PLENA Healthcare & End-of-Life Protocol
Receipt grammar for advance directives, healthcare proxies, mental-health advance directives, and dying wishes — durable across jurisdictions, capacity loss, and the institutional change that the multi-decade arc between writing and acting almost always brings.
Opening problem
A patient writes a careful advance directive in their forties — naming a healthcare proxy, declining specific interventions, requesting comfort-focused care in defined circumstances. Three decades later, in a hospital in a different country, with a different legal regime, with the originally named proxy now deceased, and with treating clinicians who have no access to the original document, the directive is functionally invisible. The default decisional chain runs as if the patient never wrote anything down.
A person with periodic mental-health crises completes a psychiatric advance directive specifying which interventions they will accept and which they refuse, with a designated mental-health proxy authorised to act on their behalf during crisis. When the crisis arrives, the emergency-department team has neither the directive nor any way to verify it; the proxy's standing is not recognised; the patient is treated under the default emergency protocols their directive was specifically written to displace.
An elderly person nearing the end of life has, over years, communicated specific wishes about the dying process — who is to be present, what rites are to be observed, what is to be done with the body, what messages are to be conveyed, to whom. Some of these wishes are partially captured in formal documents; most exist in the memories of the people who heard them spoken. When the dying period arrives, the formal documents are incomplete and the witnesses are not all present.
In each case, the patient or principal did the difficult work of articulating their wishes in advance. The system failure is one of durability and presentation, not articulation. The wishes existed; the receiving institution could not act on them at the moment they needed to.
PLENA Healthcare & End-of-Life Protocol records advance directives, healthcare proxies, mental-health advance directives, and dying wishes in a form that survives the multi-decade arc between writing and acting — capacity loss, geographic relocation, jurisdictional change, proxy succession, and the dissolution or transformation of the institutions originally expected to hold the records.
Four-layer architecture, applied to healthcare and end-of-life
The four-layer commitment-protocol architecture from Beyond the Will, adapted to the structural shape of advance medical decisions.
1. Identity & capacity attestation
Verified identity binding for the principal and any named proxy. Contemporaneous capacity attestation at the moment the directive is written — that the principal was capable of articulating and authorising the directive under the relevant jurisdiction's standard. This is the load-bearing layer for any later challenge to the directive's validity.
2. Intent & the parties to whom the directive extends
The substantive content of the directive: specific interventions accepted or refused, conditions under which the directive activates, scope of proxy authority. The named parties: primary proxy, alternate proxy, treating clinicians informed, family members informed, ecclesial or spiritual authorities named.
3. Clinical and relational graph (rather than asset graph)
The clinical context: existing diagnoses, baseline functional status, treatment history relevant to the directive, medications, allergies. The relational context: which family members and chosen-family are named, which are explicitly not granted proxy authority, prior healthcare-proxy relationships dissolved or superseded by this directive.
4. Versioning, trigger, custody
Versioning across the life of the directive: written, refreshed, amended, superseded by a later directive, revoked. Triggers: hospitalisation, capacity loss, hospice admission, mental-health crisis, dying period. Custodial chain — who holds the original, who can release it to a treating clinician, on whose authority. The custodial layer is what makes the difference between a directive that exists and a directive that gets acted on.
Five workflows the protocol covers
Each workflow produces a sealed directive, contemporaneous capacity attestation, refresh discipline across the multi-decade arc between writing and acting, and a multilingual handover packet calibrated to treating clinicians and care teams.
Advance directive (general medical)
For the substantive medical advance directive — living will, instructional directive, treatment-preference declaration — that specifies which interventions the principal accepts or refuses in defined circumstances. Captures the directive itself, the contemporaneous capacity attestation, and the multi-decade custodial chain that allows the directive to be presented at the moment of need.
- Substantive directive content with explicit scope and conditions
- Contemporaneous capacity attestation at the moment of writing
- Named witnesses where the local jurisdiction requires them
- Multilingual handover packet for cross-jurisdictional presentation
Healthcare proxy designation
For the named healthcare proxy, alternate proxy, and any sub-authority granted to particular decision-makers for particular decisions. Interoperates with the Care & Companionship Protocol when the proxy is a non-married chosen-family member whose relational standing also needs to be recorded.
- Verified identity binding for principal and proxy(ies)
- Scope of proxy authority and any sub-delegation
- Succession chain if primary proxy is unavailable
- Coordination with relational-standing record where the proxy is non-married chosen family
Mental-health advance directive
For psychiatric advance directives — distinct in legal structure and substantive content from general medical advance directives, with specific provisions for crisis intervention, voluntary versus involuntary admission, accepted and refused medications, named mental-health proxy, crisis-residence preferences, and post-crisis transition planning.
- Substantive psychiatric-directive content with crisis-specific scope
- Contemporaneous capacity attestation at the moment of writing (typically during a period of stability)
- Named mental-health proxy with crisis-specific authority
- Coordination with treating mental-health team where the principal chooses
Dying wishes (non-clinical)
For the non-clinical aspects of the dying period — who is to be present, what rites or traditions are to be observed, what messages are to be conveyed and to whom, what is to be done with personal effects in the immediate post-death period before the inheritance process formally begins. Bridges the clinical end-of-life domain to the ceremonial and relational domain.
- Presence list: who the principal designates to be present
- Ritual or traditional observances specific to the principal's tradition
- Communications: messages to be conveyed, to whom, on what timing
- Immediate post-death custodial instructions for the period before Beyond the Will inheritance handover begins
Cross-jurisdictional and capacity-loss durability
For the specific durability challenge that healthcare directives face — written in one jurisdiction, acted on in another; written when the principal had capacity, acted on after capacity loss; written when the primary proxy was alive, acted on after the proxy is deceased. Records the directive in a form that survives all of these transitions.
- Multi-jurisdictional translation packet for legal-recognition variation across regimes
- Capacity-loss handover protocol: who carries the directive forward when the principal can no longer present it
- Proxy-succession handover protocol
- Institutional-change durability via PLENA CONSERVA
Integration with existing PLENA infrastructure
VRX-1 receipt grammar
Every Healthcare & End-of-Life Protocol artifact is a VRX-1 receipt — externally anchored, cryptographically verifiable, multilingual. Treating clinicians, hospitals, mental-health facilities, and care teams can verify a directive independently of PLENA's continued existence and independently of the original drafting attorney's continued availability.
Wallet integration
Directives, proxy designations, and dying-wishes records live in the principal's PlenaProof Vault — and, with the principal's consent, in copies held by the named proxy and a designated emergency-contact party. The Wallet's custodial discipline applies. At the moment of crisis, the proxy presents the directive from their Wallet; the receiving clinician verifies the VRX-1 receipt; the directive is on the chart in minutes rather than weeks.
PLENA CONSERVA — long-term archival
Healthcare directives may be written decades before they are acted on. CONSERVA carries the multi-decade archival layer that makes a directive written in 2026 still presentable in 2056, after the original drafting jurisdiction's law has evolved, after the originally-named proxy is deceased, after the principal has moved across multiple healthcare systems.
PLENA SIGILLA — cross-border sealing
For directives requiring formal cross-border recognition — common in retirement-abroad, diaspora, and snowbird-residency contexts — SIGILLA provides the sealing layer that supports apostille-equivalent verification across jurisdictions whose healthcare-directive recognition laws differ.
Sworn Reviewer Registry
For workflows requiring named human review — capacity attestation at the moment of writing, periodic refresh review, proxy-succession review, mental-health-directive capacity review — the Sworn Reviewer Registry provides the accountable pathway.
Refusal Receipts
If a treating clinician, hospital ethics committee, or institutional reviewer declines to honour a directive — citing scope, jurisdictional non-recognition, capacity dispute, or institutional conscience — the Refusal Receipts infrastructure preserves the refusal. The principal's wishes are not silently overridden; the override leaves a record the proxy, family, and any subsequent reviewing body can act on.
Coordination with Healthcare Consent Attestation
The existing PLENA Healthcare Consent Attestation sector product covers patient-controlled receipts for clinical trials, procedures, and capacity-attested consent in the active-treatment context. This protocol's directives interoperate with those receipts: a consent receipt issued under a directive references the underlying directive; a directive amended in response to a treatment course updates with reference to the consent receipts.
Relationship to Beyond the Will
This protocol stops where inheritance begins. Dying-wishes workflow covers the immediate post-death custodial period; the formal inheritance process — executor mandate, asset graph, beneficiary structure, multi-jurisdictional probate handover — is the domain of the Beyond the Will protocol. The two are designed to hand off cleanly: a person's complete end-of-life and post-death record exists across both protocols, each governing what it is structured to govern.
Why this matters in the AGI era
AI degrades the evidentiary status of healthcare directives along the same axis as it degrades other relational evidence. Synthesised proxy designations, fabricated witness signatures, and AI-generated capacity-attestation documents can all be produced at scale. Hospitals, ethics committees, and treating clinicians respond by tightening their verification standards — and the tightening hurts the patient whose real directive cannot be quickly verified at the moment it needs to be acted on.
At the same time, AI-driven clinical decision support is rapidly entering the workflow at which directives are supposed to govern. The decision the directive was written to govern is increasingly being framed and presented to clinicians by an AI system whose framing the directive's author did not see. Cryptographically verifiable, externally anchored directives that an AI clinical-decision-support layer can cite — not paraphrase, not approximate, but cite verbatim with verification — become the discipline that makes AI-augmented clinical decision-making compatible with patient self-determination rather than its erosion.
PLENA Healthcare & End-of-Life Protocol gives patients a directive form that an AI clinical-decision-support layer cannot misquote, that a treating clinician can verify in minutes, that a hospital ethics committee can rely on under challenge, and that a court can act on decades after writing. The patient's actual wishes remain the load-bearing input to the moment of care, regardless of how much AI sits between the directive and the bedside.
What this does not do
Boundary. PlenaProof records verified human commitments. It does not replace marriage law, family law, healthcare law, or any community's internal governance. PlenaProof complements existing legal and institutional infrastructure with receipt grammar that survives the moments these instruments need to be acted on.
More specifically: PlenaProof does not draft advance directives, does not provide medical advice, does not provide healthcare-law or mental-health-law legal advice, does not adjudicate capacity, does not regulate the clinical practice of any treating provider, does not bind any hospital or ethics committee to honour a directive, and does not constitute a substitute for jurisdiction-specific directive forms where local law mandates a particular form. PlenaProof produces externally anchored receipts of what directive content was attested, by whom, when, with what capacity attestation, under what custodial chain — receipts that treating clinicians, hospitals, ethics committees, courts, and care teams can verify and weigh under their own clinical and legal standards.