3.2 Advance Directives

The template identifier for the Advance Directives section is 2.16.840.1.113883.10.20.1.1.

This section contains data defining the patient’s advance directives and any reference to supporting documentation. The most recent and up-to-date directives are required, if known, and should be listed in as much detail as possible. This section contains data such as the existence of living wills, healthcare proxies, and CPR and resuscitation status. If referenced documents are available, they can be included in the CCD exchange package.

NOTE: The descriptions in this section differentiate between “advance directives” and “advance directive documents”. The former are the directions whereas the latter are legal documents containing those directions. Thus, an advance directive might be “no cardiopulmonary resuscitation”, and this directive might be stated in a legal advance directive document.

CONF-77: CCD SHOULD contain exactly one and SHALL NOT contain more than one Advance directives section (templateId 2.16.840.1.113883.10.20.1.1). The Advance directives section SHALL contain a narrative block, and SHOULD contain clinical statements. Clinical statements SHOULD include one or more advance directive observations (templateId 2.16.840.1.113883.10.20.1.17). An advance directive observation MAY contain exactly one advance directive reference (templateId 2.16.840.1.113883.10.20.1.36) to an external advance directive document.

3.2.1 Section conformance

CONF-78: The advance directive section SHALL contain Section / code.
CONF-79: The value for “Section / code” SHALL be “42348-3” “Advance directives” 2.16.840.1.113883.6.1 LOINC STATIC.
CONF-80: The advance directive section SHALL contain Section / title.
CONF-81: Section / title SHOULD be valued with a case-insensitive language-insensitive text string containing “advance directives”.

3.2.2 Clinical statement conformance

The following figure shows a subset of the CDA Clinical Statement model containing those classes being constrained or referred to in the conformance statements that follow.

Figure 6. CDA R2 clinical statement model for advance directives

3.2.2.1 Advance directive observations

The template identifier for an advance directive observation is 2.16.840.1.113883.10.20.1.17.
The template identifier for verification of an advance directive observation is templateId 2.16.840.1.113883.10.20.1.58.

Advance directives in the ASTM CCR correspond to CDA R2 Observations in Event mood in that they assert findings (e.g. “resuscitation status is Full Code”) rather than orders.

CONF-82: An advance directive observation (templateId 2.16.840.1.113883.10.20.1.17) SHALL be represented with Observation.
CONF-83: The value for “Observation / @classCode” in an advance directive observation SHALL be “OBS” 2.16.840.1.113883.5.6 ActClass STATIC.
CONF-84: The value for “Observation / @moodCode” in an advance directive observation SHALL be “EVN” 2.16.840.1.113883.5.1001 ActMood STATIC.
CONF-85: An advance directive observation SHALL contain at least one Observation / id.
CONF-86: An advance directive observation SHALL contain exactly one Observation / statusCode.
CONF-87: The value for “Observation / statusCode” in an advance directive observation SHALL be “completed” 2.16.840.1.113883.5.14 ActStatus STATIC.
CONF-88: An advance directive observation SHOULD contain exactly one Observation / effectiveTime, to indicate the effective time of the directive.
CONF-89: An advance directive observation SHALL contain exactly one Observation / code.
CONF-90: The value for “Observation / code” in an advance directive observation MAY be selected from ValueSet 2.16.840.1.113883.1.11.20.2 AdvanceDirectiveTypeCode STATIC 20061017.
CONF-91: There SHOULD be an advance directive observation whose value for “Observation / code” is “304251008” “Resuscitation status” 2.16.840.1.113883.6.96 SNOMED CT STATIC.
CONF-92: A verification of an advance directive observation (templateId 2.16.840.1.113883.10.20.1.58) SHALL be represented with Observation / participant.
CONF-93: An advance directive observation MAY include one or more verifications.
CONF-94: The value for “Observation / participant / @typeCode” in a verification SHALL be “VRF” “Verifier” 2.16.840.1.113883.5.90 ParticipationType STATIC.
CONF-95: A verification of an advance directive observation SHOULD contain Observation / participant / time.
CONF-96: The data type of Observation / participant / time in a verification SHALL be TS (time stamp).
CONF-97: An advance directive observation SHALL contain one or more sources of information, as defined in section 5.2 Source.

3.2.2.2 Representation of “status” values

The template identifier for an advance directive status observation is 2.16.840.1.113883.10.20.1.37.
CONF-98: An advance directive observation SHALL contain exactly one advance directive status observation. CONF-99: An advance directive status observation (templateId 2.16.840.1.113883.10.20.1.37) SHALL be a conformant status observation (templateId 2.16.840.1.113883.10.20.1.57) (as defined in section 5.1 “Type” and “Status” values).
CONF-100: The value for “Observation / value” in an advance directive status observation SHALL be selected from ValueSet 2.16.840.1.113883.1.11.20.1 AdvanceDirectiveStatusCode STATIC 20061017.

3.2.2.3 Advance directive references

The template identifier for an advance directive reference is 2.16.840.1.113883.10.20.1.36.

Referenced advance directive documents are represented with the ExternalDocument class.

CONF-101: An advance directive reference (templateId 2.16.840.1.113883.10.20.1.36) SHALL be represented with Observation / reference / ExternalDocument.
CONF-102: An advance directive observation MAY contain exactly one advance directive reference.
CONF-103: The value for “Observation / reference / @typeCode” in an advance directive reference SHALL be “REFR” 2.16.840.1.113883.5.1002 ActRelationshipType STATIC.
CONF-104: ExternalDocument SHALL contain at least one ExternalDocument / id.
CONF-105: The URL of a referenced advance directive document MAY be present, and SHALL be represented in Observation / reference / ExternalDocument / text / reference. A <linkHTML> element containing the same URL SHOULD be present in the associated CDA Narrative Block.
CONF-106: The MIME type of a referenced advance directive document MAY be present, and SHALL be represented in Observation / reference / ExternalDocument / text / @mediaType.
CONF-107: Where the value of Observation / reference / seperatableInd is “false”, the referenced advance directive document SHOULD be included in the CCD exchange package. The exchange mechanism SHOULD be based on Internet standard RFC 2557 “MIME Encapsulation of Aggregate Documents, such as HTML (MHTML)” (http://www.ietf.org/rfc/rfc2557.txt). (See CDA Release 2, section 3 “CDA Document Exchange in HL7 Messages” for examples and additional details).