BRIEF OVERVIEW: Discharge Provider: MD Primary Care Physician at Discharge: PA Admission Date: 4/17/2023 Acute on chronic respiratory failure due to covid pneumonia with progressive hypoxia  PRESENTING PROBLEM: Shock [R57.9] Cardiogenic shock [R57.0] COVID pneumonia    HOSPITAL COURSE: The patient is a 76 y.o. with past and current medical history of ischemic CM since 2018, EF 24%, with more recent hospitalization in July 2022 showing cardiogenic shock with FCI 1.3 that led to inotrope support and ultimately home milrinone 0.3mcg/kg. Follows with clinic.    He had a Covid+ test on 4/11.  His wife also has COVID pneumonia as well.  Nurses assessed patient on 4/17 then called the clinic. Patient reported edema, dyspnea , fatigue, weakness, and cough. Initially he did not want to go to the ER but ultimately did go to the ER on 04/17.  Upon arrival, BP 83/59, hypoxic requiring 4L O2. Na 126, K 5.4, Cr 1.69 (baseline), Bili 4.4 (base 2), LFTs elevated. BNP 31k. Lactic 3.4 then 2.9. CXR showing pulmonary congestion. He was transferred to hospital for further management of his cardiogenic shock component.   Patient was started on remdesivir and Decadron to treat his COVID pneumonia.  His Milrinone was increased to 0.4mcg/kg to help treat his cardiogenic shock. He was put on a diuretic holiday due to worsening creatinine and hyponatremia following diuretics.  He was quite hypotensive and required the addition of midodrine which was ultimately titrated to a max of 20 mg 3 times daily.  Despite this, he remained hypotensive and ultimately was started on norepinephrine for blood pressure support.  Patient did meet with palliative care on 04/24 and discussed goals of care which included a do not resuscitate/DNI code status.  Patient's wife unfortunately was intubated in intensive care unit at other hospital and was unable to make decisions regarding patient's care.  Patient's sons actively a part of patient's decision making with one listed as patient's POA.    Patient continued to do poorly and unfortunately Milrinone was weaned back to 0.3mcg/kg due to continued hypotension.  His digoxin was also discontinued as well as his diuretics.  He was started on IV amiodarone to help suppress frequent ectopy.  Unfortunately patient continued to decline on the evening of 4/25 prompting bedside evaluation and discussion with both the patient's sons regarding continued medical therapy.  See progress note from 4/26 for further details.  Ultimately patient decided to go comfort care overnight with both sons in agreement via telephone.  After this conversation, patient began to decline quickly and patient's son (the POA) contacted regarding patient is imminent passing.  Patient's son present at the bedside and the decision was made to discontinue his pressors and proceed with full comfort care.  Patient was provided with doses of IV morphine and IV Ativan for agitation and discomfort.  Shortly after discontinuing the norepinephrine, patient passed quickly with son at bedside at 04:30 on 4/26/2023. No breath sounds or heart sounds were appreciated for 1 minute. No pulses. Pupils fixed and dilated with no response to light.   Date of Death: 4/26/23 Time of Death:  4:30 AM Preliminary Cause of Death: Cardiogenic shock due to exacerbation from COVID pneumonia