PACIO Advance Directive Interoperability Implementation Guide
0.1.0 - STU 1 Ballot

Publication Build: This will be filled in by the publication tooling

## Example CarePlan: Example-Smith-Johnson-PreferenceCarePlan1

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:

- Goals, preferences, and priorities under certain health conditions [Reported]; 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
- 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]; 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.
- Religious affiliation contact to notify [Reported]; Please attempt to notify someone from my religion at the following phone number: If I have included one: Catholic
- Religious beliefs [Reported]; 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.
- Decision to inform doctors and nurses about the role religion, faith, or spirituality play in my life [Reported]; 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.