Clinical Manual for Management of the HIV-Infected ... - myCME.com

Palliative Care and HIV
Background
Palliative care is not curative care, but is supportive,
symptom-oriented care. It is usually needed throughout
the course of disease progression to relieve patients’
suffering and promote quality of life. Palliative care is
important for patients with any medical condition. It
may be used in conjunction with disease-specific care or
as the sole approach to care. Palliative care includes the
following:
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Management of symptoms (eg, fatigue, pain)
Treatment of adverse effects (eg, nausea, vomiting)
Psychosocial support (eg, depression, advance care
planning)
End-of-life care
Following is the widely used definition of palliative care
according to the World Health Organization:
Palliative medicine is the study and management
of patients with active, progressive, far advanced
disease for whom the prognosis is limited and
the focus of care is the quality of life. [It is] the
active total care of patients whose disease is not
responsive to curative treatment. Control of pain,
of other symptoms, and of psychological, social,
and spiritual problems, is paramount. The goal of
palliative care is achievement of the best quality
of life for patients and their families.
Palliative care in AIDS patients comprises a continuum
of treatment consisting of therapy directed at AIDSrelated
illnesses (eg, infection or malignancy) and
treatments focused on providing comfort and symptom
control throughout the life span. This care may involve
multidimensional and multidisciplinary services,
including HIV medicine, nursing, pharmacy, social
work, complementary/alternative medicine, and physical
therapy.
Palliative Care in the Era of Antiretroviral Therapy
With advances in HIV-specific therapy and care, HIV
infection is no longer a rapidly fatal illness. Instead,
those patients who are able to tolerate antiretroviral
therapy (ART) often experience a manageable, chronic
illness.
The death rate from AIDS, however, continues to be
Section 7—Pain and Palliative Care | 7–7
significant: approximately 15,000-16,000 per year in
the United States. In many parts of the world, patients
are not able to obtain specific treatments for HIV or for
opportunistic illnesses, and supportive or palliative care
may be the primary mode of care available to patients
with advanced AIDS. Regardless of access to diseasespecific
treatment, people living with HIV continue
to experience symptoms from HIV disease and its
comorbid conditions, and those taking ART may
experience adverse effects. Integrating palliative care
with disease-specific care is important in the treatment
of patients with HIV to promote quality of life and to
relieve suffering.
S: Subjective
The patient with advanced HIV disease complains of 1
or more of the following:
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Agitation
Anorexia
Chronic pain
Constipation
Cough
Decubitus
ulcers or
pressure sores
O: Objective
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Delirium
Dementia
Depression
Diarrhea
Dry skin
Dyspnea
Fatigue
Fever
Conduct a complete symptom-directed physical
examination.
A: Assessment and P: Plan
Treatment
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Increased
secretions
("death rattle")
Nausea
Pruritus
Sweats
Vomiting
Weakness
Weight loss
Table 1 lists common symptoms of AIDS and their
possible causes. Also included are disease-specific
treatments and palliative interventions. Depending on
the situation, either or both of these treatments may be
appropriate. Consider the patient’s disease stage and
symptom burden, the risks and benefits of therapies,
and the patient’s wishes. Practitioners should note that
some of the palliative treatments may have substantial
long-term adverse effects and should be used to alleviate
symptoms only in late-stage or dying patients.