PRESENTING PROBLEM: Colitis Severe sepsis  AKI (acute kidney injury) Severe sepsis with acute organ dysfunction Acute deep vein thrombosis (DVT) of proximal vein of right lower extremity Altered mental status, unspecified altered mental status type Acute pulmonary embolism, unspecified pulmonary embolism type, unspecified whether acute cor pulmonale present  COVID-19 virus detected   The patient was admitted with sepsis and early multi organ dysfunction with acute kidney injury and continued hypotension.  He was also found to have a pulmonary embolus.  Blood and urine cultures were obtained and pending.  Patient was found to have significant progression of his hepatic metastatic disease from esophageal adenocarcinoma.  His palliative performance score on admission was 40 or less.  He was felt to potentially be in active phase of dying.  Family was engaged regarding comfort care given his progressive decline in the context of his metastatic esophageal adenocarcinoma.  Family elected for comfort care with hospice referral.  Hospice referral was to occur her today.  The patient, however, continue to progress and expired at 12 30 p.m. on 12/18/2022.   HOSPITAL COURSE:   Esophageal adenocarcinoma Assessment & Plan Metastatic to liver; large ascites on abdomen today, with profound third-spacing and edema in extremities. Patient appears extremely emaciated. As he is refusing treatment for his PE, broached the subject of hospice, asking whether he is wanting to continue taking medications and focusing on getting better despite the fact that his cancer is metastatic and he is getting worse, or if he wants to focus on treating pain, anxiety and sleeplessness, and not try to get better from his cancer anymore. He says, "I'm so tired of it all" and "what's the point of all this", and I ask him if he wants me to ask hospice to talk to his family about this, he says, "yes, please tell them". I call his son to try to discuss goals of care, he acknowledges that patient has been declining for some months now and he knows he is dying, but "my dad is a very proud man, and this cancer has been very hard on him". I mention that patient refused blood thinner in conversation with ED provider, and he contradicts this, saying neither he nor patient refused blood thinners. He expressed frustration that I had called him so late "without having the facts straight", explained that he was very tired having not slept in 2 days, and that he was going to say goodbye now. Therefore unable to have goals of care discussion, however did place hospice consult.    12/17 - discussed with the patient's son and his daughter.  They would like to transition to comfort care.  They are also supportive of the hospice consultation which has been placed.  We discussed the patient's recent decline, his poor palliative performance score, the progression hepatic disease, his dyspnea and hypoxia, and the pulmonary emboli in the right pulmonary arterial tree in concert with the lower extremity DVT.  We discussed the patient's clearly expressed wishes, of last evening, to forego anticoagulation and aggressive therapies.  He clearly expressed a desire for comfort care.  We discussed this as a gift decision-making and discussed implementing comfort care to include intravenous opioids for both pain and breathlessness, around the clock antiemetic, in some form anxiety lytic as needed.  We discussed his appropriateness for general inpatient hospice with a consultation placed.  I also called and spoke to his other daughter, and discussed the same as she did have hopes of him receiving hospice at home.  His need for IV symptom management would preclude this at present.  He is also requiring more services and they could likely manage at home.  He may also be in active phase of dying which would preclude transfer.  40 minutes spent just with the late morning and early afternoon discussions and interventions.   Discussed with care management.  Family will meet with hospice tomorrow.  Suspect he is in an active phase of dying.  He remains on comfort care for now   12/18 - discussed with family at the bedside earlier today.  His wife was present and addressed her directly.  His daughter was also present along with his other daughter.  We discussed his status at that time.  He was beginning to get significant mottling and clearly had terminal congestion.  His mental status had declined.  We discussed the active phase of dying and what to expect.  We discussed their time with him and their time together.  We discussed that he may choose his own time to pass and that would likely occur when they are not present and not in the room.  This was mention to assist them with any potential for complicated bereavement that make her from not being present in such an event.  We had previously discussed transitioning to hospice and they were to have had a meeting with Hospice at approximately 11:00 a.m. today.  We had considered a transition to general inpatient hospice status.  I later received a phone call at 1230, or proximally.  Informing me of his death.  His death occurred at 12:30 in the early afternoon of 12/18/2022.   AKI (acute kidney injury) Assessment & Plan Creatinine 1.67 up from 1.10 two months ago; BUN 70, GFR 35.Foley in place in retained in the transition to comfort care   * Severe sepsis with acute organ dysfunction Assessment & Plan Meets criteria with AKI, leukocytosis 20,000, hypotension, tachypnea. Source appears to be abdomen with evidence of inflammation from cecum to ascending colon. Procalcitonin is 0.88 and he has having difficulty handling his secretions, suspect there may be aspiration ongoing as well. Zosyn wold cover both sources. Give 2L of saline in ED; given his significant third spacing, moderate ascites, will be judicious with further fluids, give LR at 50 for now. Follow up blood cultures. Repeat am lactate.    12/17 - seen closed discussion regarding transition to hospice.    12/18 - continued to decline hemodynamically and from a respiratory standpoint.  Was placed on comfort care and expired on 12/18/2022   Lab test positive for detection of COVID-19 virus Assessment & Plan Unclear clinical significance given his prior positive test earlier in the month.  Per family, it did seem to contribute significantly to his decline with progressive weakness.  This, is also in the context marked progression of his hepatic disease as a metastatic complication of his esophageal adenocarcinoma.   He transitioned to comfort care on 12/17/22     Pulmonary embolism Assessment & Plan Evident on CTA today; new LLE DVT as well evident on CT abd/pelvis. In conversation between ED doc and patient, he insisted he does not want blood thinners, therefore none started; no need to check duplices. He is requiring 2-4L O2.    12/18 - patient chose to forego systemic anticoagulation.  Family concurs.  See discussion regarding transition to comfort care/hospice.   CAD (coronary artery disease) Assessment & Plan He is unable to swallow pills. Held statin/Lasix.    Secondary to depressed mental status and profound state of protein caloric malnutrition.  Eventually transitioned to comfort care         CONSULTS / RECOMMENDATION:    Hospice   INPATIENT PROCEDURES:   CT angiogram of the thorax revealed pulmonary emboli in the upper lobe branch of the right pulmonary arteries was in the posterior lateral basal segments of the right lower lobe.  Also revealed extensive hepatic metastasis.    CT the abdomen and pelvis revealed extensive infiltrative neoplasm throughout the liver which had increased some previous.  Overall size liver was increased as well.  Patient was noted to have moderate ascites which is felt to be malignant.  Was notation of a acute DVT in the left external iliac vein and common femoral vein.  He also had thickening from the cecum to the mid ascending colon and the distal descending colon.  This was new from prior was felt to potentially be a source of his sepsis.   CT of the head revealed no acute intracranial process.