I am a huge advocate for palliative care and deferring intubation if possible until a conversation with family can be had. Even if the family knew the patient would not want to be prolonged on life support once they are on it many have a difficult time withdrawing care. Having said that, in my experience, the majority of families request aggressive care unless there was a written DNR regardless if they know the patient would not want it. in EMS treat the patient to the standard of care and let things play out in the ICU with the physicians and palliative care specialist. If they can survive on Bipap or a NRB then that is great but if they need intubation then do it. How do you know this isn't a reversible disease process? Maybe she missed her Keppra dose the past few days and is hyponatremic. I do not see anything that would make me assume she is end of life or futile. She was ambulatory and at her baseline prior to this incident.