PACIO Advance Directive Interoperability Implementation Guide
0.1.0 - STU 1 Ballot

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## Example CarePlan: Example-Smith-Johnson-PreferenceCarePlan3

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 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
- 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.
- My likes and joys [Reported]; 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 and fears [Reported]; 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.
- Goals, preferences, and priorities for care experience [Reported]; 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.
- 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.
- Unfinished business [Reported]; 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.
- Preference on consulting a supportive and palliative care team to help treat physical, emotional, and spiritual discomfort and support family [Reported]; 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.
- 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.
- Preferred location to spend final days if possible to choose [Reported]; 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.