The Clinical Guide to Supportive and Palliative Care for HIV/AIDS

A Clinical Guide to Supportive and Palliative Care for HIV/AIDS • Chapter 6: Pulmonary Symptomsrecognized the contrasts in vision, hearing, and perception. When these individuals were subsequentlyre-exposed to the altitude chamber, many found that their previous experiences did notimprove their ability to recognize signs of hypoxemia in themselves. (Griffin R, retired flightsurgeon26and Colonel,picasUSAFR. Telephone communication with author, April, 2002.)During the final days or hours of life, AIDS patients, especially those with pulmonary disorders,are likely to become increasingly hypoxemic. They may be unaware of any associated symptomsand may resist efforts to improve oxygenation by removing a mask or nasal cannula. Simple ornon-rebreathing masks may create feelings of claustrophobia and anxiety. In these settings,administration of oxygen may not be a comfort measure, although in some situations it may belife-prolonging. If prolonging life is no longer a goal of the patient, family, or friends, or if lifeprolongingmeasures are now compromising comfort, it may be appropriate to consider discontinuingsupplemental oxygen. This can be done by not replacing oxygen delivery devices whenremoved by the patient or by titrating oxygen flows downward and then discontinuing supplementaloxygen over a matter of minutes or hours. Oxygen can always be restarted if the patientappears to have increased symptoms or discomfort associated with stopping oxygen. In mostcases this is not necessary.VIUse of Antibiotics in Terminal CareWhile we have made remarkable progress in increasing life expectancy by combating infectiousdiseases over the last one hundred years, there still may be wisdom in the old saying “pneumoniais the old man’s friend.” Death from infection, particularly if the patient is dehydrated,debilitated, and immunocompromised, can be rapid and peaceful. Dyspnea is likely to be minimalwhen dehydration limits fluid accumulation in the infected lung and/or the inflammatoryresponse is impaired. Pain and cough usually can be managed successfully with opioids.Likewise, with effective palliation of symptoms, central nervous system infections such as toxoplasmosis,bacteremia, or intra-abdominal sepsis may help to prevent a prolonged or difficultdying process in end-stage patients. In these situations it may not be in a patient’s best interestto pursue aggressive treatment of infections, even though it may be relatively easy to do so.Infections that are not life-threatening but do contribute to discomfort can always be treatedwith the appropriate antibiotics. For example, bronchitis or urinary tract infections can causedistressing symptoms that respond well to antibiotic treatment. But in the terminal phases ofillness, symptomatic relief of life-threatening infections may be all that is needed. Prednisonemay be adequate to combat the symptoms of Pneumocystis carinii pneumonia, and low doses ofopioids may be enough to control the distressing symptoms of bacterial pneumonia.The Role of Fluids and Dehydration in Terminal CareDecreased fluid intake is a normal part of the dying process and can lead to profound dehydration.There is some evidence that complaints of dry mouth are no greater in dehydratedpatients than in patients receiving hydration during the final stages of life, perhaps because ofincreased mouth-breathing in both groups.If symptoms of oral dryness are well controlled, dehydration can actually provide several benefitsto people in the final days of life. First, dehydration decreases symptoms from pulmonaryinfections. With a decrease in total body water there is less interstitial or alveolar fluid associatedwith the inflammatory response to an infection. This leads to a reduction in symptomsU.S. Department of Health and Human Services • Health Resources and Services Administration • HIV/AIDS Bureau 137