Handbook
Caregiving, Ageing, and End-of-Life Navigation Intelligence
Support person-centered care coordination, functional goals, caregiver sustainability, service navigation, advance-care conversations, and dignified end-of-life administration.
Updated
Definition
Support person-centered care coordination, functional goals, caregiver sustainability, service navigation, advance-care conversations, and dignified end-of-life administration.
Coverage role
Many people give or receive care across disability, illness, ageing, and end of life; coordination failures can cause harm and burnout.
Scope
Included
- needs and function mapping
- integrated care plans
- care-team roles
- medicines and appointments
- home safety
- caregiver load and respite
- advance care
- end-of-life administration
Excluded and non-goals
- determining legal capacity
- changing medication
- overriding known wishes
- replacing clinicians or lawyers
- coercing institutionalization
Boundary rules
- Route to life.caregiving-ageing-end-of-life when the requested outcome requires one or more declared capabilities and the output can be represented by its canonical artifacts.
- Route to an adjacent or specialist intelligence when domain-specific rules, tools, or professional authority dominate the problem.
- Use general.reasoning to coordinate multi-pack conflicts, hard constraints, uncertainty, and decision status.
- Return ask, defer, or escalate when required context, source authority, consent, or accountable ownership is missing.
Capability semantics
| Capability ID | Name | Semantic intent |
|---|---|---|
capability.life.caregiving-ageing-end-of-life.map_person_centered_needs |
Map Person Centered Needs | Capture values abilities needs risks environment and decision preferences. |
capability.life.caregiving-ageing-end-of-life.build_integrated_care_plan |
Build Integrated Care Plan | Coordinate health personal care household mobility social financial and emotional supports. |
capability.life.caregiving-ageing-end-of-life.coordinate_care_team |
Coordinate Care Team | Clarify consent roles contacts information sharing handoffs and escalation. |
capability.life.caregiving-ageing-end-of-life.manage_care_administration |
Manage Care Administration | Organize appointments medication lists equipment transport records and follow-up. |
capability.life.caregiving-ageing-end-of-life.support_caregiver_sustainability |
Support Caregiver Sustainability | Assess workload sleep finances emotional load backup coverage training and respite. |
capability.life.caregiving-ageing-end-of-life.plan_changing_capacity |
Plan Changing Capacity | Prepare for falls deterioration hospital transition loss of function and emergency communication. |
capability.life.caregiving-ageing-end-of-life.navigate_advance_end_of_life |
Navigate Advance End Of Life | Prepare values questions documents services family communication and practical administration. |
Canonical artifact concepts
| Artifact type | Structural category | Semantic purpose |
|---|---|---|
artifact.life.caregiving-ageing-end-of-life.person_centered_care_context |
context_profile | Person Centered Care Context for Caregiving, Ageing, and End-of-Life Navigation Intelligence: A bounded context profile that separates observations, preferences, constraints, uncertainty, time scope, and next questions. It supports the pack purpose of support person-centered care coordination, functional goals, caregiver sustainability, service navigation, advance-care conversations, and dignified end-of-life administration. |
artifact.life.caregiving-ageing-end-of-life.functional_goal_map |
model | Functional Goal Map for Caregiving, Ageing, and End-of-Life Navigation Intelligence: A purpose-bounded representation of entities, relationships, assumptions, boundaries, and evidence of adequacy. It supports the pack purpose of support person-centered care coordination, functional goals, caregiver sustainability, service navigation, advance-care conversations, and dignified end-of-life administration. |
artifact.life.caregiving-ageing-end-of-life.integrated_care_plan |
plan | Integrated Care Plan for Caregiving, Ageing, and End-of-Life Navigation Intelligence: A governed action design that sequences work, ownership, dependencies, timing, contingencies, and review. It supports the pack purpose of support person-centered care coordination, functional goals, caregiver sustainability, service navigation, advance-care conversations, and dignified end-of-life administration. |
artifact.life.caregiving-ageing-end-of-life.care_team_matrix |
model | Care Team Matrix for Caregiving, Ageing, and End-of-Life Navigation Intelligence: A purpose-bounded representation of entities, relationships, assumptions, boundaries, and evidence of adequacy. It supports the pack purpose of support person-centered care coordination, functional goals, caregiver sustainability, service navigation, advance-care conversations, and dignified end-of-life administration. |
artifact.life.caregiving-ageing-end-of-life.caregiver_load_map |
model | Caregiver Load Map for Caregiving, Ageing, and End-of-Life Navigation Intelligence: A purpose-bounded representation of entities, relationships, assumptions, boundaries, and evidence of adequacy. It supports the pack purpose of support person-centered care coordination, functional goals, caregiver sustainability, service navigation, advance-care conversations, and dignified end-of-life administration. |
artifact.life.caregiving-ageing-end-of-life.contingency_plan |
plan | Contingency Plan for Caregiving, Ageing, and End-of-Life Navigation Intelligence: A governed action design that sequences work, ownership, dependencies, timing, contingencies, and review. It supports the pack purpose of support person-centered care coordination, functional goals, caregiver sustainability, service navigation, advance-care conversations, and dignified end-of-life administration. |
artifact.life.caregiving-ageing-end-of-life.advance_care_brief |
brief | Advance Care Brief for Caregiving, Ageing, and End-of-Life Navigation Intelligence: A bounded specification of purpose, stakeholders, requirements, constraints, assumptions, and success criteria. It supports the pack purpose of support person-centered care coordination, functional goals, caregiver sustainability, service navigation, advance-care conversations, and dignified end-of-life administration. |
artifact.life.caregiving-ageing-end-of-life.end_of_life_administration_plan |
plan | End Of Life Administration Plan for Caregiving, Ageing, and End-of-Life Navigation Intelligence: A governed action design that sequences work, ownership, dependencies, timing, contingencies, and review. It supports the pack purpose of support person-centered care coordination, functional goals, caregiver sustainability, service navigation, advance-care conversations, and dignified end-of-life administration. |
artifact.life.caregiving-ageing-end-of-life.care_administration_register |
ledger | Care Administration Register for Caregiving, Ageing, and End-of-Life Navigation Intelligence: A controlled collection of uniquely identified entries with ownership, provenance, status, and review state. It supports the pack purpose of support person-centered care coordination, functional goals, caregiver sustainability, service navigation, advance-care conversations, and dignified end-of-life administration. |
artifact.life.caregiving-ageing-end-of-life.capacity_and_contingency_plan |
plan | Capacity And Contingency Plan for Caregiving, Ageing, and End-of-Life Navigation Intelligence: A governed action design that sequences work, ownership, dependencies, timing, contingencies, and review. It supports the pack purpose of support person-centered care coordination, functional goals, caregiver sustainability, service navigation, advance-care conversations, and dignified end-of-life administration. |
Method families and limits
| Method ID | Method | Use when | Avoid when |
|---|---|---|---|
method.life.caregiving-ageing-end-of-life.person_centered_goals |
person-centered goals | Use when an ambiguous request must be converted into a decision-relevant, answerable, bounded question or requirements brief. | Avoid endless clarification, leading questions, hidden presuppositions, unnecessary personal-data collection, and solutioning before the decision context is known. |
method.life.caregiving-ageing-end-of-life.integrated_health_and_social_care |
integrated health and social care | Use to organize observations, function, routines, burden, goals, and questions for self-management or professional review without diagnosing or prescribing. | Avoid delaying urgent care, changing medication or treatment, using population guidance as personalized clearance, or ignoring consent, capacity, contraindications, and caregiver burden. |
method.life.caregiving-ageing-end-of-life.role_and_consent_matrices |
role and consent matrices | Use when several people or institutions have different interests, rights, constraints, information, or acceptable outcomes and an agreement or safe boundary is needed. | Avoid where coercion, abuse, incapacity, severe power asymmetry, or non-negotiable safety and rights constraints make ordinary negotiation unsafe. |
method.life.caregiving-ageing-end-of-life.caregiver_workload_planning |
caregiver workload planning | Use to organize observations, function, routines, burden, goals, and questions for self-management or professional review without diagnosing or prescribing. | Avoid delaying urgent care, changing medication or treatment, using population guidance as personalized clearance, or ignoring consent, capacity, contraindications, and caregiver burden. |
method.life.caregiving-ageing-end-of-life.functional_ability_analysis |
functional ability analysis | Use to organize observations, function, routines, burden, goals, and questions for self-management or professional review without diagnosing or prescribing. | Avoid delaying urgent care, changing medication or treatment, using population guidance as personalized clearance, or ignoring consent, capacity, contraindications, and caregiver burden. |
method.life.caregiving-ageing-end-of-life.transition_and_contingency_planning |
transition and contingency planning | Use when work must be sequenced across dependencies, people, time, capacity, deadlines, contingencies, and review points. | Avoid false precision, schedules that ignore uncertainty or human capacity, and plans without owners, fallbacks, or stop conditions. |
Pack-specific invariants
The pack also inherits the core invariants in core/core_invariants.yaml.
| Invariant ID | Statement | Failure action |
|---|---|---|
invariant.life.caregiving-ageing-end-of-life.01_the_person_receiving_care_remains_the_primary_rights_holde |
The person receiving care remains the primary rights holder. | escalate |
invariant.life.caregiving-ageing-end-of-life.02_consent_capacity_and_authority_are_not_assumed_from_family |
Consent capacity and authority are not assumed from family relationship. | escalate |
invariant.life.caregiving-ageing-end-of-life.03_caregiver_sustainability_and_backup_are_explicit |
Caregiver sustainability and backup are explicit. | escalate |
invariant.life.caregiving-ageing-end-of-life.04_clinical_legal_and_end_of_life_decisions_use_qualified_cur |
Clinical legal and end-of-life decisions use qualified current guidance. | escalate |
Dependencies and relations
Operational general intelligences: None
Foundation concepts: general.collaborative-social, general.planning-execution, general.temporal, general.ethical-normative, general.systems
Life intelligences: life.health-navigation-self-care, life.accessibility-independent-living, life.personal-finance-resilience, life.civic-legal-public-services, life.grief-loss-major-transitions
Source roles
| Source ID | Claim roles | Runtime resolution required |
|---|---|---|
who.icope |
concept_definition, health_or_safety_boundary, population_guidance | True |
who.life_course |
concept_definition, health_or_safety_boundary, population_guidance | True |
local.authority |
jurisdiction_rule, runtime_fact, service_or_community_context | True |
un.crpd.accessibility |
concept_definition | True |
Risk and authority boundary
Risk class: critical
- Acute deterioration injury or medicine error.
- Abuse neglect exploitation or unsafe caregiver capacity.
- Capacity advance-directive benefits or end-of-life legal questions.
- Severe caregiver distress.
Accountable people retain consent, value, regulated, irreversible, and residual-risk decisions. This semantic page does not claim a deployed implementation.
Maturity
semantic: S3_reviewable_definition
contract: C3_testable_contract
implementation: I0_not_included
evidence: E2_source_roles_mapped
governance: G2_controls_and_review_defined
overlay: O2_paired_seed_complete
Paired overlay
Runtime maturity
- Capabilities: 7
- Technical floor→ceiling:
I1_runtime→I2_integrated - Autonomy floor→ceiling:
A0_assisted→A0_assisted - I1_runtime count: 6
- Evidence class:
contract: 6,semantic: 1 - Full hierarchy: MATURITY-HIERARCHY.md
Evaluation suite status
- CI status:
pass - Suite:
evaluation_suites/caregiving-ageing-end-of-life.yaml - Cases defined: 7
- Capabilities under test: 7