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

A Clinical Guide to Supportive and Palliative Care for HIV/AIDS • Chapter 23: Medical Care in Advanced AIDSPast efforts at prognosis using the Child-Turcotte-Pugh classification have not been consistent becauseof the subjective nature of several indicators. A recent report used objective laboratory parametersto assign prognosis in advanced liver disease: the Model for End Stage Liver Disease (MELD).26 picas38A revised scoring system uses three laboratory tests (INR, total bilirubin, and creatinine) to assign aprognosis in chronic liver disease.This revised scoring system has been utilized to stratify patients for liver transplantation, which hasrecently been recognized in many centers as a feasible option for people with AIDS. The scoringsystem may also prove useful in determining which patients deserve a greater emphasis on palliativeor hospice care. In fact, any individual with a high MELD score and on the waiting list for an organis also a candidate for hospice. 39 If the patient receives a liver, then the hospice benefit can berevoked. Most patients awaiting transplantation, however, will not receive a liver, will die, and wouldbenefit greatly from aggressive palliative care.Large hepatocellular carcinoma is an additional complication of chronic hepatitis and an absoluteindication for palliative or hospice care.Intensive Care Unit / Mechanical Ventilation / PCPMerely being in an intensive care unit is an indication for palliative care regardless of diagnosis.40, 41 AIDS is no exception. Effective palliative care can be provided in an ICU with propertraining. 41 42, 43Pneumocystis carinii pneumonia is still the most common AIDS-defining illness.Acute respiratory failure occurs in 5% to 30% of patients. Intubated AIDS patients with PCP experiencemortality approaching 50%. 44The attitude of patients with advanced AIDS toward mechanical ventilation at end-of-life has beenreported. 45 Eighty-seven percent of 57 patients responded that withholding mechanical ventilationin the setting of “futility” was acceptable. Therefore, while mechanical ventilation may be veryappropriate for the patient with the initial diagnosis of AIDS and PCP, the patient with advancedAIDS and drug resistant virus may be quite comfortable discussing alternatives to hospitalization andventilation.Thus palliative care and even an end-of-life style of support for the patient and family in these circumstancesshould be considered routinely and provided aggressively.QUALITY OF LIFE IN ADVANCED AIDS■ A study has demonstrated that while asymptomatic patients with HIV had physical functioningequivalent to the U.S. general population, patients with symptomatic AIDS were impaired much likepatients with other chronic illness (gastro-esophageal reflux disease (GERD), prostate disease,depression, diabetes) and those with advanced AIDS scored similar to patients with end-stage renaldisease (ESRD). 46 One difference worth noting is that all three groups of people with HIV in the studyscored lower on the Emotional Well-Being Scale than all comparison chronic illness groups exceptpatients with primary depression.Symptom Management and Quality of LifePatients with advanced HIV disease often face a vexing array of symptoms: nausea, fatigue, weightloss, pain of various origins and presentations, headaches, neuropathies, diarrhea, fevers, shortnessof breath, confusion, loss of memory, AIDS-related dementia, and others. Symptoms also arise as aresult of therapy. Many of the drugs used in HAART can cause substantial side effects. HAART’s com-486U.S. Department of Health and Human Services • Health Resources and Services Administration • HIV/AIDS Bureau