94 y.o. female presenting with shortness of breath.  She was COVID-positive.  The patient says she really only complains of shortness of breath.  Asked if she has any chest pain or any pain at all and she shakes her head no.  The patient says she just needs air.  The patient feels fatigued and just has aches everywhere.  She was sent in from her facility.  Patient was recently discharged for stroke and a GI bleed.  The patient here as a limited history otherwise because she is in such respiratory distress.  She was in the 60s with her oxygen.  She was brought in via EMS.   Medical Decision Making I saw and evaluated the patient. I have reviewed the chief complaint, triage note, past medical/surgical, family, and social history.   She was placed on BiPAP given her respiratory distress.  She went from 63% up to 89% while is in the room but she is stabilizing further and is now up to 94% on the BiPAP and she says she does not want intubated and I talked to her son who is power of attorney, and he says that if necessary to intubate her because she does have poor short-term memory.  I do not know if she is awake and alert and oriented but she generally speaking responds to questions with a yes or no appropriately.  The patient here is in A-fib with RVR which would be new for her.  I talked to her son about this and we will go ahead and start Cardizem but will hold off on the blood thinning medication because she recently had a GI bleed and he says that they saw her on Friday and she was totally fine and was doing great and we do not know when this A-fib started so it could have been inside of the window where we do not need blood thinning medication and given the risk benefits of her recent bleed we will hold off on the heparin/Lovenox.   Reevaluation at 1228 shows that the patient feels like she is breathing easier.  The patient here is answering yes/no questions.  Her son is at the bedside.  It is her other son who is at the bedside.  He says that he does not believe that she would necessarily want to be intubated and put on a ventilator and have medicines in her constantly.  He definitely knows she would not want CPR.  I asked the patient again in the room if she would want intubated and she said no.  I told the son to touch base with the other sinus or both medical power of attorney's and see if they can come to a consensus.  At this point we will hold off on intubating her because she feels like she is breathing easier but she is still tachypneic.  Heart rate is still tachycardic but she just got her Cardizem started.   Patient was reevaluated at 1300 and she is now hypotensive.  Cardizem was just bumped from 5-7.5.  The patient here was found to have a pneumonia on her chest x-ray.  At this point she is febrile with pneumonia and septic so I am going to go ahead and give her a liter of fluid to see if that helps with her blood pressure as well as her heart rate.  I did have concerns about fluid overloading her with her A-fib with RVR but this point she is hypotensive.  I did talk to the son who is here about doing central line and intubating her but at this point he still does not want to do that and would did like to wait until his brother comes up and go from there. He should be getting close so they are comfortable just holding off at this time.     I was called to the bedside at 1300 and the patient was severely hypotensive and was starting to become bradycardic.  She did have a pulse when I initially got to the room.  Son and grandson were at the bedside.  I told him at this point we would have to intubate and most likely do a central line to see if we can get her resuscitated and stable.  He at that point decided that his mom would not want all of that which is what we had initially talked about when he was here in the room and to just allow her to pass away peacefully.  The patient did lose pulses.  She went asystole on the monitor.  She had no spontaneous respirations.  She had no reaction to her pupils.  The patient had no gag reflex.  No spontaneous respirations.  I could not hear any heartbeat on auscultation with stethoscope.  I did clear the patient deceased at 1319 on 9/12/2023.  Condolences were given to the family at the bedside.  I did discuss think there is anything that they need from us to help them with this process we will be happy to do as much as we can.  The son is very comfortable with what has happened and is at peace with his mother passing away given the hardships that she has recently faced with her medical conditions.   Patient here was also discussed with her other son the whole scenario and he is also at peace and comfortable with the unfortunate event.