Ethical considerations

The appropriateness of allocating finite resources to the terminally ill is frequently challenged, and as AIDS is a progressive disease and has no cure many health care workers have questioned the validity of decisions to allow HIV-infected patients to receive intensive care. Patients with AIDS have the same right of access to intensive care as non-HIV-infected patients with conditions such as cirrhosis with varices, severe chronic heart failure with angina, or unresectable non-small-cell lung carcinoma, all of which have similar short- and long-term prognoses to AIDS (Wachter, et,ai 1988). Patients with these conditions are often admitted to the ICU even though they may have no guarantee of recovery or return to normal life; in contrast, ICU admission is frequently refused to AIDS patients.

When HIV-infected patients are questioned about their desire for life-sustaining therapy at a time when they are physically well, the majority say that they would opt for active intervention (Steinbrook,, al 1986). When asked what treatment they would want if they developed P. carinii pneumonia, 95 per cent of HIV-infected men stated that they would want hospital admission and antibiotics, 55 per cent would want intensive care (and mechanical ventilation if respiratory failure supervened), and 48 per cent would want cardiopulmonary resuscitation. If the scenario was one of P. carinii pneumonia on the background of HIV-associated dementia, only 19 per cent and 17 per cent respectively wanted transfer to intensive care with mechanical ventilation and cardiopulmonary resuscitation. Seventy-three per cent of HIV-infected men wanted to discuss these issues with their regular out-patient physician; however, only 33 per cent had been able to do this. HIV-infected patients and their relatives deserve the same considerations as any other critically ill patient; they should be informed and consulted about their medical condition and the need for intensive care, mechanical ventilation/intubation, and cardiopulmonary resuscitation should any of these situations arise.

There appear to be few reasons for not offering full intensive care to HIV-infected patients if it is clinically indicated and the prognosis is clearly explained and understood by the patient and his or her physician. If, during the course of treatment, deterioration occurs and continuing or commencing new therapy is not indicated, and this scenario has been discussed with the patient by his or her doctor at a time when he or she was well, for example when seen in the out-patient clinic or first admitted to the hospital, then active support can be discontinued.

Many patients, whether HIV infected or not, now have 'living wills' or 'advance directives' which lay out their wishes for treatment in the event of physical and/or mental incapacity. Others give durable power of attorney to their partner or another family member, so that treatment decisions can be made even if the patient is too ill to partake in discussions.

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