A 68-year-old retired City of Philadelphia recreation director was admitted to a local city hospital for treatment of difficulty breathing as a result of emphysema. In the middle of the night, the oxygen levels in her blood dropped and she became disoriented. Without first examining her, a resident ordered the nurse to give her a sedative. Within ten minutes she went into cardiac arrest and a “code red” was called. The doctors had incorrectly recorded her advanced directive instructions and, rather than providing her cardiac resuscitation as she had requested, they stood by and watched her die. We retained experts in bioethics and pharmacology and in spite of the difficulty in proving that she would have survived had she been resuscitated, the matter settled for $200,000.