The bipap machine was brought to my dad's home by a therapist of some kind from the medical supply company. She showed my parents how to operate it. She also brought an oxygen tank. The doctor's instructions (He's an ALS and MND specialist) were to use the oxygen during the day and the bipap at night. My mom called me because she'd had a bad experience with the woman. Mom was trying to write down all the instructions for the care of the machine and the therapist told her nobady else took all those notes, they just remembered it. Well for God's sake, my mom is 78 years old. Let her do what she needs to do. Consequently, after the woman left, Mom was trying to figure out where to hook up the face mask tube and couldn't remember how to do it. The woman had showed her how, but did not have her practice it with guidance. My dad was exhauseted after this visit and a physical therapy appointment. He lay down to rest. I don't know if he had the oxygen on or not. Mom at first said he'd had it and later said he was just resting without it. She called me again a few hours later quite concerned that she couldn't rouse him to get him to come to dinner. I told her to call 911, which she did. They came and took him to the hospital. He had highly elevated co2 levels and was slipping away from us. When I arrived at the hospital several hours later (as soon as I could catch a ferry and drive 50 miles) Dad was on oxygen, but still out of it. They then made the decision to use the bipap machine. I had read something about oxygen being bad for ALS patients, but I couldn't remember what it was. I tried to ask, but was assured that the oxygen was helping because his oxygen levels had been low. The bipap machine was attempted for several hours, but it was having no effect on lowering his co2 levels. We had to make a choice. Dad had never told me if he wanted the traceostomy or not. He was intubated and put on a ventilator to allow him to become conscious enough to make his own decision. The next day he was sedated, and came out of it enough to communicate in the afternoon. We explained the situation. I can only imagine how hard a decision this was for him. The doctors said his lungs were not strong enough to function even with the help of a bipap machine. He said he needed to think about his options (we were using yes/no questions and he was able to respond by wiggling his eyebrows up and down or shaking his head slightly). IWe spent some time telling him our memories, rubbing his legs when they hurt, gently patting his forhead and chest. My brother was on the way from San Diego by plane. He went to the airport and the airline helped him patch together a series of flights. Dad needed to be sedated again a little later because he was in pain. It was a lower dose this time. When he came out of it again the whole family was with him. Th pulmonologist explained his choices. He again said he needed to think about it. he did not want to die, but I also know he did not want to be on a ventilator in a nursing home. My mom could not have done all the care herself, and while dad was sedated we had investigated 24 hour home nursing care (so expensive as to be prohibitive) and the care centers that would take patients on ventilators. For the next several hours, we sang for dad, we told him more memories of his life, we showed him photographs, we hugged him as well as we could with all those tubes on. He began to be in more pain. he said he was ready to make a decision. The hardest thing I have ever done in my life is to ask him the questions he could answer yes or no to. One of them:"Do you want the ventilator tubes removed and be allowed to die naturally?" He wiggled his eyebrows "Yes" When the ventilator was removed, he was able to speak to us for a short while. Then the co2 levels began to rise, and he became less rational. He was on oxygen at this time. They told us it would help him go more comfortably without struggling for air. They also periodically put him back on the bipap, but it was not making a difference. I do not know if administering the oxygen had a deleterious effect. I had to make a chioce to trust what the doctor was saying. My heart was begging them to try the bipap longer, but it was clearly uncomfortable for him, and I did not want to torture my dad in his last hours.20 hours later, my beloved father passed away with all of us around him. My sister and I bathed him and dressed him. My nephew (8 years old) said he looked like Grandpa again in his own clothes. I realize this is an extremely long post. I only hope our experience helps someone else be more informed of the issues and ask critical questions before an emergency. We tried our best to be knowlegdeble, but somtimes you don't know the right question to ask until you are in the moment. My best to everyone here.