 | Palliative Care and HIVJuly 2006 | 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:  | 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 AIDS-related 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 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 disease-specific 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. | |
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| SOAP (Subjective, Objective, Assessment, Plan) | | | Assessment and Plan | | | Treatment | | 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. Table 1. Common Symptoms in Patients with AIDS and Possible Disease-Specific and Palliative Interventions| Symptom | Possible Causes | Disease-Specific or Curative Treatment | Palliative Treatment* |
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Key to abbreviations: OIs = opportunistic infections; ART = antiretroviral therapy; MAC = Mycobacterium avium complex; NSAIDs = nonsteroidal antiinflammatory drugs; CMV = cytomegalovirus; VZV = varicella zoster virus; PCP = Pneumocystis jiroveci pneumonia; TB = tuberculosis; SSRI = selective serotonin reuptake inhibitor. * 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. Adapted with permission from Selwyn PA, Rivard M. Palliative care for AIDS: Challenges and opportunities in the era of highly active anti-retroviral therapy. Innovations in End-of-Life Care. 2002;4(3), Available at www.edc.org/lastacts. | | CONSTITUTIONAL |
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| Fatigue, weakness | | | ART | | | Treat specific infections | | | Erythropoietin, transfusion | |
| | Psychostimulants (methylphenidate, pemoline, dextroamphetamine, modafinil) | | | Testosterone/androgens | | | Corticosteroids (prednisone, dexamethasone) | |
| | Weight loss/anorexia | | | ART | | | Chemotherapy | | | Nutritional support/enteral feedings | |
| | Testosterone/androgens | | | Oxandrolone | | | Megestrol acetate | | | Dronabinol | | | Recombinant growth hormone | | | Corticosteroids | |
| | Fevers, sweats | | Disseminated MAC and other infections | | | HIV lymphoma, and other malignancies | |
| | Specific treatment of OIs or malignancy | | | ART | |
| | NSAIDs (ibuprofen, naproxen, indomethacin) | | | Anticholinergics (hyoscine, thioridazine) | | | H2-antagonists (cimetidine) | |
| | PAIN |
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| Nociceptive, somatic, visceral | | Opportunistic infections | | | HIV-related malignancies, nonspecific | |
| | Specific treatment of disease entities | |
| | NSAIDs | | | Opioids | | | Corticosteroids | |
| | Neuropathic | | HIV-related peripheral neuropathy | | | CMV | | | VZV | | | Medications (eg, dideoxynucleosides: didanosine, zalcitabine, stavudine), isoniazid, vincristine | |
| | ART | | | Discontinue offending medication; | | | Change antiretroviral or other regimen | |
| | NSAIDs | | | Neuropathic pain medications:
| tricyclics (amitriptyline, imipramine) | | | benzodiazepines (clonazepam) | | | anticonvulsants (gabapentin, lamotrigine) | |
| | | Opioids (eg, methadone) and adjuvants | | | Corticosteroids | | | Acupuncture | |
| | GASTROINTESTINAL |
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| Nausea, vomiting | | Antiretroviral medications | | | Esophageal candidiasis | | | CMV | |
| | Specific treatment of disease entities | | | Change antiretroviral regimen | |
| | Dopamine antagonists (prochlorperazine, haloperidol) | | | Prokinetic agents (metoclopramide) | | | Antihistamines (diphenhydramine, promethazine) | | | Anticholinergics (hyoscine, scopolamine) | | | Serotonin antagonists (granisetron, ondansetron, dolasetron) | | | H2 blockers (cimetidine) | | | Proton pump inhibitors (omeprazole) | | | Somatostatin analogues (octreotide) | | | Benzodiazepines (lorazepam) | | | Marijuana, dronabinol | |
| | Diarrhea | | MAC | | | Cryptosporidiosis | | | CMV microsporidiosis | | | Other intestinal infections | | | Malabsorption | | | Medications (eg, protease inhibitors) | |
| | Specific treatment of disease entities | | | Discontinue offending medication | |
| | Bismuth, methylcellulose | | | Psyllium | | | Kaolin | | | Diphenoxylate + atropine | | | Loperamide | | | Calcium carbonate | | | Ferrous sulfate | | | Octreotide | | | Tincture of opium | |
| | Constipation | | Dehydration | | | Malignancy | | | Anticholinergic medications | | | Opioids | |
| | Hydration | | | Radiation and chemotherapy | | | Medication adjustment | |
| | Activity/diet | | | Prophylaxis for patients taking opioids | | | Peristalsis-stimulating agents:
| anthracenes (senna) | | | polyphenolics (bisacodyl) | | | Softening agents:
-surfactant laxatives (docusate)
-bulk-forming agents (bran, methylcellulose)
-osmotic laxatives (lactulose, sorbitol)
-saline laxatives (magnesium hydroxide)
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| | RESPIRATORY |
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| Dyspnea | | PCP | | | Bacterial pneumonia | | | Anemia | | | Pleural effusion, mass, or obstruction | | | Decreased respiratory muscle function | |
| | Specific treatment of disease entities | | | Erythropoietin, transfusion | | | Drainage, radiation, or surgery | |
| | Use of fan, open windows, oxygen | | | Opioids | | | Bronchodilators | | | Methylxanthines | | | Benzodiazepines (eg, lorazepam) | |
| | Cough | | PCP, bacterial pneumonia | | | TB | | | Acid reflux | | | Postnasal drip | |
| | Specific treatment of disease entities | |
| | Cough suppressants (dextromethorphan, codeine, other opioids) | | | Decongestants, expectorants (various) | |
| | Increased secretions ("death rattle") | | Fluid shifts | | | Ineffective cough | | | Sepsis | | | Pneumonia | |
| | Antibiotics as indicated | |
| | Atropine, hyoscine, transdermal scopolamine, glycopyrrolate | | | Fluid restriction, discontinue intravenous fluids | |
| | DERMATOLOGIC |
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| Dry skin | | Dehydration | | | End-stage renal disease | | | End-stage liver disease | | | Malnutrition medications (eg, indinavir) | |
| | Hydration | | | Dialysis | | | Nutritional support | | | Discontinue offending medication | |
| | Emollients with or without salicylates | | | Lubricating ointments or creams (eg, petrolatum, Eucerin) | |
| | Pruritus | | Fungal infection | | | End-stage renal disease | | | End-stage liver disease | | | Dehydration | | | Eosinophilic folliculitis | |
| | Antifungal agents (itraconazole for eosinophilic folliculitis) | | | Dialysis | | | Hydration | | | Topical corticosteroids | |
| | Topical agents (menthol, phenol, calamine, doxepin, capsaicin) | | | Antihistamines (doxepin - oral, diphenhydramine) | | | Corticosteroids (topical or systemic) | | | Serotonin antagonists (ondansetron) | | | Opioid antagonists (naloxone, naltrexone) | | | Antidepressants | | | Anxiolytics | | | Neuroleptics | | | Thalidomide | |
| | Decubitus ulcers, Pressure sores | | Poor nutrition | | | Decreased mobility, prolonged bed rest | |
| | Increase mobility | | | Enhance nutrition | |
| | Prevention (nutrition, mobility, skin integrity) | | | Wound protection (semipermeable film, hydrocolloid dressing) | | | Debridement (normal saline, enzymatic agents, alginates) | |
| | NEUROPSYCHIATRIC |
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| Delirium/agitation | | Electrolyte imbalances, glucose abnormalities | | | Dehydration | | | Toxoplasmosis | | | Cryptococcal meningitis | | | Sepsis | | | Medication adverse effects (eg, benzodiazepines, opioids, efavirenz) | | | Intoxication | |
| | Correct imbalances | | | Hydration | | | Specific treatment of disease entities | | | Discontinue offending medications | |
| | Neuroleptics (haloperidol, risperidone, chlorpromazine) | | | Benzodiazepines (eg, lorazepam, midazolam) (Note: in some patients, these may have adverse effects.) | |
| | Dementia | | AIDS-related dementia | | | Other dementia | |
| | ART | |
| | Psychostimulants (methylphenidate) | | | Low-dose neuroleptics (haloperidol) | |
| | Depression | | Chronic illness | | | Reactive depression, major depression | |
| | Antidepressants (SSRIs, tricyclics, other) | |
| | Psychostimulants (methylphenidate, pemoline, dextroamphetamine, modafinil) | | | Corticosteroids (prednisone, dexamethasone) | |
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| Patient Education | | |
| Discuss advance care planning with patients, and the option of hospice care,
if appropriate. | | | Provide the patient and his or her family with detailed information so that
they understand the illness and associated treatments. | | | Instruct patients to discuss their pain or other bothersome symptoms with
their health care providers. | | | Encourage patients to talk with their health care providers if they are
feeling anxious, depressed, or fearful. | | | Discuss with patients what their death might be like. Some patients may feel
relieved to be able to talk openly about their last days. Assure them that their
pain will be controlled and that their health care providers will be there to
help them. | |
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| References | | | The appearance of external hyperlinks does not constitute endorsement by the Department of Veterans Affairs of the linked Web sites, or the information, products or services contained therein. | | |
| American Academy of HIV Medicine. Palliative Care. The HIV Medicine
Self-Directed Study Guide (2003 ed.). Los Angeles: AAHIVM; 2003. |  | | National Hospice Organization. Guidelines for Determining Prognosis for
Selected Non-Cancer Diagnoses. Alexandria, VA: National Hospice
Organization; 1996. | | | O'Neill JF, McKinney M. Caring for the Caregiver. In: O'Neill JF, Selwyn PA, Schietinger H, eds. The Clinical Guide to Supportive and Palliative Care for HIV/AIDS. Rockville, MD: Health Resources and Services Administration; 2003. Available online at hab.hrsa.gov/tools/palliative/. Accessed May 20, 2006. | | | Selwyn PA, Rivard M. Palliative care for AIDS: Challenges and opportunities in the era of highly active anti-retroviral therapy. Innovations in End-of-Life Care. 2002;4(3). Available online at www.edc.org/lastacts. | | | Selwyn PA, Rivard M. Palliative care for AIDS: challenges and opportunities in the era of highly active anti-retroviral therapy. J Palliat Med. 2003 Jun;6(3):475-87. | | | University of Washington Center for Palliative Care Education. Module 1: Overview of HIV/AIDS Palliative Care. Accessed February 7, 2006. | | | U.S. Health Resources and Services Administration. A Guide to Primary Care of People with HIV/AIDS, 2004 ed. Rockville, MD: Health Resources and Services Administration; 2004:123-131. Available online at hab.hrsa.gov/tools/primarycareguide/. Accessed May 20, 2006. | | | Weinreb NJ, Kinzbrunner BM, Clark M. Pain Management. In: Kinzbrunner BM,
Weinreb NJ, Policzer JS, eds. 20 Common Problems: End-of-life Care. New York:
McGraw Hill Medical Publishing Division; 2002:91-145. | | | World Health Organization. Cancer Pain Relief and Palliative Care, Report of a
WHO Expert Committee. Geneva: World Health Organization; 1990. | |
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