Grandpa Albert is 92 years young and has lived independently as a widower for 10 years. Albert is a survivor of the Battle of the Bulge and years of smoking. Unfortunately, the years of smoking has caught up with his lungs and he has COPDchronic obstructive pulmonary disease. This requires an inhaler to open his lungs. Frequent breathing treatments on a hospital nebulizer are required to relax his stiff lungs and allow the damaged alveoli to exchange oxygen. The trips for breathing treatments occur more frequently and with greater urgency, Grandpa Albert is becoming tired of breathing masks and nasal cannulas. He thus makes an independent, autonomous, decision-authorizing advanced directives, appointing his daughter Janet as his patient advocate. The advanced directives include a DNRdo not resuscitaterequest and funeral instructions for burial.

In early October, Janet decides to take a rare respite from the main caretaker obligations of Albert to travel with her husband to the Porcupine Mountains in the northwest reaches of the Upper Peninsula of Michigan. Janet leaves her daughter Dana in charge of Grandpa Albert. In case of medical trouble, Dana is told that all his legal papers are in the lockbox in the bedroom closet. Janet feels quite comfortable with this situation; she has made similar arrangements for overnights and weekends with Grandpa and Dana. Dana knows his medical providers and has been with Grandpa Albert for hospital breathing treatments. On the second day of her fall color tour, Janet gets a call from Dana in Ontonagon that Grandpa has been admitted to the hospital and is requiring a ventilator to increase his oxygen saturation. Otherwise, he will become hypoxic and succumb to COPD. Janet tells Dana, "No, no. That is not what Grandpa wants."

At the hospital, Day #1, the emergency room and the intensivist pulmonologist consult on how to handle this difficult case. Dana has brought the advanced directives and all legal papers from the bedroom closet. The advanced directives are not signed by Albert or by patient advocate Janet. The advanced directives also include a DNR order, again, unsigned by Albert. Dana pleads with the ER and the pulmonologist, "Please don't intubate my grandpa. He does not want life-saving measures."

However, the pulmonologist, who is very familiar with Grandpa Albert, knows he will pull through just fine once he gets intensive breathing treatments on the ventilator. In the ER, Grandpa Albert's oxygen saturation declines from 90 to 82 percent, requiring admission and pulmonary support. Grandpa Albert is admitted to the ICU and placed on a ventilator with strong doses of albuterol to open his stiff lungs. He slowly responds with an increase in his O2 saturations and his PEEP (positive end-expiratory pressure). Grandpa is slowly improving, but his mentation is very poor, and he's unable to communicate.

On Day #2 Janet is calling the hospital and threatening to sue, claiming assault and battery since there was no consent to intubate and ventilate her father. "I'm the patient advocate," she says, "and this is against his wishes to be kept alive by artificial means."

Janet is told by the ICU: "We don't have signed paperwork. The legal papers your daughter brought to the hospital are unsigned and don't list an alternate patient advocate." Janet is livid. She handwrites a living will from the hotel business lounge in Calumet, cutting and pasting a Legal Zoom document found on the internet. She signs it and faxes the document.

The hospital in-house lawyer contacts Janet to tell her, "We can't act on a faxed copy, and besides, this isn't your decision. You have signed on behalf of your father without his consent."

Janet has no choice but to get in the car and drive to southern Michigan to express her father's wishes. When gassing up her car on the way home and searching for her credit card for payment at the pump, she finds her lawyer's thumb drive in her purse. This thumb drive contains Grandpa's entire downloaded estate plan, including his living will and appointment of Janet as his patient advocate. Janet drives even faster to the hospital to prove her point to the administration.

On Day #3, before Janet's arrival and with Dana at his bedside, Grandpa Albert is extubated and initially does quite well from a pulmonary standpoint, but now his heart is irregular, his EKG is throwing periventricular contractions, or pvc's. The ICU staff calls a code blue. Albert is given the full course of resuscitation, including the paddles, several doses of epinephrine, and chest compressions to shock his heart back into rhythm. Grandpa survives with four broken ribs but is again intubated, placed on the ventilator to maximize his oxygen exchange. Dana's response is: "Wait until my mother gets here!"

Provide several solutions/answers to the compliance concerns raised in Grandpa Albert's scenario. Please don't focus on concerns, but rather solutions for streamlining the process for the next "Grandpa Albert." Please indicate your concerns regarding upcoding, HIPAA (use of Zoom or telemetry), advanced directives, court resolution, and legal obligations required of the patient and whether the hospital must err on the side of caution to save a life. Is this considered a sentinel event that should be peer reviewed? If the matter is peer reviewed, should the hospital administration meet and disclose with Grandpa Albert, Janet and Dana?