Question

A 78-year-old woman with metastatic breast cancer to the bones and liver, complicated by malignant biliary obstruction, is brought to the emergency department for severe, generalized pain and worsening shortness of breath over the past 24 hours. She is lethargic, intermittently groaning, and oriented only to person. Vital signs are temperature 37.1 C (98.8 F), blood pressure 90/60 mm Hg, pulse 115/min, and respiratory rate 28/min. Oxygen saturation is 86% on room air. Laboratory studies show a serum creatinine of 3.8 mg/dL (baseline 1.1 mg/dL) and total bilirubin of 6.2 mg/dL.

No written advance directive is on file in the hospital system. Her husband of 50 years is at the bedside; he is distraught and insists the team "do everything, including a breathing machine, to keep her alive." The patient's adult daughter, who lives out of state, is contacted on the phone. The daughter provides a legally executed Durable Power of Attorney for Healthcare (DPOA-HC) document signed by the patient two years ago naming the daughter as the sole healthcare agent. The daughter firmly states that her mother recently expressed a strong desire to avoid mechanical ventilation and wishes only for interventions that prioritize comfort.

The patient is in visible respiratory distress, with accessory muscle use and severe grimacing when repositioned. Which of the following is the most appropriate next step in management?