Case study: Harriet Billings, a 76 year – old retired nurse, developed endocarditis and mitral valve dysfunction from an infected pacemaker lead. Harriet’s past history included a 3-month hospital stay following mitral valve surgery 7 years earlier. She was overweight and had longstanding chronic lung disease but was precise in managing all her medications. Harriet had lived alone for the past 1 year following the death of her husband. She had recently updated has advance directive and Durable Power of Attorney for Health Care, reaffirming that she wanted to be intubated, have hemodialysis, and to have cardiopulmonary resuscitation, should they be necessary. In addition, she gave her brother power to make healthcare decisions for her should she become incapacitated.