Advance Care Planning (PZP)
1.0.0-rc2 - trial-use

Advance Care Planning (PZP), published by IKNL. This guide is not an authorized publication; it is the continuous build for version 1.0.0-rc2 built by the FHIR (HL7® FHIR® Standard) CI Build. This version is based on the current content of https://github.com/IKNL/PZP-FHIR-R4/ and changes regularly. See the Directory of published versions

## Artifacts Summary

This page provides a list of the FHIR artifacts defined as part of this implementation guide.

### Requirements: Actor Definitions

The following artifacts define the types of individuals and/or systems that will interact as part of the use cases covered by this implementation guide.

ACP Actor Consulter | The ACP Actor Consulter is a system that creates and initiates a data access request to retrieve digital health and administrative information.
ACP Actor Provider | The ACP Actor Provider is a system that responds to data access requests for digital health and administrative information.

### Structures: NL Core Derived Resource Profiles

These are ACP profiles derived from the nl-core profiles and are based on the Dutch Health and Care Information models (Zorginformatiebouwstenen - zibs).

ACP AdvanceDirective | 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. Based on nl-core-AdvanceDirective and HCIM AdvanceDirective.
ACP ContactPerson | 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.
ACP Encounter | 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.
ACP HealthProfessional Practitioner | A person who is authorized to perform actions in the field of individual healthcare. Based on nl-core-HealthProfessionalPractitioner and HCIM HealthProfessional.
ACP HealthProfessional PractitionerRole | 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.
ACP MedicalDevice | 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.
ACP MedicalDevice Product ICD | 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.
ACP Patient | A person who receives medical, psychological, paramedical, or nursing care. Based on nl-core-Patient and HCIM Patient.
ACP Procedure | Advance Care Planning procedure. Based on nl-core-Procedure-event profile and HCIM Procedure.
ACP TreatmentDirective | 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. Based on nl-core-TreatmentDirective2 and HCIM TreatmentDirective2.

### Structures: Resource Profiles

These are ACP profiles based on FHIR core resources.

ACP Medical Policy Goal | The primary, agreed-upon goal of a patient's medical treatment policy. Based on Goal resource.
ACP Organ Donation Choice Registration in Donor Register | 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.
ACP Position Regarding Euthanasia | The patient's position regarding euthanasia. Based on Observation resource.
ACP Preferred Place of Death | 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.
ACP Request to Inform Relatives | A CommunicationRequest representing the advice or instruction given to the patient to discuss their advance care planning (ACP) and treatment agreements with their relatives or proxies.
ACP Sense of Purpose | 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.
ACP Specific Care Wishes | 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.

### Structures: Questionnaire and QuestionnaireResponses

These define forms used by systems conforming to this implementation guide to capture or expose data to end users.

ACP Questionnaire | Questionnaire based on structured form 'Uniform vastleggen proactieve zorgpanning advance care planning (ACP)'
ACP QuestionnaireResponse Hendrik Hartman 1 | An example of a QuestionnaireResponse for Hendrik Hartman on 2020-10-01
ACP QuestionnaireResponse Hendrik Hartman 2 | An example of a QuestionnaireResponse for Hendrik Hartman on 2022-11-08
ACP QuestionnaireResponse Samira van der Sluijs | An example of a QuestionnaireResponse for Samira van der Sluijs on 2025-11-17

### Behavior: Capability Statements

The following artifacts define the specific capabilities that different types of systems are expected to have in order to comply with this implementation guide. Systems conforming to this implementation guide are expected to declare conformance to one or more of the following capability statements.

ACP CapabilityStatement Consulter | This CapabilityStatement describes the rules for the ACP Actor Consulter that is responsible for providing responses to queries submitted by ACP Consultors.
ACP CapabilityStatement Provider | This CapabilityStatement describes the rules for the ACP Actor Provider that is responsible for providing responses to queries submitted by ACP Consultors.

### Structures: Extension Definitions

These define constraints on FHIR data types for systems conforming to this implementation guide.

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

### Terminology: Value Sets

These define sets of codes used by systems conforming to this implementation guide.

ACP ContactPerson Role zib2024 backport | ValueSet containing additional codes to the ContactPerson's RolCodelijst. These codes are applied from the zib2024 release onwards. Currently, the ValueSet contains only SNOMED CT code `310141000146103` (Schriftelijk gemachtigde zorg en behandeling / Holder of medical power of attorney) from the zib2024 release. The ValueSet is bound to a slice in `RelatedPerson.relationship.
ACP MedicalDevice ProductType ICD | ICD product code for MedicalDevice ProductType. This ValueSet is conceptually based on SNOMED CT codes that are descendants of `72506001` (implanteerbare cardioverter-defibrillator), i.e. an `is-a` filter. However, the codes are explicitly enumerated rather than using an intensional `is-a` filter to make the ValueSet easier to understand and implement for consumers.
ACP Position Regarding Euthanasia | ValueSet for Position Regarding Euthanasia, representing the the patient's position regarding euthanasia and information on the presence of a euthanasia statement.
ACP Preferred Place of Death | ValueSet for Preferred Place of Death, representing the place where the patient prefers to die, if possible.
ACP Primary Agreed-upon Goal of Medical Policy | ValueSet for Medical Policy Goal, representing the primary agreed-upon goal of a patient's medical treatment policy.
ACP Yes, No, Unknown valueSet | ValueSet representing 'Yes, No, Unknown' answers.

### Example: Example Instances

These are example instances that show what data produced and consumed by systems conforming with this implementation guide might look like.

ACP AdvanceDirective - DNR - Pat 1
ACP AdvanceDirective - DNR - Pat 2
ACP ContactPerson - Maya van der Sluijs-Mulder - Pat 2
ACP ContactPerson - Michiel Hartman - Pat 1
ACP ContactPerson Gert-Jan de Jong - Pat 2
ACP Encounter - 1 - Pat 2
ACP Encounter - 2 - Pat 2
ACP Encounter - Pat 1
ACP HealthProfessional Practitioner - Desiree Wolters - Pat 2
ACP HealthProfessional Practitioner - Dr. van Huissen - Pat 1
ACP HealthProfessional Practitioner - Santos - Pat 2
ACP HealthProfessional PractitionerRole - Desiree Wolters - Pat 2
ACP HealthProfessional PractitionerRole - Dr. van Huissen - Pat 1
ACP HealthProfessional PractitionerRole - Santos - Pat 2
ACP Medical Policy Goal - Pat 1
ACP Medical Policy Goal - Pat 2
ACP MedicalDevice - ICD - Pat 1
ACP MedicalDevice - ICD - Pat 2
ACP MedicalDevice Product ICD - Pat 1
ACP MedicalDevice Product ICD - Pat 2
ACP Organ Donation Choice Registration In Donor Register - Pat 2
ACP Organ Donation Choice Registration in Donor Register - Pat 1
ACP Patient - Hendrik Hartman - Pat 1
ACP Patient - Samira van der Sluijs - Pat 2
ACP Position Regarding Euthanasia - Pat 1
ACP Position Regarding Euthanasia - Pat 2
ACP Preferred Place Of Death - Pat 2
ACP Preferred Place of Death - Pat 1
ACP Procedure - 1 - Pat 2
ACP Procedure - 2 - Pat 2
ACP Procedure - Pat 1
ACP Request to Inform Relatives - Pat 1
ACP Request to Inform Relatives - Pat 2
ACP Sense Of Purpose - Pat 2
ACP Sense of Purpose - Pat 1
ACP Specific Care Wishes - Pat 1
ACP Specific Care Wishes - Pat 2
ACP TreatmentDirective - Administration of blood product - Pat 1
ACP TreatmentDirective - Admission to intensive care unit - 1 - Pat 1
ACP TreatmentDirective - Admission to intensive care unit - 2 - Pat 1
ACP TreatmentDirective - Admission to intensive care unit - Pat 2
ACP TreatmentDirective - Antibiotic Therapy - Pat 2
ACP TreatmentDirective - Antibiotic therapy - Pat 1
ACP TreatmentDirective - Artificial Respiration - 1 - Pat 2
ACP TreatmentDirective - Artificial Respiration - 2 - Pat 2
ACP TreatmentDirective - Artificial respiration - Pat 1
ACP TreatmentDirective - Cardiopulmonary Resuscitation - Pat 2
ACP TreatmentDirective - Cardiopulmonary resuscitation - Pat 1
ACP TreatmentDirective - Hospital Admission - Pat 2
ACP TreatmentDirective - Hospital admission - Pat 1
ACP TreatmentDirective - Other - Pat 2
ACP TreatmentDirective - Switch Off ICD - Pat 1
ACP TreatmentDirective - Switch Off ICD - Pat 2