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A 65-year-old man with metastatic cancer and past medical history of schizophrenia, developmental delay, and COPD was admitted to the hospital with a spinal fracture. He experienced postoperative complications and continued to require intermittent oxygen and BIPAP in the intensive care unit (ICU) to maintain oxygenation. Upon consultation with the palliative care team about goals of care, the patient with telephonic support of his long time caregiver, expressed his wish to go home and the palliative care team, discharge planner, and social services coordinated plans for transfer home. Altho