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

A Clinical Guide to Supportive and Palliative Care for HIV/AIDS • Chapter 24: Medical Care at the End of LifeHospice Organization developed guidelines for physicians desiring to refer AIDS patients for hospiceservices. 3 These are listed in Table 24-1.With26widespreadpicasuse of HAART, predicting life expectancy is now more complex. Recent studies ofpatients with access to triple drug therapy suggest that disease progression to AIDS or death may beassociated with timing of initial antiretroviral therapy. 4, 5, 6 A recent Canadian study found that thosestarting therapy with a CD4 cell count lower than 200 cells/mm 3 were three times more likely to diethan those treated earlier in their course. The crude mortality rate for patients with access to HAARTearly in their trajectory (after 1997) is 6.7% at 28 months, much different from the statistic in the earlyepidemic. 7 Viral load as a prognostic factor does not seem as important when patients have accessto treatment. Previous studies may simply reflect that these patients were not treated soon enough torescue a failing immune system.Table 24-1: Factors Associated with Shortened Life ExpectancySymptom or SignCommentCD4 persistently low Advanced disease: < 50 cells/mm 3Viral burden remains > 100,000 copies/mldespite combination therapyFunctional Status < 50Spending > 50% of day in bed(Karnofsky Performance Status)Failure of optimized therapye.g., multi-drug resistance or failureDesire to forego more therapyMay occur after multiple hospitalizationsSignificant wastingLoss of > 30% lean body massProgressive hepatitis C despite therapy Hepatic failure; drug intoleranceProgressive multifocalProgressive dependencies; dementialeukoencephalopathy (PML)Unresponsive Kaposi’s sarcoma involving Progression despite therapyan organEnd-stage organ diseaseRenal, hepatic, or cardiac failurePersistent diarrhea > 1 mo.No response to treatmentUnresponsive lymphoma/ other malignancy Progression despite therapyDesire of patient for deathAcknowledgment by patient & familyof poor prognosisAdapted from Moore 8 , NHO 9Despite the development of multiple resistant strains, patients who are able to adhere to therapyseem to be living longer. Providers caring for people with long treatment histories often becomefrustrated with the lack of drug choices, but good supportive care can allow a patient to live until thenext therapy is released. Liver failure, malignancies, and cardiovascular events are the issues facingpatients with advanced disease; providers now need to be familiar with the palliative aspects ofmanaging these problems.494U.S. Department of Health and Human Services • Health Resources and Services Administration • HIV/AIDS Bureau