Discharge Summary "Hospital Course:  Patient is a 67 yo female who presented to our emergency department on the night of 10/25/2023 for complaints of shortness of breath add epigastric abdominal pain.  She was admitted to the general medical floor with a primary diagnosis of acute on chronic hypoxic respiratory failure and was treated with antibiotics given her current chronic obstructive pulmonary disease diagnosis.   Through the first 24 hours of her hospitalization, she had multiple desaturation events that required replacement of a supplemental oxygen with high-flow nasal cannula oxygen.  During this time, she had respiratory pathogen testing performed and subsequently tested positive for COVID-19.  She was started on IV remdesivir and Decadron for COVID-19 therapy.    On the night of 10/26 into 10/27, the patient had another episode of desaturations while on high-flow oxygen that required transition to BiPAP therapy.  A rapid response was called at this time, and appropriate lab work and vital signs were gathered.  The patient was notably lethargic at this time and was having marked difficulty protecting her airway.  With her arterial blood gas testing, she was found to be hypercapnic with respiratory acidosis even on BiPAP therapy.  After reviewing all this information, the decision was made to transfer her to the intensive care unit for higher level of care with more closer monitoring given her critical illness.   In the early morning of 10/27/2023, after rapid response was called, emergent intubation was performed in conjunction with central line placement for vascular access.  No difficulties or complications were associated with these procedures.  The patient was placed on a ventilator for respiratory therapy and assistance.  She was monitored closely on 10/27/2023, which included in decisional procedure for arterial line placement for hemodynamic monitoring.   On 10/28/2023, a spontaneous breathing trial was performed by the patient became agitated and had to be sedated again.  On the afternoon of 10/28/2023, the patient was able to be successfully extubated to BiPAP therapy without respiratory distress.  The patient generally tolerated BiPAP well at that time.   On 10/29/2023, the patient began to be more progressively anxious with more prominence of anxiety/fidgeting with her BiPAP.  However, the patient was decisional at that time with being alert and oriented to person, place, time, and reason for hospital admission.  Multiple goals of care discussions were had with the patient the stay, and her code status was amended to reflect her wishes.  However, the patient had clinical deterioration throughout this day, eventually requiring multiple one time doses of Valium therapy in order to prevent at her from removing her BiPAP mask.   Today, 10/30/2023, the patient was found to be notably lethargic and anxious throughout the morning with little to no sleep reported.  She was found to have notable desaturation events with BiPAP removed simply for her morning medicines.  Around noon, a repeat goals of care discussion was had between myself, Dr. (attending physician), the patient's sister (DPOA), and patient's daughter.  After reconsideration of the patient's clinical status, in concordance with her wishes prior to clinical deterioration/hospitalization, the DPOA indicated that she wanted the patient to become comfort care only since she did not want to be reintubated or have a tracheostomy performed on her in the event she required continued ventilation assistance.  We discussed all the options available to the patient, and DPOA and daughter were in concordance about pursuing comfort care for the patient.    Adequate time was provided for family members to be contacted and arrive to the hospital to say final thoughts and wishes to the patient.  Once this was performed, chaplain services was contacted and close family members were brought to bedside as comfort medicines and care were provided.  No acute distress was noted during the administration of these medicines, and BiPAP was removed.  I closely monitored the patient's vital signs until signs of death/asystole were visible on the patient's monitor, which had been turned off at bedside for family comfort.  The patient passed away at 3:35 p.m. today, 10/30/2023, peacefully and in no acute distress with family at bedside.  Chaplain services were made available for family after the patient's passing, and preferences of funeral home were relayed to the charge nurse for transfer the patient after transfer out of the ICU.   Procedures: Intubation (10/27/2023), Central Line (10/27/2023), Arterial Line (10/27/2023)   Consults: Respiratory Therapy, ICU/CCU, Dietitian"