Patient is deceased (12.13.21);  Hospitalized (12.4.21);  COVID-19 positive (12.4.21);  fully vaccinated Admission:  12.4.21 Death:  12.13.21 HISTORY OF PRESENT ILLNESS: Patient is a 65 y.o. male , with a past medical history of chronic obstructive pulmonary disease (non oxygen dependent), hyperlipidemia, hypothyroidism, and squamous cell carcinoma of the larynx who presented today to the ER with significant weakness.  Significant other is at bedside and helps with the history as patient is very hard of hearing.  She reports patient has had progressive weakness over the last few days.  Patient does have a history of squamous cell carcinoma of the larynx, and in the past has had both Corpak and a PEG tube placed.  Patient has been having increasing difficulty eating, and she reports he has not been drinking well.  She states that she has been giving him brought off from the soup that she makes for him to eat.  Patient was incontinent of stool today, and was unable to ambulate, so was brought to the emergency room.  She denies any recent falls or trauma.   In the ER labs and imaging studies were obtained.  Patient was noted to be dehydrated and have a lactic acid of 5.5.  Patient was given IV fluids and lactic acid improved to 4.8.  In addition patient's creatinine was elevated from baseline.  In addition to being weak, patient was also confused.  COVID-19 was positive, however chest x-ray showed chronic obstructive pulmonary disease with no infiltrates. Hospice note on day of death:  Hospice Certification for GIP from Dr and Dr  Terminal condition: Acute hypoxic respiratory failure secondary to COVID 19 pneumonia Related conditions:squamous call carcinoma larynx, COPD, emphysema LCD CRITERIA:  Pt is a 65 y.o. male  with a terminal condition of Acute hypoxic respiratory failure secondary to COVID 19 pneumonia and a past medical history of chronic obstructive pulmonary disease (non oxygen dependent), hyperlipidemia, hypothyroidism, and squamous cell carcinoma of the larynx who was admitted on 12/4/21 with significant weakness. Patient has had progressive weakness over the last few days. Patient does have a history of squamous cell carcinoma of the larynx, and in the past has had both Corpak and a PEG tube placed. Patient has been having increasing difficulty eating and drinking. Pt found to be COVID positive upon admission. Pt declined during hospitalization with electrolyte imbalances and refusal of further aggressive cares. Transitioned to comfort care 12/11 per family request and pt now actively dying with symptom management concerns for work of breathing. Pt did not respond to treatment and is now appropriate for GIP level of hospice care.  Pt needs aggressive symptom management for the following symptoms:  severe respiratory distress; severe pain from work of breathing secondary to end stage disease process.  Pt requires acute hospital setting due to need for IV medications, frequent RN assessment; medication adjustments; sudden deterioration requiring intensive nursing intervention. Pt being admitted GIP level of hospice care per hospice medical director and attending physician order.   Current symptoms not managed with oxycodone intenson 5 ot 10 mg every 1 hour PRN and recently started morphine infusion 5 mg/ hour.  No boluses ordered. Pt admitted GIP for pain from work of breathing.  Respirations 28-30 with use of abdominal and chest accessory muscles. Changes to plan of care: Orders received for: Robinul 0.2 mg IVP every 4 hours Morphine 2mg/hr with 6 to 10 mg IVP every 15 minutes PRN Zofran 4 mg IV every 6 hours PRN Ativan 1 mg IVP every 12 hour PRN Pt had been started on a morphine infusion at 1222.  Went in to room with medications to proceed with Power Hour.  Pt passed soon after entering room without additional boluses