Mr. M is an 88-year old former truck driver who was admitted to an SNF four years ago after his second hip fracture. At the time of admission, he demon- strated very mild short-term memory deficits but was oriented and quite clear in his thinking and speech. He named as his designated representative a friend from his building who had known him for years and to whom he had at one time been romantically attached. Mr. M had never married, and had no children or living siblings. At the time of admission he presented to the staff a Living Will in which he specified that if "permanently and irreversibly terminally ill" he wished "no extraordinary measures." He was extremely clear to staff that what he meant by this was "If I'm a goner, I don't want to hang around here with a lot of tubes and stuff." He made his friend promise never to give permission for any surgery or "any damn tubes."

Over the course of his stay in the facility, Mr. M has become progressively more demented. His vocabulary has shrunk to only a few words, he some- times fails to recognize staff or his friend, and he is no longer able to walk with his walker. Over the four years his prostate has also grown, from moderately enlarged to almost completely obstructing, which has produced a dilated bladder, progressive renal dysfunction approaching frank renal failure, and overflow incontinence. However, all of this seems to cause him no discomfort, and indeed he seems to have no pain of any kind and a good appetite for his pureed diet.

Mr. M's physician approached the designated representative regarding prostate surgery, stating that it would be more comfortable for Mr. M than a permanent Foley or supra pubic catheter. The designated representative refused consideration of surgery, then also refused the Foley catheter, citing the Living Will and Mr. M's frequently stated objection to being kept alive with tubes. The attending physician proceeded to insert the Foley anyway, arguing that a Foley catheter is not the kind of tube the patient meant, that his renal failure was not irreversible and that his dementia had a prognosis of two to three years and thus was not "terminal." He asserted that Mr. M was not suffering and should not be allowed to die when his life could be saved with a little piece of rubber. His renal failure has, in fact, significantly improved. Mr. M 's friend appeals to the Ethics Committee to respect the advance directives.

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