HOSPITAL COURSE: 72-year-old female (refused an interpreter) with history of hepatitis C cirrhosis, pancytopenia, hypertension, CKD stage IV, insulin-dependent type 2 diabetes, GERD, history of CVA resulting in a seizure disorder admitted for acute hypoxemic respiratory failure due to COVID-19 pneumonia. Tenuous respiratory status - on continuous BiPAP with multi-organ failure.     Acute hypoxemic respiratory failure due to COVID-19 pneumonia/ possible superimposed bacterial infection Neutropenia, resolved Afebrile/sats 70s on RA initially/placed on 15L NRB. Rapidly escalating oxygen requirements, now has been on continuous BiPAP since 1/17. As of the last 2 days (1/18 and 1/19), encephalopathic and less interactive with increased accessory muscle usage. Neutropenia has resolved, remains on cefepime and doxycycline. High risk of pulmonary edema given need to correct free water deficit but this is likely contributing to her encephalopathy. D-dimer is elevated, but in the setting of thrombocytopenia, holding heparin. pulmonlogy signed off 1/19   Pt requiring 100%FI02 this am. Got 40mg IV lasix x1 by XC MD. Able to wean back to 70%FI02.    1/21: Pt stable on Bipap, 50%FI02, satting 100%. CRP trending down to 2.5. Procalc 0.35-improved from prior Lungs sound clear. However pt is unresponsive to pain and pupils are sluggish/minimally reactive if at all. Unclear etiology of her worsening neurological state. Reviewed MAR, no sedating meds on board in last 24hours to explain unresponsive state. Pts ammonia yesterday was <10, however LFTs have worsened suggesting possibility of worsening hepatic encephalopathy. Did not have any prolonged periods of hypoxia to suggest acute hypoxic brain injury. A stat CT head to r/o ICH was ordered but not obtained until 8pm on 1/21.    Per XC MD note from 1/21:   "Received page from radiology regarding CT head results.    CT: Large intraparenchymal hemorrhage centered in the right thalamus/posterior basal ganglia, measuring approximately 5 x 5 x 4 cm cm. Rupture into the ventricles with hydrocephalus. Significant mass effect from the large intraparenchymal hematoma, with deviation of the third ventricle to the left of midline by about 11 mm, and extensive effacement of sulci in the cerebral hemispheres, and partial effacement of the sylvian fissure on the right. This is most likely a hypertensive hemorrhage. Extensive, marked changes of presumed chronic small vessel ischemia in cerebral white matter.   I called and spoke with Dr. of neurology to discuss the case. He felt that her chance of recovery was negligible, especially considering she is on BiPAP for CAP and COVID pneumonia and has liver failure. Should the family desire to pursue aggressive measures, the patient would likely need to be intubated given the severity of the hemorrhage and she would need platelets to maintain Plt >50 (currently 34).    I then spoke with Dr. of neurosurgery. He received the images as well and feels this is a massive hemorrhage. There are no surgical recommendations and this stroke is likely unsurvivable.    I called the patients daughter to update her on the changes. I explained that regardless of further interventions, her stroke is likely unsurvivable and if she were to survive, her deficits would be catastrophic. Given her other medical issues and prior discussions of limited further aggressive care, I recommended we focus on her comfort. I explained that could mean taking her off the BiPAP, stopping any unnecessary medications, and stopping her artifical nutrition. During this, we would provide her with medications to keep her comfortable, such as morphine for air hunger. I also explained that if we removed her BiPAP, I suspect she would likely pass within hours but that healthy family can come to her bedside. She did have questions regarding her will which was not completed before she became unresponsive and I directed her to obtain legal counsel to discuss financial issues as this is not my area of practice. She requested to reach out to her siblings before any changes were made.      Update 2245: Spoke with patients son. He indicated he was the patients hcPOA. I explained the current situation and he is understandably upset. At this time, he wants to continue her current plan of care. I explained in depth that this is not likely a survivable event and that she could pass tonight regardless of ongoing BiPAP use. I also explained that in situations like this, BiPAP and tube feeds can prolong the dying process and suffering. He is trying to reach back out to his sisters to discuss further. He had hoped they could all be present when his mother passes, though daughter is COVID+ so I explained she would not be able to be here, though his mother could have 4 healthy visitors at her bedside. He will call again after speaking with family further.   Update 0200: Met with the family at bedside (6 people as well as daughter via video conference) multiple times after their arrival. Extensive discussion with everyone about her diagnosis and poor prognosis. Questions answered. After further discussion, family decided to proceed with comfort care orders given her current interventions will not improve her outcome and they continue to decline intubation which would likely be necessary for her survival. Comfort care orders placed. Recommended RN give morphine for comfort before removing BiPAP. OK to remove feeding tube as well for comfort but leave foley and IV in. I discontinued all unnecessary medications at end of life including antibiotics. I did choose to leave her Keppra as the risk of seizure is high and could cause discomfort for both the patient and her family. I advised that I remain available to further discuss with them if needed.    Update 0600: re-evaluated patient. Most of family still present at bedside. She is having cheyne-stokes breathing and I educate the family that death is likely imminent. She has been requiring a significant amount of ativan and narcotics to remain comfortable, though there is concern her PIV may have been leaking. Now that we are using PO liquid she is much more comfortable."    The pt passed peacefully at 0633 on 1/22 with family at bedside.    GOC Multiple conversations with family with different Hospitalist providers this week. Decision-makes are daughter, son and his wife. They continue to understand severity of patients illness and declining trajectory with multiorgan system failure. Today (01/19), explained to daughter that patient remains incredibly sick and she is unlikely to survive if needing intubation, recommended DNI which she was understanding. She agreed that intubation would not be within patients goals of care. Discussed continuous BiPAP use and that this can be very uncomfortable. Currently, she is tolerating this however with non-violent restraints, ativan and 1:1 at bedside. Daughter is still hopeful to continue BiPAP, but also understands that this is not sustainable. Other concern is nutrition as patient has not been fed. Previous discussions have been to initiate NG tube, but this is not currently possible given continuous BiPAP.   1/20 Discussed with admin, who agreed to make exception to allow son to come to bedside to aid family decisions re nutrition, comfort care, etc.  After numerous conversations and meetings facilitated by medicine and palliative, Family agreed that they want to attempt tube feeds per NG, continue bipap for now to give pt opporunity to improve clinically, however if further deteriorates would want to withdraw cares with family visitation at bedside.         AKI on CDK Hypernatremia Hypokalemia Baseline Cr around 2.0, which has been up-trending. Additionally, further worsening hypernatremia despite D5. Very tenuous respiratory status given HF and cirrhosis, but as encephalopathy will only worsen with deranged Na, will need to increase D5 rate.    1/20 creat at 2.57, NA 151. Got 40mg lasix overnight per XC MD for increasing hypoxia.   Hx of acute decompensate heart failure Hx of CHF. Last TTE 1/20/21 with normal EF. Repeat echo on 1/17/22 appears wnl. Does not appear volume overloaded at present but does have worsening 02 requirement, increasing infiltrates on CXR. BNP on 1/17 WNL.    Sounds dry on my exam on 1/20, however did get lasix 40meq by XC MD overnight.    -careful monitoring of fluid status   Acute metabolic encephalopathy  Has been worsening since 1/14. Likely d/t hypernatremia, however other considerations include hepatic encephalopathy. Pt injured left posterior wrist when attempting to get out of restraint causing a hematoma to form. Started 1:1 on 1/14 overnight.    1/21 unresponsive as above.        Hep C Cirrhosis Had been stable on torsemide po and spinolactone. LFTs baseline on admission.  -hold torsemide and spironolactone at this time due to worsening renal function   Hx of CVA: Thrombocytopenia Chronically her plts run 60-100. PLTs have been variable, currently 37.  PTA plavix and heparin were held given worsening thrombocytopenia      IDDMII: Fasting glucose 103 on 1/19 when received lantus 18 units evening of 1/18. Increased to 372 on 1/21, pharmD adjusting regimen and adding NPH.    Seizure disorder: resuming keppra IV while NPO   Asthma: albuterol PRN   GERD: famotidine held as NPO, on PPI IV for PPX   HTN: Hold PTA amlodipine and toprol XL, continue IV metoprolol PRN and monitor for b-blocker withdrawal