The man had w17span-master675ritten an advance directive four years ago, before his advancing dementia had made communication difficult. He had been very specific.

In case of a life-threatening condition, “he wanted comfort care only, no heroics,” said Dr. Rebecca Aslakson, a critical care anesthesiologist at Johns Hopkins Hospital in Baltimore.

But last month an uncontrollable nosebleed caused the 79-year-old to begin vomiting blood. The nursing home that cared for him sent him to a hospital, where doctors put him on a ventilator. They slowed the bleeding, but couldn’t stop it.

After a week and two surgical procedures, the patient was transferred to Johns Hopkins. There, physicians stopped the nosebleed, performed a tracheostomy (a procedure to create an opening in the throat that would permit long-term ventilator use) and placed a feeding tube in his stomach.

Two weeks after that, a surgeon happened to find the patient’s advance directive in his medical chart. None of the other health care providers had noticed it, which meant they had all inadvertently violated it.

Such missteps occur more commonly than most of us, with our carefully composed documents stored in drawers somewhere, would like to think. They help explain why researchers and medical staff working with patients near the end of life have grown increasingly disenchanted with advance directives, including living wills and powers of attorney for health care.  

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