Advance Care Planning (PZP) STU3
1.0.0 - release

Advance Care Planning (PZP) STU3 - Downloaded Version 1.0.0 See the Directory of published versions

## Artifacts Summary

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

### Structures: Questionnaires

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

Uniform vastleggen proactieve zorgplanning (PZP) o.b.v. zibs2017 - Release 17-08-2026 | This form was developed to clearly document agreements resulting from the advance care planning (ACP) process. It is NOT a checklist. It can only be completed by a healthcare provider after a professional and nuanced conversation. For advice on conducting these conversations, please refer to the guideline for advance care planning in the palliative phase and Palliaweb, see https://palliaweb.nl/zorgpraktijk/proactieve-zorgplanning. Enter 'unknown' if a topic is not discussed or if the patient does not (yet) have an opinion.When transferring to a long-term care setting, consider adding conversation records about advance care planning (ACP) to the transfer documents.

### Structures: Resource Profiles

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

ACP AdvanceDirective | A living will is 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.
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 Inform Relatives Request | 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. Based on CommunicationRequest resource.
ACP Legally Capable Regarding Medical Treatment Decisions | Indicates whether the patient is currently assessed as having the capacity to understand and oversee the consequences of medical treatment decisions. If the patient is not legally capable, there should be a legal representative captured in a RelatedPerson resource. Based on Observation resource
ACP Medical Policy Goal | The primary, agreed-upon goal of a patient's medical treatment policy. Based on Goal resource.
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 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 Patient | A person who receives medical, psychological, paramedical, or nursing care. Based on nl-core-Patient and HCIM Patient.
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 Procedure | Advance Care Planning procedure. Based on nl-core-Procedure-event profile and HCIM Procedure.
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.
ACP TreatmentDirective | This profile specifies verified treatment directives. A treatment directive contains 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.

### Terminology: Value Sets

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

ACP Health Professional Specialty | ValueSet for specialty of the health professional, to be used in the questionnaire. This ValueSet allows codes from both the UZI role coding and the AGB specialty list. The ValueSet is derived from the zib Healthcare Professional Specialty, representing the specialty of the healthcare professional using UZI and AGB codes.
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 Codes | 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 Codes | 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 Codes | ValueSet for Medical Policy Goal, representing the primary agreed-upon goal of a patient's medical treatment policy.
ACP Yes, No, Unknown Codes | ValueSet representing 'Yes, No, Unknown' answers.
ACP Yes, No, Yes with restrictions, Unknown Codes | ValueSet that extends the BehandelingToegestaan code list by adding an 'Unknown' option. It provides the codes representing the possible answers: 'Yes', 'No', 'Yes with restrictions', and 'Unknown'.
ACPContactPersonRoleVS | 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.

### Example: Example Instances

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

Example CommunicationRequest - ACP-InformRelativesRequest-2025-Pat1
Example CommunicationRequest - ACP-InformRelativesRequest-Pat1
Example CommunicationRequest - ACP-InformRelativesRequest-Pat2
Example Consent - ACP-AdvanceDirective-DNR-2025-Pat1
Example Consent - ACP-AdvanceDirective-DNR-Pat1
Example Consent - ACP-AdvanceDirective-DNR-Pat2
Example Consent - ACP-TreatmentDirective-AdministrationOfBloodProduct-2025-Pat1
Example Consent - ACP-TreatmentDirective-AdministrationOfBloodProduct-Pat1
Example Consent - ACP-TreatmentDirective-AdmissionToICU-1-Pat1
Example Consent - ACP-TreatmentDirective-AdmissionToICU-2-Pat1
Example Consent - ACP-TreatmentDirective-AdmissionToICU-2025-Pat1
Example Consent - ACP-TreatmentDirective-AdmissionToICU-Pat2
Example Consent - ACP-TreatmentDirective-AntibioticTherapy-2025-Pat1
Example Consent - ACP-TreatmentDirective-AntibioticTherapy-Pat1
Example Consent - ACP-TreatmentDirective-AntibioticTherapy-Pat2
Example Consent - ACP-TreatmentDirective-ArtificialRespiration-1-Pat2
Example Consent - ACP-TreatmentDirective-ArtificialRespiration-2-Pat2
Example Consent - ACP-TreatmentDirective-ArtificialRespiration-2025-Pat1
Example Consent - ACP-TreatmentDirective-ArtificialRespiration-Pat1
Example Consent - ACP-TreatmentDirective-CardiopulmonaryResuscitaion-Pat2
Example Consent - ACP-TreatmentDirective-CardiopulmonaryResuscitation-2025-Pat1
Example Consent - ACP-TreatmentDirective-CardiopulmonaryResuscitation-Pat1
Example Consent - ACP-TreatmentDirective-HospitalAdmission-2025-Pat1
Example Consent - ACP-TreatmentDirective-HospitalAdmission-Pat1
Example Consent - ACP-TreatmentDirective-HospitalAdmission-Pat2
Example Consent - ACP-TreatmentDirective-Other-Pat1
Example Consent - ACP-TreatmentDirective-Other-Pat2
Example Consent - ACP-TreatmentDirective-SwitchOffICD-2025-Pat1
Example Consent - ACP-TreatmentDirective-SwitchOffICD-Pat1
Example Consent - ACP-TreatmentDirective-SwitchOffICD-Pat2
Example Device - ACP-MedicalDeviceProduct-ICD-Pat1
Example Device - ACP-MedicalDeviceProduct-ICD-Pat2
Example DeviceUseStatement - ACP-MedicalDevice-ICD-Pat1
Example DeviceUseStatement - ACP-MedicalDevice-ICD-Pat2
Example Encounter - ACP-Encounter-1-Pat2
Example Encounter - ACP-Encounter-2-Pat2
Example Encounter - ACP-Encounter-2025-Pat1
Example Encounter - ACP-Encounter-Pat1
Example Goal - ACP-MedicalPolicyGoal-2025-Pat1
Example Goal - ACP-MedicalPolicyGoal-Pat1
Example Goal - ACP-MedicalPolicyGoal-Pat2
Example Observation - ACP-LegallyCapableTreatmentDecisions-Pat1
Example Observation - ACP-LegallyCapableTreatmentDecisions-Pat2
Example Observation - ACP-OrganDonationChoiceRegistration-2025-Pat1
Example Observation - ACP-OrganDonationChoiceRegistration-Pat1
Example Observation - ACP-OrganDonationChoiceRegistrationInDonorRegister-Pat2
Example Observation - ACP-PositionRegardingEuthanasia-2025-Pat1
Example Observation - ACP-PositionRegardingEuthanasia-Pat1
Example Observation - ACP-PositionRegardingEuthanasia-Pat2
Example Observation - ACP-PreferredPlaceOfDeath-2025-Pat1
Example Observation - ACP-PreferredPlaceOfDeath-Pat1
Example Observation - ACP-PreferredPlaceOfDeath-Pat2
Example Observation - ACP-SenseOfPurpose-2025-Pat1
Example Observation - ACP-SenseOfPurpose-Pat1
Example Observation - ACP-SenseOfPurpose-Pat2
Example Observation - ACP-SpecificCareWishes-2025-Pat1
Example Observation - ACP-SpecificCareWishes-Pat1
Example Observation - ACP-SpecificCareWishes-Pat2
Example Patient - ACP-Patient-HendrikHartman-Pat1
Example Patient - ACP-Patient-SamiraVanDerSluijs-Pat2
Example Practitioner - ACP-HealthProfessional-Practitioner-DesireeWolters-Pat2
Example Practitioner - ACP-HealthProfessional-Practitioner-DrVanHuissen-Pat1
Example Practitioner - ACP-HealthProfessional-Practitioner-Gerrits-Pat1
Example Practitioner - ACP-HealthProfessional-Practitioner-Santos-Pat2
Example PractitionerRole - ACP-HealthProfessional-PractitionerRole-DesireeWolters-Pat2
Example PractitionerRole - ACP-HealthProfessional-PractitionerRole-DrVanHuissen-Pat1
Example PractitionerRole - ACP-HealthProfessional-PractitionerRole-Gerrits-Pat1
Example PractitionerRole - ACP-HealthProfessional-PractitionerRole-Santos-Pat2
Example Procedure - ACP-Procedure-1-Pat2
Example Procedure - ACP-Procedure-2-Pat2
Example Procedure - ACP-Procedure-2025-Pat1
Example Procedure - ACP-Procedure-Pat1
Example RelatedPerson - ACP-ContactPerson-GertJanDeJong-Pat2
Example RelatedPerson - ACP-ContactPerson-MayaVanDerSluijsMulder-Pat2
Example RelatedPerson - ACP-ContactPerson-MichielHartman-Pat1
Example RelatedPerson - ACP-ContactPerson-MirjamDeLeeuwHartman-Pat1

### Other

These are resources that are used within this implementation guide that do not fit into one of the other categories.

ACP-QuestionnaireResponse-HendrikHartman-20201001 | Example QuestionnaireResponse ACP Hendrik Hartman 20201001
ACP-QuestionnaireResponse-HendrikHartman-20221108 | Example QuestionnaireResponse ACP Hendrik Hartman 20221108