Age: 66.0
Sex: M
Vaccine: COVID19
Symptoms: Streptococcus test positive, Unresponsive to stimuli, White blood cell count increased
Clinical narrative: HOSPITAL COURSE: This is a 66-year-old male with history of hep C cirrhosis, BPH with chronic retention, methamphetamine/tobacco/PTSD/homelessness, mesothelioma and non-small cell carcinoma of the lung s/p chemo/XRT, and middle lobectomy/thoracotomy at medical facility in 2013.  He had a hospitalization in July 2020 where he was noted to have recurrent pulmonary malignancy, but was not a surgical candidate. He was counseled to discharge to Transitional Care but he instead requested discharge to the street. He repeated has declined appropriate care when in the hospital, and he has repeatedly left the hospital against medical advice and without appropriate follow-up plan in place. He was interviewed by Dr. on 7/2 who documented fixed delusions but capacity to make his own medical decisions, feeling patient's interpretation of facts "did not appear to be unduly influenced by delusion". I discussed the patient's care with admitting physician, and we agreed that in the combination of social and medical chaos, and noting a prior decision by another Dr. not to proceed with surgical intervention of a pulmonary mass, that heroic resuscitative efforts would be futile, and patient should be limited code - no compressions or intubation. Dr., palliative care, reviewed chart and also agrees that No Code is appropriate.  On the last day of hospitalization, September 8, 2021, this patient was seen and examined at the bedside and he was comatose and did not respond to voice, touch, or a sternal rub.  For maintenance of an adequate blood pressure this patient was on a maximal dose of vasopressin at 20 mL/h.  This patient was noted with severe acute kidney injury on admission and on the day of discharge his sodium was 139, potassium 5.6, BUN 144, and creatinine 5.22.  This patient was seen in consultation by the nephrology service but his blood pressure was too low to allow hemodialysis.  If the patient's white blood count was 16.7 on the day of discharge.  Total bilirubin was elevated at 3.7,  AST 49, ALT 74, and serum albumin was low at 1.4.  Blood cultures on admission September 4, 2021 were positive for Streptococcus pneumonia a and Staphylococcus hominis.  This patient was receiving appropriate IV antibiotic therapy during this hospitalization.  The patient again was comatose and given the constellation of the severe end organ damage in the setting of severe sepsis the patient was subsequently transitioned to comfort care and end-of-life care.  I discussed this case with Dr. with the nephrology service and Dr. with the palliative care service and we all agreed that a transition to comfort care was the best treatment plan for this patient.  In the morning on September 8, 2021 I did not renew the patient's treatment with IV vasopressin and I discontinued all IV antibiotic therapy.  Telemetry was also discontinued.  IV morphine and IV Ativan were ordered for treatment of pain and anxiety respectively.  This patient subsequently expired at 12:45 PM on September 8, 2021.  I was unable to make contact with any family members or any possible DURABLE POWER OF ATTORNEY for this patient.  The mortuary on duty was contacted this afternoon.  This patient was pronounced expired on September 8, 2021 at 12:45 PM.