Narrative:  Patient is a 72M with history of obesity (BMI>50), lymphedema, HFrEF with recovered LVEF (LVEF previously 30-45%, improved to 67% 2/2020, on torsemide 200mg BID), coronary artery disease, COPD on baseline 3L supplemental O2 NC, OSA on CPAP, pulmonary HTN (likely combined group 2/3), atrial fibrillation on warfarin (CHADS2VASC 4, prior failed DCCV), CKD III (b/l Cr 1.4), T2DM (HbA1C 9.9% 6/2021), prior Clostridioides colitis, known AAA, HTN/dyslipidemia, and GERD who initially presented 7/8/2021 with several days of worsening shortness of breath with associated cough, subjective fever/chills, and increasing O2 requirement to 4L. Upon arrival to the MC ED, patient was afebrile with mild tachycardia/tachypnea and O2 sats low 90s% on 3-4L. Labs were notable for HCO3 26, BUN/Cr 32/1.64, glucose 140, globulin gap 3.6, unremarkable LFTs, proBNP 1414, troponin .02 x2, lactate 1.4, INR 1.7, WBC count 4.4 with lymphopenia ALC 520, Hb 12.4 with MCV 87.6, and plts 130. COVID-19 testing returned POSITIVE despite prior vaccination (CRP 90.8, ferritin 1564, D-dimer 681). Patient was admitted to local hospital for ongoing evaluation and management. HOSPITAL COURSE: #Acute on chronic hypoxemic respiratory failure with hypercarbia #COVID-19 infection with severe features c/b NCIP (elevated CRP/ferritin/D-dimer) #Possible bacterial PNA patient initially presented 7/8/2021 with about 1 week of shortness of breath and increasing oxygen requirement from baseline (with symptoms onset 7/3/2021). He was found to be Covid positive, with labs notable for leukopenia with signs of inflammation (elevated CRP/ferritin/D-dimer). #History of HFpEF with elevated proBNP He did not require escalating oxygen supplementation initially after starting on 5 days of remdesivir and 10 days of dexamethasone per protocol for COVID. He was treated for a possible component of superimposed bacterial pneumonia given left lower lobe/left hilar consolidation seen on chest x-ray and positive sputum for coag-negative staph, treated broadly initially then transitioned to IV ceftriaxone. There was additionally concern for volume overload given history of CHF with an IV lasix diuresis requirement intermittently through the admission. Supplemental O2 was weaned throughout admission, down to 3-4L (on 3L at home). Patient was otherwise continued on home albuterol/tiotropium/LABA-ICS inhalers and used his home CPAP nightly throughout admission until 7/18. He remained stable to improving until 7/18 when he developed a pneumomediastinum and evidence of small apical PTX. He was placed on 6L and was doing well but then had a sudden decompensation on the evening of 7/21 where his oxygen requirements increased significantly and he required high flow oxygen. Over the next couple of days his oxygen requirements continued to go up and patient began refusing care and making statements that he 'was done'. His wife was able to come in on 7/23 where we sat down and had a goals of care discussion and we ultimately decided to not escalate care and change his code status to DNR/DNI. When his oxygen saturations dropped we started prn morphine for comfort and transitioned him to Comfort care measures on the evening of 7/24. He was started on a dilaudid gtt and peacefully passed away at 2021 on 7/24 with his wife at bedside.