Mr. Martino’s otolaryngologist recently recommended a tracheostomy as palliative surgery to alleviate his symptoms, but his wife reports that he refused the procedure. The clinic notes from 4 days ago state that he refused a tracheostomy because he does not want to “go on living like an old sick person”. The wife verifies that just over a year ago, this former marine prided himself on his ability to run a full marathon, work 60 hours a week as a general contractor, and enjoyed going out for a few beers weekly with the guys on Friday evenings.