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Based on interview, record review, and review of the facility's policy, the facility failed to protect the rights of 1 of 10 sampled patients, Patient (P) 1. P1 presented to the facility on 07/28/2024 and full code status was documented. However, the facility failed to implement their policy regarding patient's rights when he expired on 08/18/2024 and no resuscitation was attempted.

The findings include:

Review of the facility's policy titled, "Withholding/Withdrawal of Life-Support Interventions, Including CPR, Ventilation, and Artificial Nutrition/Hydration," last revised 08/11/2023, revealed the purpose of the policy was to support the philosophy of the Medical Center to provide dignity of care by adhering to the wishes of the patient and by instituting only medically appropriate care. Further review of the policy revealed if a patient did not, while still competent, give or refuse consent to a life-support that later became necessary, was currently incompetent, and either had not executed an advance directive, consent to withholding or withdrawal of life-supports other than artificial nutrition and hydration could be given by others in the following order, a) from the patient's court-appointed guardian, b) from the patient's spouse, c) from a majority of the patient's adult children, d) from the patient's parents, e) from a majority of the patient's adult siblings or f) from a majority of the patient's other nearest class of adult relatives.

Review of the "Order of Appointment of Guardian," dated 10/14/2021, revealed the Cabinet for Health and Family Services, Guardianship Services was appointed guardian for P1.

Review of P1's "Admission Record" revealed the facility admitted the patient on 07/28/2024 at 8:05 AM from the long term care facility where the patient resided. Further review revealed diagnoses included chronic kidney disease (CKD), type 2 diabetes mellitus (DM) with diabetic nephropathy, chronic obstructive pulmonary disease (COPD), and schizoaffective disorder, bipolar type.

Review of the hospital's "Emergency Department (ED) Note," dated 07/28/2024 at 8:59 AM, revealed P1 had presenting symptoms of altered mental status (AMS) and hypoxia, reportedly evidenced by oxygen saturation in the 50s (normal should be in the 90s). Further review revealed P1 had a fentanyl patch (opioid used for pain relief) in place and had audible wheezing and crackles as well as somnolence. Further review of the ED note revealed upon arrival the fentanyl patch was removed, and P1 was given Narcan (used to rapidly reverse an opioid overdose) with immediate improvement in mental status. Continued review revealed upon awakening, P1 reported feeling generally unwell with a cough and shortness of breath. P1 was placed on 2 Venturi mask oxygen due to mouth breathing, and the nasal cannula (NC) oxygen had been ineffective. A chest X-ray (CXR) was obtained and a workup for infection was done. Additional review of the ED note revealed P1 had atelectasis (collapse) in bilateral lung bases, continued shortness of breath, and a productive cough which was felt to be aspiration pneumonia (PNA). Further notation in the ED note revealed hypercapnia (increased carbon dioxide levels in the blood) and increasing AMS at two hours post admission, as well as elevated lactate and acute kidney injury (AKI) with hyperkalemia (high potassium level in the blood). P1 was placed on Bilevel Positive Airway Pressure (BiPAP), received a fluid bolus, and did well with that as well as another administration of Narcan. P1 was also placed on a broad spectrum antibiotic. Review of the ED note further revealed the clinical impression included aspiration pneumonitis, AKI, and hyperkalemia as well as accidental overdose and the respiratory failure complication of hypoxia and hypercapnia. P1's mother arrived at the bedside.

Review of P1's "History and Physical (H&P)," dated 07/28/2024 at 8:47 AM, revealed P1 also had a history of lung cancer, and P1's mother was able to provide further history. Further review revealed P1's mother reported she had last seen P1 two days prior when P1 had complained of pain, and P1 had been started on new medication for that. Continued review revealed a high white blood cell count at 17,300; persistent anemia; potassium level at 6.3; AKI as evidenced by creatinine greater than 3.0; and with overall findings consistent with aspiration PNA. Additional review revealed a plan to admit to the family medicine service, continued monitoring of respiratory status and global coma scale (GSC), antibiotics including vancomycin, Zosyn, trending infectious markers, following laboratory testing, admitting to the Progressive Care Unit (PCU), and consultation from podiatry for an ankle ulceration as well as critical care/pulmonology and nephrology.

Review of a "Pulmonary Consult Note," dated 07/28/2024 at 4:32 PM, revealed P1 continued with BiPAP and continued with crackles and rhonchi, but without wheezes or stridor. Further review revealed the nephrologist's recommendations were to continue trending troponins until decreased, trend lactate until normalizing, obtain echocardiogram, completed infectious disease (ID) evaluation with urinalysis and culture, to err on the side of caution for treating PNA with specific antibiotics, as well as checking labs, temperatures, and deescalating antibiotics per the results. Continued review revealed recommendation for AKI, to hydrate, start bicarbonate, treat with insulin/glucose, start Lokelma to reduce potassium level, consult nephrology for possible acute dialysis, as well as monitor oxygenation status carefully for questionable congestive heart failure (CHF) as well as monitoring potassium levels every two hours until improved. Her assessment was that P1 was critically ill, with multiple organ dysfunction, including acute hypoxemic respiratory failure requiring BiPAP, AKI superimposed on CKD, life-threatening hyperkalemia, acute exacerbation of congestive heart failure (CHF), PNA/aspiration PNA, sepsis, lactic acidosis, accidental overdose, chronic troponin elevation, complicated urinary tract infection (UTI), DM, coronary artery disease, history of non small-cell lung cancer with status post (s/p) COPD, obstructive sleep apnea (OSA), and a risk of sudden and life threatening deterioration in medical condition.

Review of a "Nephrology Consult Note," dated 07/29/2024 at 7:52 AM, revealed his impression of P1's problems included peripheral vascular disease (PVD) of lower extremity with ulceration, acute; arterial leg ulcer, acute; respiratory failure complication of hypoxia and hypercapnia with acute septic shock; acute on chronic renal failure, stage 4 severe; aspiration pneumonitis; and an accidental overdose further complicated by metabolic encephalopathy, hyperkalemia, and DM.

Review of a "Cardiology Consult Note," dated 07/30/2024 at 9:36 AM, revealed the consultation was prompted for preoperative risk stratification because P1 had been previously scheduled for peripheral arteriogram and current suspicion of osteomyelitis with recommendation for Magnetic Resonance Imaging (MRI) once P1 was stable. Further review revealed impression for PVD and arterial leg ulcer that was secondary to critical limb ischemia, and P1 was not a good candidate for any revascularization/intervention at that time. Other impressions included suspected acute respiratory failure, septic shock, acute on chronic renal failure, aspiration pneumonitis, accidental overdose, metabolic encephalopathy, resolved hyperkalemia, and DM.

Review of the medical record census revealed P1 was moved to a medical/surgical unit on 08/02/2024.

Review of a "Family Medicine Note," dated 08/08/2024 at 3:50 PM, revealed P1 still had demonstrated suspicion of osteomyelitis with poor candidacy for intervention and had failed to progress despite the treatment plan. The note included the assessment that P1 might have been a good candidate for hospice/palliative care with plan for goals of care conversation with P1 and family.

Review of a "Family Medicine Note," dated 08/10/2024 at 8:12 AM, revealed P1's right ankle wound culture had grown Methicillin Sensitive Staph Aureus (MSSA), remained altered, been started on home clonazepam due to his agitation and anxiety, and remained on high-flow oxygen. Further review revealed P1's renal function continued to decline with a recommendation for dialysis to start that day with fistula placement the previous night. Per the note, P1 had received multiple antibiotics including Zosyn for four days, vancomycin for seven days, meropenem for six days, nafcillin for six days, Rocephin for four days, and Flagyl for three days, with the more current treatment of Unasyn for the second day.

Review of a "Family Medicine Note," dated 08/13/2024 at 11:08 AM, revealed P1's renal function had improved somewhat, so P1 had not had dialysis as previously noted to have been planned. However, further review revealed concern for uremia due to the blood urea nitrogen (BUN) level, which rose to 111 (normal 24 or less) that day and altered mental status which had waxed and waned during this admission. The note also stated the plan was to reach out to nephrology to consider dialysis. Continued review revealed P1 continued to require six liters per minute (L) of oxygen supplementation.

Review of a "Family Medicine Note," dated 08/14/2024 at 12:22 PM, revealed P1's hemoglobin that day was 6.9 and iron was 15, with a plan for iron replacement and a one unit blood transfusion as well as continued need for supplemental oxygen but down to four L per minute.

Review of a "Family Medicine Note," dated 08/16/2024 at 7:38 AM, revealed an addendum note from Physician 1 that due to end stage renal disease (ESRD), metastatic lung cancer, acute on chronic respiratory failure, and congestive heart failure, P1 was worsening with decreased responsiveness and nutrition intake, and as a result, it was the opinion of Physician 1 that P1 would benefit from transitioning to comfort care/hospice care and "Do Not Resuscitate, Do Not Intubate" status. Further review revealed P1 had been more lethargic that morning, had not been able to awaken enough to eat for the previous few days, and had continued to have increased oxygen requirements even with diuresis which had been difficult due to resulting hypotension. Continued review revealed Physician 1's opinion that P1 was medically declining, which was discussed with P1's mother, who stated she did not want P1 to suffer anymore. Additional review revealed the physician was currently working with the state to make him "DO NOT INTUBATE (DNI), DO NOT RESUSITATE (DNR)."

Review of a "Social Services Note," dated 08/16/2024 at 12:05 PM and authored by Social Worker (SW) 4, revealed she had submitted P1's code status change request to the State Guardian with status approval pending.

Review of SW4's email revealed she sent the original DNR request on 08/16/2024 at 12:05 PM to dailrn@ky.gov.

Review of a "Hospice Consult Note," dated 08/16/2024 at 12:28 PM, revealed P1 was appropriate for a hospice level of care period. Further review revealed P1 was appropriate for an inpatient level of hospice care as evidenced by not tolerating oral intake, requiring intravenous (IV) pain medications, the severity of renal dysfunction, and the current antibiotic strategy. Further review revealed the impression included PVD, metastatic lung cancer, suspected acute respiratory failure, and acute on chronic renal failure. Continued review revealed with comfort measures in place and the full level of hospice care, P1's life expectancy would be limited to days. The review also revealed Physician 1 had spoken with social services regarding necessary documentation given that P1 had a State Guardian.

Review of an email from Nurse Consultant (NC) 1 to SW1, dated 8/16/2024 at 3:09 PM, indicated the errors/omissions from the original DNR request that would have to be corrected prior to approval.

Review of a "Family Medicine Note," dated 08/17/2024 at 7:24 AM, revealed P1's mother was at the bedside during the examination and reported P1 had complained of pain and seemed restless, and she was also tearful at that time. Per the note, P1's mother had voiced understanding that they were awaiting paperwork given P1 was a ward of the state. Further review revealed P1 continued to decline with reports of pain and restlessness that date along with periods of lethargy and continued not to take oral nutrition. Continued review revealed the previous weeks team felt P1 would benefit from comfort care at this point, as P1's chronic medical conditions were worsening and causing the recovery to be poor. Additional review revealed hospice had been consulted on 08/16/2024, and P1's mother and sister were agreeable to the plan for DNI/DNR comfort measures during goals of care discussion. Further review revealed staff was working with the state to change P1's code status.

Review of NC1's email to SW1 and State Guardian (SG) 1, dated 08/17/2024 at 9:30 AM, revealed NC1 had reviewed the paperwork that was submitted the previous day after hours, and everything was ready for the DNR, and the only element missing was metastatic lung cancer diagnostics. NC1 further requested that SW1 please send records to support that diagnosis. Further review revealed several elements were still needed for the end of life (EOL) care request and detailed those with the offer of assistance if needed.

Review of a "Social Services Note," dated 08/17/2024 at 9:32 AM, revealed contact with the weekend on-call State Guardian, who had reported the paperwork be resent for code status change, had not been received, and P1 still had "Full Code" status at that time. Per the note, social services would follow up on the following Monday (08/19/2024).

Review of a "Family Medicine Note," dated 08/18/2024 at 8:42 AM, revealed P1 required increased oxygen, increased BiPAP parameters, with a blood pressure that dropped to 80/40 millimeters of mercury (mm Hg). Further review revealed P1 was not awake, alert, or responding and was exhibiting agitation at times. Continued review revealed that given P1's ESRD, known lung cancer, acute respiratory failure, altered mental status, and the current worsening of P1's condition, it was the opinion of Physician 1 and Physician 2 that attempted resuscitation in the case of cardiopulmonary arrest would be painful and not result in any change of the outcome of this patient. He further noted that adding intensity to P1's treatment care was futile and would not change the inevitable outcome. Continued review revealed the staff continued care but did not add any additional intensity of treatment at that time and that Physician 1 did change P1's code status to DNR/DNI. Additional review revealed P1 had received a fluid bolus in order to support blood pressure and continued on BiPAP.

Review of P1's "Orders" revealed P1's code status was changed to DNI and DNR on 08/18/2024 at 8:42 AM, followed by an order for comfort care with Ativan (anti-anxiety agent) and morphine (opioid pain reliever) on 08/18/2024 at 9:29 AM.

Review of P1's "Death Note," dated 08/18/2024 at 12:04 PM, revealed on the day of P1's death, this date, P1 experienced significant worsening with a drop in blood pressure, worsening respiratory status, worsening mental status (unable to respond). Further review revealed based on P1's status, it was determined P1 was actively dying and would not survive this hospital stay. Continued review revealed it had been determined P1 was suffering from the interventions that were implemented and was placed on comfort care. P1's time of death was 10:42 AM.

Review of NC1's email, dated 08/19/2024 at 9:03 AM, revealed Guardianship was notified that P1 had passed away the day before by the patient's daughter. Further review revealed SG1 contacted SW1, she confirmed P1 had passed away the previous afternoon, and two physicians approved P1 to receive comfort measures without the state's approval. Continued review revealed SG1 requested the names of the doctors and summary of what had occurred.

Review of an email with SG1, dated 08/29/2024 at 10:02 AM, revealed his statement that the weekend on-call State Guardian worked through a contract with a private company, and he did not have contact information for her.

Review of the "DNR Request Instruction Form," provided by NC1, revealed the application must be sent by fax or emailed to Guardianship.RN@ky.gov. However, review of the "DNR Request Instruction Form," provided by SW4 as the guide when she submitted the original request on 08/16/2024 at 12:05 PM, revealed the email address was DAILRN@ky.gov.

During interview with the SG Supervisor on 08/27/2024 at 10:29 AM, she stated the facility was supposed to go through nurse consultants for the process approval for change to DNR and hospice, but they had not completed the paperwork. She stated the nurse consultant returned the paperwork to the facility to be completed/updated, and the facility did not do that. She stated the facility did their own paperwork when two physicians decided to order comfort measures. She stated not only did the facility not complete the paperwork, they did not notify the guardian or provide their documents. She further stated when the guardian contacted the hospital, the SW had stated she would provide the document but had not. She stated P1's family contacted the guardian to ask about burial, and that was how they knew P1 had passed.

During interview with SG1 on 08/28/2024 at 1:10 PM, he stated P1 was at the facility for medical concerns, and on 08/16/2024, SW1 had contacted the nurse consultants regarding DNR status. He stated there was back and forth communication between them. He stated the nurse consultants never got completed documents and followed up the following day, which was a Saturday. He stated he received a phone call from his supervisor on the following Monday, asking if he knew P1 had passed, and he stated he had not been notified by phone or other means of communication. SG1 stated he called SW1 to ask about what had transpired, and she confirmed the two physicians had decided together with statements to provide comfort care only. He stated SW1 told him she did not receive the email from the consultant because she did not work on weekends.

During interview with NC1 on 08/28/2024 at 8:15 AM, she stated physicians had made recommendations for P1 for DNR and EOL care, did not complete the process, and knew they did not complete the process. She stated the SW at the facility notified the guardian they had done that, but if that was how the process worked, she would not have a job. She stated if a physician wanted to request code status change, the necessary documentation was the completed request form, the H&P, and a progress note with a clear description of why it was recommended, and then the request went to the nurse consultant for review. She stated they had to receive medical records to support the diagnosis also. She stated once having that in hand for DNR, she could approve it. She stated EOL care was a separate process and required a separate application. If requested at the same time, she stated she could use the same records. She stated there were three different submissions with incomplete information, with the last one received on 08/19/2024. She stated she and NC2 traded being on-call every other week, so there was almost always someone available to take care of whatever documents were coming in. For P1, she stated the last request received was on Friday night, 08/16/2024, and she replied back the following morning, on Saturday. She stated SW1 subsequently notified the guardian that care had been withdrawn with two physicians decision, without approval, and she was not notified. NC1 stated everything in the forms were such that they were accommodating for the physician, and the process did not require court approval. Even with EOL, she stated, if they had everything in hand, approval could be given within about 12 hours. She stated the facility's stumbling blocks were with their own errors. She stated the instructions on the form were very clear, so there should not have been a reason to have made the errors.

During interview with the 5 Center Unit Manager on 08/27/2024 at 2:55 PM, she stated it was necessary to speak to the SG to obtain permission and changes, such as with medications or procedures. She stated the facility had to go through the SG for a DNR status request, with H&P, physician notes, and consultation notes in order to facilitate the application. She stated the SW usually sent the request by fax and also talked to the state worker by phone. She stated it was not just the SG to make the decision. She stated it used to take days for a decision, but now the turn around could be in 24-48 hours, except on weekends. She stated the SG office had on-call staff, but it could be hours before receiving a response.

During interview with Registered Nurse (RN) 3 on 08/29/2024 at 11:56 AM, she stated she worked the Sunday (08/18/2024) that P1 passed away. She stated she learned in shift report that morning that P1 had been on continuous BiPAP and blood pressures were soft, and she found P1's mother crying at the bedside. She stated the mother did not want P1 to be coded, and the mother told her that P1 had been through enough. She stated she advised the mother that P1 was still a full code, but the hospital had been working on the paperwork. She stated P1's mother knew P1 was declining and asked what had to be done to obtain the DNR approval. She stated P1's mother got in her phone and provided the SG Supervisor's phone number to the SW. She stated Physician 1 came to the floor and advised her the code status had been changed to DNR. She stated the mother was there the entire time and called other family to come be with her when she thought they would have to do chest compressions. She stated several family members came and stayed with P1 the entire time. She stated the nursing staff knew to call the guardians for something like a procedure consent. She stated, for issues like the DNR, SW and physicians were involved for them.

During interview with RN 1 on 08/29/2024 at 12:19 PM, she stated she cared for P1 the day before P1 passed and had cared for P1 earlier in the week. She stated P1 had declined so much that P1 was no longer communicating or eating and was mostly unresponsive, but moaned and grimaced at times. She stated P1's mother was at the bedside and mostly cried but would call out for pain medication or any needs for P1.

During interview with SW1 on 08/27/2024 at 2:59 PM, she stated her team of six SWs typically saw every patient admitted to the hospital and completed a Social Services screening tool which asked if a given patient had a guardian, if alert and oriented. If not alert and oriented and had no family with them, she stated they determined guardian or Power of Attorney (POA) information from documentation from sources such as emergency medical services or nursing home. She stated guardians legally appointed could be a state employed or could be a family or friend, but must have the documentation for actual consents. She stated SWs were responsible to determine who had authority for giving consent and updated the chart so physicians/nurses knew who to contact. She stated they called SGs to inform that a patient was in the hospital, and if a DNR was already in place, they could honor that; if not, full code status was documented for those patients. She stated SW was part of the clinical team, and worked with physicians everyday, so they made sure the staff knew who the guardian was. SW1 stated for requesting a DNR, staff tried to be proactive. She stated there was an application to request a change to DNR. She stated the doctor filled out the form, and the SW attached clinical information requested on the form, and then sent this to the Commissioner's office in Frankfort for the nurse consultants. She stated there were two nurse consultants on duty, weekdays from 8:00 AM - 4:30 PM. She stated EOL requests had to be approved by the Commissioner, and if he/she was not in the office, approval could be delayed another day. She stated the nurse consultants had an on-call number for after hours with contact information; staff just had to listen to the voice mail, and it provided the contact information. She stated the nurse consultants sent the application back if not exactly right, even for details like the physician's signature did not include the MD credential, for example. She stated End of Life/Comfort care required a separate application and a consulting physician, with both required to be very precise. She stated staff had worked well with guardians, who usually would help facilitate communication with the nurse consultants. She stated on weekends and holidays, the guardians had not been as accessible. She stated their most recent DNR application was started on a Friday but was never resolved. She also stated the SW staff attempted to contact the emergency nurse consultant line over the weekend but never got a response. She stated if staff did not get the approved application back, the expectation was the facility must wait until the next business hours or until a callback was received. She stated P1 had ESRD and did die, so the Administrator On-Call was consulted to help. She stated, if it had been through the week, staff would have had an ethics consult to help with the decision. She further stated she felt the nurse consultants really wanted to help but had very strict rules that required compliance.

During interview with SW3 on 08/29/2024 at 11:16 AM, she stated she worked the weekend P1 died. She stated she spoke with the SG who was on call for that day, who had advised SW3 that she could not locate any DNR request documents. SW3 stated the on-call SG told her there was nothing she could do, and the nurse consultants were not available. She stated she called the nurse consultants via the number on the instructions, but nobody answered or returned the call. She stated the on-call SG resent the form and instructions, but since it had already been done and submitted, and the consultants were not available, that led to the decision to follow up on the next regular business day. She stated she called SW4, who was assigned to cover the 5th floor, and she came to the hospital to check her email the next day, 08/18/2024. SW3 stated her understanding was that the documentation had been submitted, then resent after corrections, and that was all she knew per report from SW1. She stated she had not seen any emails from the nurse consultants while she was working that weekend. She stated she did not work that unit, so she had not known P1's condition until that morning when she went to the floor. SW3 stated the phone was ringing by the time she arrived that morning as Physician 1 wanted to know the status with the DNR/EOL. From there, she stated she went to the floor, talked to P1's nurse who reported P1's condition was not good, and Physician 1 was trying to learn the status with the DNR request. From there, she stated, she went to P1's room where P1's mother was at the bedside, tearful and upset. She stated the mother begged her to help make the DNR happen because P1 was suffering. She stated the mother verbalized she understood the process that was ongoing. SW3 stated from there, she looked for Physician 1 and asked the nurses to have him call her, and then she started calling the on-call guardian to determine what needed to be done. She stated she did not try again to call the nurse consultant. She stated she informed Physician 1 what she knew about the DNR request status, and she could not reach the nurse consultants.

During interview with SW4 on 08/29/2024 at 12:33 PM, she stated she sent the original DNR request on 08/16/2024. She stated she sent it to the e-mail address on her instructions, but never got a response. She stated then SW1 resent it later on the same afternoon, they received the response, completed the requested corrections, and resent the request but did not hear back that day. She stated SW3 pursued the matter further, on the following day, which was a Saturday. She stated, on Sunday, SW3 called her at home because she still had not heard back from the nurse consultant. SW4 stated she came to the facility to check her email but did not have any from the nurse consultant. SW4 further stated she had learned on 08/16/2024 that P1 was declining, so she worked on the request quickly that day. She stated she resent the request to the email on the instructions, dailrn@ky.gov, but never received a response, and then SW1 helped by resending the request herself. SW4 stated the request was returned, they made the indicated corrections, and resent it on Friday evening (08/16/2024), but they did not hear back before departing for the day. She stated when she came in on Sunday, 08/18/2024, to look at emails, she had nothing from the nurse consultants, so she resent the application.

During interview with Physician 1 on 08/29/2024 at 1:00 PM, he stated P1 had worsening respiratory status, oral nutrition intake, and alertness. He stated by that Saturday (08/17/2024), P1 was obtunded and just not doing well at all. He stated he alerted the Chief Executive Officer (CEO) and Chief Medical Officer (CMO) of not having DNR approval, but felt P1 was at the point that further intervention would not prevent death and would hurt P1, who was already in pain. He stated staff was trying to do what was the most beneficial for P1, and continued intervention was just causing and prolonging the pain. Physician 1 stated he had been following P1 for several years, found the lung cancer, and managed P1's long term pain. Physician 1 stated when P1 was last evaluated with oncology, they had found a new nodule. Physician 1 stated with P1's frontal lobe dementia, P1 was not able to fully understand what was happening. However, Physician 1 stated, by knowing P1, he was aware P1 had received chemotherapy and radiation already and had been resistant to further treatments. Physician 1 stated his focus was that P1 could not stand the pain.

During interview with Physician 2/CMO on 08/29/2024 at 10:33 AM, he stated the guardian communication process was not adequate. He stated P1 was uncomfortable, declining, terminally ill, and he concurred with Physician 1 that attempting resuscitation would have been painful and would not have prevented a terminal event. He stated he felt resuscitation was not a possibility. He stated dealing with guardianship did not work well when patients' conditions changed after hours. He stated this frequently happened and totally broke down making clinical decisions. He stated Physician 1 had been practicing for 27 years, was very capable with working with patients at EOL, and had also worked with patients with SGs before. He stated Physician 1 called him, was morally distressed, and felt the guardianship process was not patient care oriented. Physician 2 stated Physician 1 felt he was legally being forced to harm the patient. He stated he was not the Administrator-On-Call, but Physician 1 had reached out to him as a senior physician leader and also as a colleague. He stated Physician 1 had shared the story while he reviewed the chart. He stated he assessed P1 was critically ill on arrival with septic shock, likely developed encephalopathy, and then terminal illness. He stated the only issue staff had was the guardianship office was a barrier to the appropriate care of P1. He further stated the family was present and understood P1 was at the end of life, the care team was aware, and Physician 1 also cared for P1 at the nursing facility, so he knew P1 personally. Physician 2 stated this was a recurrent issue with guardianship because they treated patients as if it was a weekday operation. He stated there was no moral or legal obligation to provide specific treatments, so what Physician 1 did was obtain a second opinion. Physician 2 stated he called aggressive care in this situation as equal to assault, and it could be the right thing if temporary harm was caused for an outcome of recovery/benefit. However, in this case, he stated there was zero potential for benefit. Physician 2 stated for any patient who was critically ill and had a spokesman/power-of-attorney, staff expected that person to be present, and they usually were. Thus, he stated it would be expected that an appointed guardian would be present in making decisions. Physician 2 stated no care was withdrawn for P1,