1-Update CarePlan scope to say: Self-maintained patient or care-giver authored plans identifying their goals and an integrated understanding of actions to be taken. This does not include the legal Advance Directives, which should be represented with either the Consent resource with Consent.category = Advance Directive or with a specific request resource with intent = directive. Informal advance directives could be represented as a Goal, such as "I want to die at home." 2-Add comments to CarePlan.supportingInfo as follows: CarePlan.supportingInfo, 0..*, Reference(Any) Add comment: "supportingInfo can be used to convey one or more Advance Directives or Medical Treatment Consent Directives by referencing Consent, or any other request resource with intent = directive" 3-Update Goal boundaries to say: Goal does not include the legal Advance Directives, which should be represented with the Consent resource with Consent.category = Advance Directive or a request resource with the intent = directive. Legal Advance Directives may specify clinical goals that can be represented as a Goal resource as well. Informally, advance directives could be represented as a Goal resource regardless of whether it was included in the legal Consent, such as "I want to die at home." 4-Update the CarePlan.intent value set to include directive