Jody Smith, a retired nurse with three adult children and numerous adult grandchildren, lives alone in a small rural area. Her income is limited. Two months ago, she fell and broke her left hip. After surgery for an artificial hip replacement, she was transferred to a rehabilitation center, where she had a left-sided cerebrovascular accident (CA). She was then readmitted to the acute care facility, where she

"has received aggressive therapy for the CVA. Completely paralyzed on her left side, Mrs. Smith has decided that she no longer desires aggressive therapy and frequently asks the staff why she cannot die in peace.

"The rehabilitation is so painful and l'll never walk again. What's the use?" Both the doctors and her family are much more optimistic. the orthopedic surgeon is convinced that she will walk again, and the neurologist believes that she will make a full recovery and be able to return home and care for herself.

Both doctors have excluded Mrs. Smith from their conversations, assuring her children that she will be

"as good as new" and ignoring her requests to discontinue anticoagulant and rehabilitative therapy.

While not in a life-threatening condition, Mrs. Smith refuses to cooperate with the physical and occupational therapists and to take her medications. She also refuses to perform simple tasks, relying on staff to meet her activities of daily living.