Intensive care for patients with AIDS: clinical and ethical issues

Pneumocystis carinii pneumonia (PCP) remains a common and morbid infection among patients with the acquired immunodeficiency syndrome (AIDS). Most patients who die of PCP do so because of respiratory failure. The survival after intubation and mechanical ventilation for PCP and respiratory failure has gone through three eras: Era I (1981-85), when the survival rate to hospital discharge was about 10%; Era II (1986-88), when the hospital survival rate rose to about 40%; and Era III (1989-present), when the hospital survival rate fell again to about 25%. Patients with CD4 counts of less than 50, patients who develop pneumothoraces while intubated, and patients spending more than 2 weeks in the ICU receiving mechanical ventilation appear to have very poor (< 10% survival) prognoses. As the survival rate has fallen in recent years, so too has the cost-effectiveness of ICU care for patients with severe PCP. It now costs about $200,000 (U.S.) to save a year of life through the use of the ICU in PCP, a relatively cost-ineffective intervention. Our present approach is to provide patients information about prognosis and options and allow them to make an informed choice about whether they would like ICU care should the medical need arise. Whether the high costs and low cost-effectiveness of intensive care should and will be factored into this decision are questions of great clinical and ethical importance for the future.