Pt to ED with respiratory distress and AMS. Found to be lethargic w/ BGs in 500s. Pt. Was seen earlier in ED 1/6/22 w/ positive COVID test. OA on 1/8/22, pt. Was found to be hypoxic, hypothermic w/ tachypnea. Initial CXR Limited examination secondary to reduced lung volumes with bibasilar atelectasis. SIRS criteria met and blood/urine cultures drawn. Pt. Started on broad spectrum antibiotics- vanc/cefepime/flagyl.  Labs demonstrated pt. To be in severe DKA w/ multiple electrolyte derrangements. .... Pt. Started on high flow NC, fluids, insulin gtt. Steroids initiated for COVID pneumonia. Pt. Also found to have new onset A-fib w/ RVR and cardizem and heparin gtt initiated. Pt. Unable to tolerate BIPAP and initial ABGs demonstrated pt. To be in severe metabolic acidosis. Blood pressures were running low. Central line placed and pt. started on bicarb gtt and levophed. Pt. Intubated and transferred to ICU.   In the ICU, pt. Sugars improved. DKA protocol followed and pt. Eventually transitioned to subQ Insulin w/ initiation of tube feeds. Pt. converted to NSR.. Cardiology consulted and recommended continuation of heparin gtt with transition to oral anticoagulation/ beta-blocker when patient able to take by mouth.  ID consulted and transitioned antibiotics to vanc/cefepime for possible superimposed infection as well as continuation of steroids. Patient was extubated and tolerated well on high flow oxygen. Over the course of stay, patient was found to have worsening kidney function and nephro consulted. No hemodialysis needed during his stay. Replenished fluids through IV and oral feeds. He was also found to hypernatremic with a 7L free water deficit, replenished with D5 IV fluids. Over the course of stay, patient continued to need high flow oxygen. He remained NPO with thickened fluids due to possible aspiration risk. Due to his continued need for oxygen support and increased leukocytosis, he was started on zosyn, as well as therapeutic lovenox for possible PE. His kidney function would not tolerate CTA, but lower extremity ultrasound did not demonstrate a DVT, and 2D echo demonstrated an EF of 65% without right heart strain.  After discussion with ID vancomycin was also added along with fluconazole for the growth of candida on respiratory culture.  Patient's respiratory status remained poor, and patient was maintained on 15L HFNC with NRB. Patient kept pulling off his oxygen devices and saturations would drop. Patient was then transitioned to BiPAP.  With oxygenation dropping, patient was headed in the direction of reintubation. Code status was addressed with patient and patient expressed his wishes for no intubation. Patient's oxygenation was still in the 80's with worsening mental status. Chest Xray revealed a small pneumothorax. That pneumothorax was followed over two days and had worsened. Patient remained unresponsive throughout. Cardiothoracic surgery was consulted for possible surgical intervention that would be of any medical benefit to the patient. However, risks outweighed the benefits with further intervention as far as chest tube or intubation. No intervention was performed. Palliative care services were consulted as well. Pt's respiratory failure progressively worsened and pt expired on 1/25/2022.