive in this condition for a long period of time, I would like for them to keep trying life-sustaining treatments for 2 months.","_id":"CRnZQuAdtM5aHoFq8"} {"resourceType":"Observation","id":"Example-McBee-PersonalInterventionPreference3","meta":{"profile":["http://hl7.org/fhir/us/pacio-adi/StructureDefinition/ADI-PersonalInterventionPreference"]},"text":{"status":"additional","div":"

If my response above indicates that I do not want life-sustaining treatments,

I expressly authorize my attending physician to withhold or withdraw artificial nutrition and hydration and instruct my healthcare agent (or, if I have not designated a healthcare agent, my default surrogate), my family and the doctors and nurses who are taking care of me to respect this request.

"},"status":"final","category":[{"coding":[{"system":"http://hl7.org/fhir/us/pacio-adi/CodeSystem/ADIPreferenceCategoryCS","code":"intervention-preference","display":"Intervention preference"}]}],"code":{"coding":[{"system":"http://loinc.org","code":"77352-3","display":"Thoughts on artificial nutrition and hydration [Reported]"}]},"subject":{"reference":"Patient/Example-McBee-Patient1"},"effectiveDateTime":"2016-05-18T22:33:22Z","performer":[{"reference":"Patient/Example-McBee-Patient1"}],"valueString":"If my response above indicates that I do not want life-sustaining treatments, I expressly authorize my attending physician to withhold or withdraw artificial nutrition and hydration and instruct my healthcare agent (or, if I have not designated a healthcare agent, my default surrogate), my family and the doctors and nurses who are taking care of me to respect this request.","_id":"3u2Xn2fegRr8C7KNM"} {"resourceType":"Observation","id":"Example-McBee-PersonalInterventionPreference2","meta":{"profile":["http://hl7.org/fhir/us/pacio-adi/StructureDefinition/ADI-PersonalInterventionPreference"]},"text":{"status":"additional","div":"

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 prefer that they stop all life-sustaining treatments and let me die as gently as possible. I realize that I will not receive life-sustaining treatments including but not limited to breathing machines, blood transfusions, dialysis, heart machines, and IV drugs to keep my heart working. I also realize that medical personnel will not attempt cardiopulmonary resuscitation (CPR), and they will allow me to die naturally.

"},"status":"final","category":[{"coding":[{"system":"http://hl7.org/fhir/us/pacio-adi/CodeSystem/ADIPreferenceCategoryCS","code":"intervention-preference","display":"Intervention preference"}]}],"code":{"coding":[{"system":"http://loinc.org","code":"75777-3","display":"Information to tell doctors if my health deteriorates due to a terminal illness and I am unable to interact meaningfully with family, friends, or surroundings [Reported]"}]},"subject":{"reference":"Patient/Example-McBee-Patient1"},"effectiveDateTime":"2016-05-18T22:33:22Z","performer":[{"reference":"Patient/Example-McBee-Patient1"}],"valueString":"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 prefer that they stop all life-sustaining treatments and let me die as gently as possible. I realize that I will not receive life-sustaining treatments including but not limited to breathing machines, blood transfusions, dialysis, heart machines, and IV drugs to keep my heart working. I also realize that medical personnel will not attempt cardiopulmonary resuscitation (CPR), and they will allow me to die naturally.","_id":"kWPZn4GTaJetqDise"} {"resourceType":"Observation","id":"Example-McBee-PersonalInterventionPreference1","meta":{"profile":["http://hl7.org/fhir/us/pacio-adi/StructureDefinition/ADI-PersonalInterventionPreference"]},"text":{"status":"additional","div":"

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.

"},"status":"final","category":[{"coding":[{"system":"http://hl7.org/fhir/us/pacio-adi/CodeSystem/ADIPreferenceCategoryCS","code":"intervention-preference","display":"Intervention preference"}]}],"code":{"coding":[{"system":"http://loinc.org","code":"75776-5","display":"Preference on consulting a supportive and palliative care team to help treat physical, emotional, and spiritual discomfort and support family [Reported]"}]},"subject":{"reference":"Patient/Example-McBee-Patient1"},"effectiveDateTime":"2016-05-18T22:33:22Z","performer":[{"reference":"Patient/Example-McBee-Patient1"}],"valueString":"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.","_id":"Qiqsr9QrTrACyRr6o"} {"resourceType":"Observation","id":"Example-McBee-OrganDonationObservation1","meta":{"profile":["http://hl7.org/fhir/us/pacio-adi/StructureDefinition/ADI-OrganDonationObservation"]},"text":{"status":"additional","div":"

Consent to Donate

I don’t want to donate my organs.

"},"status":"final","code":{"coding":[{"system":"http://loinc.org","code":"75781-5","display":"Thoughts on organ and tissue donations [Reported]"}]},"subject":{"reference":"Patient/Example-McBee-Patient1"},"effectiveDateTime":"2016-05-18T22:33:22Z","performer":[{"reference":"Patient/Example-McBee-Patient1"}],"valueString":"Consent to Donate: I don’t want to donate my organs.","_id":"2fSDEWTNNXpe69CSD"} {"resourceType":"Observation","id":"Example-McBee-CareExperiencePreference4","meta":{"profile":["http://hl7.org/fhir/us/pacio-adi/StructureDefinition/ADI-CareExperiencePreference"]},"text":{"status":"additional","div":"

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 am awaiting a message from the Noble Committee. Please keep me alive if I look promising this year.

"},"status":"final","category":[{"coding":[{"system":"http://hl7.org/fhir/us/pacio-adi/CodeSystem/ADIPreferenceCategoryCS","code":"care-experience-preference","display":"Care experience preference"}]}],"code":{"coding":[{"system":"http://loinc.org","code":"81366-7","display":"Unfinished business [Reported]"}]},"subject":{"reference":"Patient/Example-McBee-Patient1"},"effectiveDateTime":"2016-05-18T22:33:22Z","performer":[{"reference":"Patient/Example-McBee-Patient1"}],"valueString":"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 am awaiting a message from the Noble Committee. Please keep me alive if I look promising this year.","_id":"nv5WGcZ9k5rCQ9ZDC"} {"resourceType":"Observation","id":"Example-McBee-CareExperiencePreference3","meta":{"profile":["http://hl7.org/fhir/us/pacio-adi/StructureDefinition/ADI-CareExperiencePreference"]},"text":{"status":"additional","div":"

Please attempt to notify someone from my religion at the following phone number: (If I have included one)

Not Religious

"},"extension":[{"url":"http://hl7.org/fhir/us/pacio-adi/StructureDefinition/adi-enclosedPrecondition-extension","valueCodeableConcept":{"text":"Please attempt to notify someone from my religion at the following phone number"}}],"status":"final","category":[{"coding":[{"system":"http://hl7.org/fhir/us/pacio-adi/CodeSystem/ADIPreferenceCategoryCS","code":"care-experience-preference","display":"Care experience preference"}]}],"code":{"coding":[{"system":"http://loinc.org","code":"81365-9","display":"Religious or cultural affiliation contact to notify [Reported]"}]},"subject":{"reference":"Patient/Example-McBee-Patient1"},"effectiveDateTime":"2016-05-18T22:33:22Z","performer":[{"reference":"Patient/Example-McBee-Patient1"}],"valueString":"If I have included one - Not Religious","_id":"i6gaoREioSgEKsqEi"} {"resourceType":"Observation","id":"Example-McBee-CareExperiencePreference2","meta":{"profile":["http://hl7.org/fhir/us/pacio-adi/StructureDefinition/ADI-CareExperiencePreference"]},"text":{"status":"additional","div":"

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 don’t like being treated like an object. I would like to be greeted like a person before working on me.

"},"status":"final","category":[{"coding":[{"system":"http://hl7.org/fhir/us/pacio-adi/CodeSystem/ADIPreferenceCategoryCS","code":"care-experience-preference","display":"Care experience preference"}]}],"code":{"coding":[{"system":"http://loinc.org","code":"81380-8","display":"Goals, preferences, and priorities for care experience [Reported]"}]},"subject":{"reference":"Patient/Example-McBee-Patient1"},"effectiveDateTime":"2016-05-18T22:33:22Z","performer":[{"reference":"Patient/Example-McBee-Patient1"}],"valueString":"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 don’t like being treated like an object. I would like to be greeted like a person before working on me.","_id":"G6zW4scr5sdxN4dkf"} {"resourceType":"Observation","id":"Example-McBee-CareExperiencePreference1","meta":{"profile":["http://hl7.org/fhir/us/pacio-adi/StructureDefinition/ADI-CareExperiencePreference"]},"text":{"status":"additional","div":"

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:

Like Bach, especially the cantatas. St. Martin in the Fields

"},"status":"final","category":[{"coding":[{"system":"http://hl7.org/fhir/us/pacio-adi/CodeSystem/ADIPreferenceCategoryCS","code":"care-experience-preference","display":"Care experience preference"}]}],"code":{"coding":[{"system":"http://loinc.org","code":"81360-0","display":"My likes and joys [Reported]"}]},"subject":{"reference":"Patient/Example-McBee-Patient1"},"effectiveDateTime":"2016-05-18T22:33:22Z","performer":[{"reference":"Patient/Example-McBee-Patient1"}],"valueString":"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: Like Bach, especially the cantatas. St. Martin in the Fields","_id":"g8fWNf745TX65FAXH"} {"resourceType":"Observation","id":"Example-McBee-AutopsyObservation1","meta":{"profile":["http://hl7.org/fhir/us/pacio-adi/StructureDefinition/ADI-AutopsyObservation"]},"text":{"status":"additional","div":"

Autopsy

I want an autopsy if my doctor thinks it will help others.

"},"status":"final","code":{"coding":[{"system":"http://loinc.org","code":"75782-3","display":"Thoughts regarding autopsy [Reported]"}]},"subject":{"reference":"Patient/Example-McBee-Patient1"},"effectiveDateTime":"2016-05-18T22:33:22Z","performer":[{"reference":"Patient/Example-McBee-Patient1"}],"valueString":"Autopsy: I want an autopsy if my doctor thinks it will help others.","_id":"CicySCygpS3MJCvvK"} {"resourceType":"Observation","id":"Example-McBee-CareExperiencePreference1","meta":{"profile":["http://hl7.org/fhir/us/pacio-adi/StructureDefinition/ADI-CareExperiencePreference"]},"text":{"status":"additional","div":"

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:

Like Bach, especially the cantatas. St. Martin in the Fields

"},"status":"final","category":[{"coding":[{"system":"http://hl7.org/fhir/us/pacio-adi/CodeSystem/ADIPreferenceCategoryCS","code":"care-experience-preference","display":"Care experience preference"}]}],"code":{"coding":[{"system":"http://loinc.org","code":"81360-0","display":"My likes and joys [Reported]"}]},"subject":{"reference":"Patient/Example-McBee-Patient1"},"effectiveDateTime":"2016-05-18T22:33:22Z","performer":[{"reference":"Patient/Example-McBee-Patient1"}],"valueString":"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: Like Bach, especially the cantatas. St. Martin in the Fields","_id":"23NJhJpXi37vvLnZN"} {"resourceType":"Observation","id":"Example-McBee-CareExperiencePreference2","meta":{"profile":["http://hl7.org/fhir/us/pacio-adi/StructureDefinition/ADI-CareExperiencePreference"]},"text":{"status":"additional","div":"

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 don’t like being treated like an object. I would like to be greeted like a person before working on me.

"},"status":"final","category":[{"coding":[{"system":"http://hl7.org/fhir/us/pacio-adi/CodeSystem/ADIPreferenceCategoryCS","code":"care-experience-preference","display":"Care experience preference"}]}],"code":{"coding":[{"system":"http://loinc.org","code":"81380-8","display":"Goals, preferences, and priorities for care experience [Reported]"}]},"subject":{"reference":"Patient/Example-McBee-Patient1"},"effectiveDateTime":"2016-05-18T22:33:22Z","performer":[{"reference":"Patient/Example-McBee-Patient1"}],"valueString":"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 don’t like being treated like an object. I would like to be greeted like a person before working on me.","_id":"XbYegoG6qBXpdme9R"} {"resourceType":"Observation","id":"Example-McBee-CareExperiencePreference3","meta":{"profile":["http://hl7.org/fhir/us/pacio-adi/StructureDefinition/ADI-CareExperiencePreference"]},"text":{"status":"additional","div":"

Please attempt to notify someone from my religion at the following phone number: (If I have included one)

Not Religious

"},"extension":[{"url":"http://hl7.org/fhir/us/pacio-adi/StructureDefinition/adi-enclosedPrecondition-extension","valueCodeableConcept":{"text":"Please attempt to notify someone from my religion at the following phone number"}}],"status":"final","category":[{"coding":[{"system":"http://hl7.org/fhir/us/pacio-adi/CodeSystem/ADIPreferenceCategoryCS","code":"care-experience-preference","display":"Care experience preference"}]}],"code":{"coding":[{"system":"http://loinc.org","code":"81365-9","display":"Religious or cultural affiliation contact to notify [Reported]"}]},"subject":{"reference":"Patient/Example-McBee-Patient1"},"effectiveDateTime":"2016-05-18T22:33:22Z","performer":[{"reference":"Patient/Example-McBee-Patient1"}],"valueString":"If I have included one - Not Religious","_id":"BuGR4JLTfpw7DdPvb"} {"resourceType":"Observation","id":"Example-McBee-CareExperiencePreference4","meta":{"profile":["http://hl7.org/fhir/us/pacio-adi/StructureDefinition/ADI-CareExperiencePreference"]},"text":{"status":"additional","div":"

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 am awaiting a message from the Noble Committee. Please keep me alive if I look promising this year.

"},"status":"final","category":[{"coding":[{"system":"http://hl7.org/fhir/us/pacio-adi/CodeSystem/ADIPreferenceCategoryCS","code":"care-experience-preference","display":"Care experience preference"}]}],"code":{"coding":[{"system":"http://loinc.org","code":"81366-7","display":"Unfinished business [Reported]"}]},"subject":{"reference":"Patient/Example-McBee-Patient1"},"effectiveDateTime":"2016-05-18T22:33:22Z","performer":[{"reference":"Patient/Example-McBee-Patient1"}],"valueString":"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 am awaiting a message from the Noble Committee. Please keep me alive if I look promising this year.","_id":"5r98MQe4zvnmEpeRN"} {"resourceType":"Observation","id":"Example-McBee-PersonalInterventionPreference1","meta":{"profile":["http://hl7.org/fhir/us/pacio-adi/StructureDefinition/ADI-PersonalInterventionPreference"]},"text":{"status":"additional","div":"

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.

"},"status":"final","category":[{"coding":[{"system":"http://hl7.org/fhir/us/pacio-adi/CodeSystem/ADIPreferenceCategoryCS","code":"intervention-preference","display":"Intervention preference"}]}],"code":{"coding":[{"system":"http://loinc.org","code":"75776-5","display":"Preference on consulting a supportive and palliative care team to help treat physical, emotional, and spiritual discomfort and support family [Reported]"}]},"subject":{"reference":"Patient/Example-McBee-Patient1"},"effectiveDateTime":"2016-05-18T22:33:22Z","performer":[{"reference":"Patient/Example-McBee-Patient1"}],"valueString":"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.","_id":"oe7H2XY68Yxz6nWbG"} {"resourceType":"Observation","id":"Example-McBee-PersonalInterventionPreference2","meta":{"profile":["http://hl7.org/fhir/us/pacio-adi/StructureDefinition/ADI-PersonalInterventionPreference"]},"text":{"status":"additional","div":"

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 prefer that they stop all life-sustaining treatments and let me die as gently as possible. I realize that I will not receive life-sustaining treatments including but not limited to breathing machines, blood transfusions, dialysis, heart machines, and IV drugs to keep my heart working. I also realize that medical personnel will not attempt cardiopulmonary resuscitation (CPR), and they will allow me to die naturally.

"},"status":"final","category":[{"coding":[{"system":"http://hl7.org/fhir/us/pacio-adi/CodeSystem/ADIPreferenceCategoryCS","code":"intervention-preference","display":"Intervention preference"}]}],"code":{"coding":[{"system":"http://loinc.org","code":"75777-3","display":"Information to tell doctors if my health deteriorates due to a terminal illness and I am unable to interact meaningfully with family, friends, or surroundings [Reported]"}]},"subject":{"reference":"Patient/Example-McBee-Patient1"},"effectiveDateTime":"2016-05-18T22:33:22Z","performer":[{"reference":"Patient/Example-McBee-Patient1"}],"valueString":"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 prefer that they stop all life-sustaining treatments and let me die as gently as possible. I realize that I will not receive life-sustaining treatments including but not limited to breathing machines, blood transfusions, dialysis, heart machines, and IV drugs to keep my heart working. I also realize that medical personnel will not attempt cardiopulmonary resuscitation (CPR), and they will allow me to die naturally.","_id":"ipkAb7BgNKibn7fqi"} {"resourceType":"Observation","id":"Example-McBee-PersonalInterventionPreference3","meta":{"profile":["http://hl7.org/fhir/us/pacio-adi/StructureDefinition/ADI-PersonalInterventionPreference"]},"text":{"status":"additional","div":"

If my response above indicates that I do not want life-sustaining treatments,

I expressly authorize my attending physician to withhold or withdraw artificial nutrition and hydration and instruct my healthcare agent (or, if I have not designated a healthcare agent, my default surrogate), my family and the doctors and nurses who are taking care of me to respect this request.

"},"status":"final","category":[{"coding":[{"system":"http://hl7.org/fhir/us/pacio-adi/CodeSystem/ADIPreferenceCategoryCS","code":"intervention-preference","display":"Intervention preference"}]}],"code":{"coding":[{"system":"http://loinc.org","code":"77352-3","display":"Thoughts on artificial nutrition and hydration [Reported]"}]},"subject":{"reference":"Patient/Example-McBee-Patient1"},"effectiveDateTime":"2016-05-18T22:33:22Z","performer":[{"reference":"Patient/Example-McBee-Patient1"}],"valueString":"If my response above indicates that I do not want life-sustaining treatments, I expressly authorize my attending physician to withhold or withdraw artificial nutrition and hydration and instruct my healthcare agent (or, if I have not designated a healthcare agent, my default surrogate), my family and the doctors and nurses who are taking care of me to respect this request.","_id":"9MBw77BtxiHx7SLNM"} {"resourceType":"Observation","id":"Example-McBee-PersonalInterventionPreference4","meta":{"profile":["http://hl7.org/fhir/us/pacio-adi/StructureDefinition/ADI-PersonalInterventionPreference"]},"text":{"status":"additional","div":"

If I have a severe, irreversible brain injury or illness and can’t dress, feed, or bathe myself, or communicate my medical wishes, but doctors can keep me alive in this condition for a long period of time, I would like for them to keep trying life-sustaining treatments for 2 months.

"},"status":"final","category":[{"coding":[{"system":"http://hl7.org/fhir/us/pacio-adi/CodeSystem/ADIPreferenceCategoryCS","code":"intervention-preference","display":"Intervention preference"}]}],"code":{"coding":[{"system":"http://loinc.org","code":"75778-1","display":"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]"}]},"subject":{"reference":"Patient/Example-McBee-Patient1"},"effectiveDateTime":"2016-05-18T22:33:22Z","performer":[{"reference":"Patient/Example-McBee-Patient1"}],"valueString":"If I have a severe, irreversible brain injury or illness and can’t dress, feed, or bathe myself, or communicate my medical wishes, but doctors can keep me alive in this condition for a long period of time, I would like for them to keep trying life-sustaining treatments for 2 months.","_id":"neuafWhj8mMJr8bte"} {"resourceType":"Observation","id":"Example-McBee-PersonalInterventionPreference5","meta":{"profile":["http://hl7.org/fhir/us/pacio-adi/StructureDefinition/ADI-PersonalInterventionPreference"]},"text":{"status":"additional","div":"

Although I understand that, depending on the situation and circumstances, medical personnel may not be able to follow my wishes, here are my general thoughts on cardiopulmonary resuscitation (CPR):

I want my healthcare agent to make the decision, but if my chances are slim to none that I'll leave the hospital, even if they resuscitate me, then I absolutely do not want CPR.

"},"status":"final","category":[{"coding":[{"system":"http://hl7.org/fhir/us/pacio-adi/CodeSystem/ADIPreferenceCategoryCS","code":"intervention-preference","display":"Intervention preference"}]}],"code":{"coding":[{"system":"http://loinc.org","code":"75779-9","display":"Thoughts on cardiopulmonary resuscitation (CPR) [Reported]"}]},"subject":{"reference":"Patient/Example-McBee-Patient1"},"effectiveDateTime":"2016-05-18T22:33:22Z","performer":[{"reference":"Patient/Example-McBee-Patient1"}],"valueString":"Although I understand that, depending on the situation and circumstances, medical personnel may not be able to follow my wishes, here are my general thoughts on cardiopulmonary resuscitation (CPR): I do not want CPR attempted.","_id":"ipBg4ASCNDr3ektiQ"} {"resourceType":"Observation","id":"Example-McBee-PersonalInterventionPreference6","meta":{"profile":["http://hl7.org/fhir/us/pacio-adi/StructureDefinition/ADI-PersonalInterventionPreference"]},"text":{"status":"additional","div":"

Although I understand that, depending on the situation and circumstances, medical personnel may not be able to follow my wishes, here are my general thoughts on cardiopulmonary resuscitation (CPR):

I want my healthcare agent to make the decision, but if my chances are slim to none that I'll leave the hospital, even if they resuscitate me, then I absolutely do not want CPR.

"},"status":"final","category":[{"coding":[{"system":"http://hl7.org/fhir/us/pacio-adi/CodeSystem/ADIPreferenceCategoryCS","code":"intervention-preference","display":"Intervention preference"}]}],"code":{"coding":[{"system":"http://loinc.org","code":"75779-9","display":"Thoughts on cardiopulmonary resuscitation (CPR) [Reported]"}]},"subject":{"reference":"Patient/Example-McBee-Patient1"},"effectiveDateTime":"2016-05-18T22:33:22Z","performer":[{"reference":"Patient/Example-McBee-Patient1"}],"valueString":"Although I understand that, depending on the situation and circumstances, medical personnel may not be able to follow my wishes, here are my general thoughts on cardiopulmonary resuscitation (CPR): I want my healthcare agent to make the decision, but if my chances are slim to none that I'll leave the hospital, even if they resuscitate me, then I absolutely do not want CPR.","_id":"2KypQdqFBDjXfWGyW"} {"resourceType":"Observation","id":"Example-McBee-PersonalInterventionPreference7","meta":{"profile":["http://hl7.org/fhir/us/pacio-adi/StructureDefinition/ADI-PersonalInterventionPreference"]},"text":{"status":"additional","div":"

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.

"},"status":"final","category":[{"coding":[{"system":"http://hl7.org/fhir/us/pacio-adi/CodeSystem/ADIPreferenceCategoryCS","code":"intervention-preference","display":"Intervention preference"}]}],"code":{"coding":[{"system":"http://loinc.org","code":"75780-7","display":"Preferred location to spend final days if possible to choose [Reported]"}]},"subject":{"reference":"Patient/Example-McBee-Patient1"},"effectiveDateTime":"2016-05-18T22:33:22Z","performer":[{"reference":"Patient/Example-McBee-Patient1"}],"valueString":"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.","_id":"jaCvRoKJvMBrroCmP"} {"resourceType":"Observation","id":"Example-McBee-PersonalInterventionPreference8","meta":{"profile":["http://hl7.org/fhir/us/pacio-adi/StructureDefinition/ADI-PersonalInterventionPreference"]},"text":{"status":"additional","div":"

Here are my thoughts on funeral or burial plans:

If I were to pass away: I have a plot. My wife has the details, also my secretary, Ms. Williams, will know.

"},"status":"final","category":[{"coding":[{"system":"http://hl7.org/fhir/us/pacio-adi/CodeSystem/ADIPreferenceCategoryCS","code":"intervention-preference","display":"Intervention preference"}]}],"code":{"coding":[{"system":"http://loinc.org","code":"81356-8","display":"Death arrangements [Reported]"}]},"subject":{"reference":"Patient/Example-McBee-Patient1"},"effectiveDateTime":"2016-05-18T22:33:22Z","performer":[{"reference":"Patient/Example-McBee-Patient1"}],"valueString":"Here are my thoughts on funeral or burial plans: If I were to pass away: I have a plot. My wife has the details, also my secretary, Ms. Williams, will know.","_id":"vn8SLZ78A5kBKgdww"} {"resourceType":"Observation","id":"Example-McBee-OrganDonationObservation1","meta":{"profile":["http://hl7.org/fhir/us/pacio-adi/StructureDefinition/ADI-OrganDonationObservation"]},"text":{"status":"additional","div":"

Consent to Donate

I don’t want to donate my organs.

"},"status":"final","code":{"coding":[{"system":"http://loinc.org","code":"75781-5","display":"Thoughts on organ and tissue donations [Reported]"}]},"subject":{"reference":"Patient/Example-McBee-Patient1"},"effectiveDateTime":"2016-05-18T22:33:22Z","performer":[{"reference":"Patient/Example-McBee-Patient1"}],"valueString":"Consent to Donate: I don’t want to donate my organs.","_id":"N9aecTuipSSRm7fw7"} {"resourceType":"Observation","id":"Example-McBee-AutopsyObservation1","meta":{"profile":["http://hl7.org/fhir/us/pacio-adi/StructureDefinition/ADI-AutopsyObservation"]},"text":{"status":"additional","div":"

Autopsy

I want an autopsy if my doctor thinks it will help others.

"},"status":"final","code":{"coding":[{"system":"http://loinc.org","code":"75782-3","display":"Thoughts regarding autopsy [Reported]"}]},"subject":{"reference":"Patient/Example-McBee-Patient1"},"effectiveDateTime":"2016-05-18T22:33:22Z","performer":[{"reference":"Patient/Example-McBee-Patient1"}],"valueString":"Autopsy: I want an autopsy if my doctor thinks it will help others.","_id":"fc4egZLFRWF3k2aj7"} {"resourceType":"Organization","id":"Example-McBee-OrganizationCustodian1","meta":{"profile":["http://hl7.org/fhir/us/core/StructureDefinition/us-core-organization"]},"text":{"status":"generated","div":"

Generated Narrative: Organization

Resource Organization "Example-McBee-OrganizationCustodian1"

Profile: US Core Organization Profile

identifier: United States National Provider Identifier/1234567893

active: true

name: MyDirectives.com

telecom: +1(202)776-7700

address: 740 E. Campbell Rd. Suite 825 Richardson TX 75081 US

"},"identifier":[{"system":"http://hl7.org/fhir/sid/us-npi","value":"1234567893"}],"active":true,"name":"MyDirectives.com","telecom":[{"system":"phone","value":"+1(202)776-7700","use":"work"}],"address":[{"type":"physical","line":["740 E. Campbell Rd. Suite 825"],"city":"Richardson","state":"TX","postalCode":"75081","country":"US"}],"_id":"rFuBaPJ4CgcG36ujm"} {"resourceType":"Organization","id":"Example-McBee-OrganizationAssembler1","meta":{"profile":["http://hl7.org/fhir/us/core/StructureDefinition/us-core-organization"]},"text":{"status":"generated","div":"

Generated Narrative: Organization

Resource Organization "Example-McBee-OrganizationAssembler1"

Profile: US Core Organization Profile

identifier: urn:oid:1.3.6.1.4.1.42424242.4.99930.4/4

active: true

name: ADVault, Inc.

telecom: +1(202)776-7700

address: 740 E. Campbell Rd. Suite 825 Richardson TX 75081 US

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Generated Narrative: Organization

Resource Organization "Example-McBee-OrganizationCustodian1"

Profile: US Core Organization Profile

identifier: United States National Provider Identifier/1234567893

active: true

name: MyDirectives.com

telecom: +1(202)776-7700

address: 740 E. Campbell Rd. Suite 825 Richardson TX 75081 US

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!-- Snipped for Brevity -->
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