Age: 63.0
Sex: M
Vaccine: PNC20, PNC20
Symptoms: Agitation, Autonomic nervous system imbalance, Blood pressure decreased, Bradycardia, Bronchoscopy abnormal
Clinical narrative: 3/16/24 - Patient and wife reported that the patient started experiencing numbness and the weakness on both lower extremities since 9:30 PM last night.  Due to the new symptoms, patient had the difficulty standing up and walking.  Patient also reported frozen feeling on his both feet.  But he denied vision change, hearing change, numbness and tingling, chest pain, difficulty breathing, nausea, vomiting, abdominal pain.  He also denies any injury or falls in past 2 weeks. 3/17 neurology consulted. Intubated. Began first dose of IVIG  3/18 LP confirmed GBS diagnosis. Second dose of IVIG.  3/19 Discussions regarding tracheostomy held with family. Pt expressing wishes to not proceed with trach but concerns that patient is not alert and oriented. Tracheostomy put on hold. Third dose of IVIG  3/20 Fourth and final dose of IVIG. Patient continues to express wishes to stop treatment and not proceed with tracheostomy or further care 3/21 Pt continues to be agitated and not wanting to proceed with treatment 3/22 Palliative Care consulted.  Psych consulted to determine patient's capacity to make decisions. Pt deemed not able to make decisions.  3/24 Bronched with copious purulent samples collected. Concern for ileus vs partial obstruction due to no bowel movement since admission and vomiting episode despite multiple enemas, multiple suppositories, daily senna and miralax, relistor. Hypernatremia-increased FWF  3/27 scheduled for trache placement; however, due to high FiO2 requirements (60%), recent pneumonia the surgery was to be rescheduled once pulmonary function improved  3/28 ID consulted due to new pneumonia, increasing WBC, and fever. Ceftriaxone started for possible lyme disease 3/29 FiO2 requirements continue to be high with persistent hypoxemia. CT negative for PE. Bronched again  3/31 continuing linezolid for MRSA pneumonia and ceftriaxone discontinued due to no risk factors for lyme disease 4/1 neurology reevaluted due to persistent extremity weakness, autonomic dysfunction, respiratory failure, and sensory deficit. PLEX treatment started 4/2 febrile in the morning. Brief BP drop with HME exchange 4/3 now possibly able to feel all 4 extremities. Received 2nd PLEX treatment. Hypoxic event with bradycardia. FiO2 requirements increased to 100%. No PIP or plats and no thick mucous suctioned. Slowly able to wean FiO2 back down to baseline. GOC conversation held with wife and pts sister. The wife expressed that she thinks the patient is very tired and "just done." She's noticed an acute change in his demenor over the last day or son. She stated that he lived for his grandchildren; he loved tailgating his grandson's football games and playing with his 2yo granddaughter. They both reiterate that his current quality of life would not be acceptable for him, they do not think he would even accept being in a wheel chair long term and would certainly not want a trach. They described a very active and athletic man, a college athlete, who would never want to be bed bound or unable to take care of himself. I related that the patient, in moments of unclear lucidity, has told multiple providers that he was done and was ready to die. His wife and sister nodded and agreed, they also feel that this is likely representative of his true feelings. In this setting they will have a larger discussion with their extended family. They would like to have a family meeting at 10 AM tomorrow to discuss this further. Pt also febrile to 101.4. Required pressors overnight.   4/4 Pt no longer able to have PLEX due to fever. Family meeting held today. Pt and family opted to transition to comfort care. Patient expired at 1446. Death Certificate