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Patterns of care in advanced HIV disease in a tertiary treatment centre
I Goldstone1, D Kuhl, A Johnson
1British Columbia Centre for Excellence in HIV/AIDS, Vancouver, Canada.
Insights
In advanced HIV disease, aggressive end-of-life care, including resuscitation, increased significantly despite palliative care availability. This indicates a need to reassess treatment expectations for patients with advanced HIV/AIDS.
Area of Science:
- Medical research
- Public health
- Palliative care
Background:
- Advanced HIV disease presents complex end-of-life care challenges.
- Palliative care services were available at St. Paul's Hospital, Vancouver.
- The study examines care patterns for in-patient deaths in 1992.
Purpose of the Study:
- To analyze patterns of care during the terminal phase of advanced HIV disease.
- To identify trends in aggressive therapy versus palliative care at the end of life.
- To inform expectations regarding treatment outcomes in advanced HIV.
Main Methods:
- Retrospective chart review of all in-patient deaths in 1992.
- Data collected on demographics, services utilization, and care patterns.
- Analysis of four identified care patterns at death.
Main Results:
- 126 deaths reviewed; median age at death was 39 years.
- Four care patterns identified: aggressive therapy with/without resuscitation, palliative care unit, palliative care unit with respite.
- A 200% increase in resuscitation initiation compared to prior years was observed.
Conclusions:
- A trend towards increased aggressive end-of-life therapy in advanced HIV disease was noted.
- Despite palliative care, aggressive interventions were common, with no survivors discharged after resuscitation.
- Providers and patients need to reconsider treatment goals in advanced HIV disease.
Abstract:
A retrospective chart review of all in-patient deaths in 1992 was undertaken to examine patterns of care in advanced HIV disease at St Paul's Hospital, Vancouver, Canada. St Paul's Hospital cares for approximately 75% of the Province of British Columbia's AIDS caseload. This represents about 18% of Canada's caseload. Data were collected on demographic characteristics, the utilization of home care and community services, income and social support, symptom presentation at terminal admission and the utilization of acute hospital care and hospital based palliative care. A total of 126 deaths were reviewed. All but two subjects were homosexual/bisexual men. The median age at death was 39 years (range 24-67). Four patterns of care at death were identified: (1) aggressive therapy with resuscitation 24 (19%), (resuscitation was initiated in 58%); (2) aggressive therapy with a no resuscitation order 49 (39%), in which the palliative period was a median of three days; (3) death on the palliative care unit 33 (29%), with a median survival once palliative of 20 days; and (4) death on the palliative care unit following respite admissions 16 (13%), with a median survival once palliative of 64 days. Despite a well known and respected Palliative Care Unit and community palliative care programme, there is a marked trend towards death occurring during aggressive therapy with a 200% increase in the initiation of resuscitation compared to the previous three years. No-one has been discharged alive from hospital following the initiation of resuscitation since 1988. This study illustrates the need for providers and persons infected with HIV to reconsider expectations about treatment outcomes in advanced HIV disease.