An elderly patient with steroid and oxygen dependent COPD, and NYHA Class IV CHF, presents with dyspnea.  The patient is alert but looks somewhat desperate, confused, and exhausted.  Exam reveals accessory muscle use, grunting expirations, poor air movement, and cool clammy skin.  The patient speaks in two-word phrases.  Attempts to improve the situation are made with Lasix, nebulizers, and non-invasive ventilatory support.  The patient cannot tolerate BiPAP due to anxiety.