Personal Advance Care Plan Document
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Contents
CDA Personal Advance Care Plan Document Project
Welcome to the Personal Advance Care Plan Project Wiki Site. This wiki will be used to manage the information necessary to support development of CDA R2 Implementation Guide that specifies how to create a patient generated document with content that expresses an individual's advance care plan. An advance care plan is a plan that is made in advance of when it may be needed. The Personal Advance Care Plan document will record (for the purpose of digital information exchange) a person's care goals, preferences, and priorities, the person's appointed healthcare agents, organ donation preferences, final arrangements, and other directives commonly reported in what the industry calls a person's "Advance Directives", "Living Will", "Healthcare Power of Attorney", etc. Examples of these type of documents, in paper form, are included below. The selected samples will inform and guide the template designs developed in this CDA Implementation Guide.
- Guiding principles used to manage the project, encourage collaboration, and focus the scope of the content to be included.
- The PSS sets the scope and boundaries for the project
- The document content requirements will be documented and preserved on this wiki to support ballot reconciliation and for future reference
- Content requirements will be generated by analyzing actual examples readily in the United States, available on the internet,and considered to be a reputable reference resource by the steering committee
- All samples will be considered by the industry team. Some samples may be determined to be out of scope or certain parts or aspects may be deemed out of scope.
- Decision making over controversial topics will be postponed as long as is feasible for the project
- Options will be developed using in a collaborative approach
- Input will be sought from Patient Care (Co-sponsor)
- Input will be sought from a panel of industry experts who are focused on the use case for personal advance care plan documents. This group will not be directly involved with the creation of CDA templates, nor will they deal with the particulars of the publishing formalism of a CDA Implementation Guide. A separate non-technical meeting will be convened to partition the discussion
- Working sessions will be conducted with a technical team who will focus on IG publication and CDA template design.
- Final decisions will be governed through Structured Documents (Project Sponsor)
- Expression of goals, preferences and priorities will be formulated as standard questions, but responses will not be limited to specific coded answers. The objective is to allow a person to answer a "known" question in what ever way fits their intention. Questions shall be structured and vocabulary will be created as a part of this project. Answers may be standardized by implementers, but they won't have to be to conform to this specification. Answers will be structured, but specific vocabulary for answers will not be in scope for this project.
- The structure of the document, sections, and entries and the semantics used within will be as aligned with the C-CDA R2.1 Care Plan Document templates as is possible.
Project Information
- Project Listservs: strucdoc@lists.hl7.org patientcare@lists.hl7.org
- Project Scope Statement (as of 9/10/2015): http://www.hl7.org/documentcenter/public/wg/structure/PSS_StrucDocs_IG_for_CDA_R2_ACP_R1_2015%20v20150910.docx
| Meeting Times | Current Agenda |
Conference CallsTechnical Team conference callMeets every Tuesday at 3:00 PM Eastern Time for 1 hour. 9/15/2015 Meeting Cancelled due to conflict. Next meeting on 9/22. Participation Information
Phone Number: +1 (770) 657-9270 Web Meeting InfoLisa Nelson to Host
Industry Team conference call
Once a month on Tuesdays at 5:00 PM Eastern Time for 1 hour. Participation InformationGoTo Meeting Conf#: +1 (224) 501-3412
Web Meeting InfoLisa Nelson to Host |
Agenda ItemsCurrent Agenda - Technical Team
Current Agenda - Industry Team
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Past Minutes
- 2015 09 08 Minutes - Technical Team
- 2015 09 15 Minutes - Technical Team
- 2015 09 15 Minutes - Industry Team
Open Issues
Open Issues (Last updated 9/2)
| ISSUE # | Date Entered | Summary of Issue | Existing Positions | Proposed Options | Comments |
|---|---|---|---|---|---|
| 101 | 2015-08-15 | Project title needs to be finalized | Many different points of view exist regarding the ideal title for this project
Some feel the title needs to be short to be manageable while other would prefer a longer and more descriptive name
Some feel the words "advance care plan" are misleading because they do not see the association to "Care Plan" documents. Others would prefer to see the words "Goals, Preference, and Priorities" in the title.
Some feel the word "Patient" or the words "Patient Generated" would help to clarify that this document is a type of patient generated document. Others prefer the term "patient" not be used because individuals may create an advance care document when they are not sick and not a "patient". They argue the term "patient" is too limiting. |
The project title will be reviewed with the industry team and this issue will remain open as additional feedback is sought. | The present "working title" will be used until an option is developed that carries consensus support |
Reference Resources
Resource (Last updated 9/8)
| ITEM # | Date Added | Resource Title | Description | Link |
|---|---|---|---|---|
| 01 | 2015-09-08 | The Commission on Law and Aging, American Bar Association. Giving Someone a Power of Attorney For Your Health Care: A Guide with an Easy-to-Use, Legal Form for All Adults | The form in this guide is a simple version of a Health Care Advance Directive. It allows you to choose someone to make health care decisions for you if you can't. If you name a health care agent when you are healthy, you will make sure that someone you trust can make health care decisions for you if you are injured or become too ill to make them yourself. | http://wiki.hl7.org/index.php?title=File:2011_ABA_Model_Directive.pdf |
| 02 | 2015-09-08 | The La Crosse Region Power of Attorney for Healthcare Document | A document developed to meet the legal requirements of WI, MN, and IA. This document provides a way for a person to create a power of attorney for healthcare that will meet the basic requirements of these states. Resource includes detailed instructions about how to complete the document. | http://wiki.hl7.org/index.php?title=File:12860_POAHC.lse.12.08.pdf |
| 03 | 2015-09-08 | Department of Veterans Affairs - VA Advance Directive Durable Power of Attorney for Health Care and Living Will | This advance directive form is an official document where you can write own your preferences for your health care. If someday you can't make health care decisions for yourself anymore, this advance directive can help guide the people who will make decisions for you. | http://wiki.hl7.org/index.php?title=File:Veterans_Administration_Form_Advance_Directive_%28July_2012%29.pdf |
| 04 | 2015-09-08 | Advance Directives for Health Care, Oklahoma Bar Association | The form is offered as a public service by the Oklahoma Bar Association. Permission is granted to reproduce without modification. | http://wiki.hl7.org/index.php?title=File:OklahomaAdvDirective2006.pdf |
| 05 | 2015-09-08 | MyDirectives.com Universal Advance Directive Document | A sample UADD document for a fictitious person, Roger McBee. The advance directive document includes expressions of his medical treatment goals and preferences. There is no guarantee that your medical care providers will follow all of your wishes, but one this is certain: if your advance medical directives cannot be quickly located and retrieved when needed, then medical care providers, your family and friends, will not be able to take your wishes into consideration when they make critical decisions regarding your treatment. | http://wiki.hl7.org/index.php?title=File:Roger_McBee_uADD_%288-20-2014%29.pdf |
| 06 | 2015-09-08 | 5 Wishes Advance Directive Document | A document that allows you to record your wishes for: the person you want to make care decisions for you when you can't, the kind of medical treatment you want or don't want, how comfortable you want to be, how you want people to treat you, and what you want your loved ones to know. | http://wiki.hl7.org/index.php?title=File:5wishes.pdf |
| 07 | 2015-09-08 | Adams Living Will & Power of Attorney for Health Care Kit. Copyright 2009, TOPS Downers Grove IL 60515. Provided under license from the copyright holder, Nova Publishing Co | A resource I found at Staples which helps people make their own health care wished know, control the care they receive, and ensure death with dignity if you become incapacitated. | Available from www.tops-products.com
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| 08 | 2015-09-08 | Baylor Heart and Vascular Hospital, A Guide to Your Care | Our goal while you are a patient in our hospital is to help you experience the best possible outcome from your stay. For this to happen, everyone--you, your family and your health care team--must all work together and communicate clearly [..] You may be very sick and hard choices may need to be made about your treatment. Making those decisions can be difficult and emotions may be strong. We hope the information in this guide will ease your mind, make you feel comfortable communicating with your health care team about your treatment or any other issues, and enhance the experience of both you and your family. | http://baylorhearthospital.com/a-guide-to-your-care.html |
| 09 | 2015-09-08 | Example of document content that IS NOT IN SCOPE for this project, Physician Orders for Life-Sustaining Treatment (POLST). | First follow these orders, then contact the physician. This document is a Physician Order Sheet based on the person's current medical condition and wishes. Any section not completed implies full treatment for that section. Everyone shall be treated with dignity and respect. This is an example of a document this IS NOT a Patient Generated Document. Although it may be completed after taking a person's wishes into consideration, it is not an example of the type of Patient Generated Document that this CDA Implementation Guides specifies. |
http://wiki.hl7.org/index.php?title=File:California_POLST_Form_%282010%29.pdf |
| 10 | 2015-09-12 | Compassion and Choices: the Good-to-Go Tool Kit | A set of forms for expressing a person's end of life choices | www.compassionandchoices.org |
Content Requirements
Structure for documenting key content requirements - TBD
