The human immunodeficiency retrovirus causes acquired immunodeficiency syndrome (AIDS), in which immunity is profoundly reduced through destruction of CD4 T lymphocytes and macrophages. The CD4 recognize infected cells and foreign antibodies, activate antibody-producing lymphocytes, and orchestrate cell-mediated immunity in which infected cells and foreign antigens are destroyed. When viral loads climb and CD4 counts drop, the immune system cannot resist the development of opportunistic infections and malignancies. AIDS is defined as a CD4 count < 200/ul or occurrence of AIDS defining conditions. AIDS is a syndrome once considered rapidly fatal. However, HIV has become a chronic disease as antiretroviral drugs and drugs controlling opportunistic infections have successfully prolonged life: over 35.3 million people across the globe are living with HIV, of whom 1.3 million are North Americans. Overall, the impact of antiretroviral on survival has made it difficult to use traditional prognostic indicators, and the clinical course of HIV/AIDS is fluctuating, with considerable variation among patients, and is marked by a number of opportunistic infections requiring treatment. Effective prevention strategies, earlier diagnosis, and the use of antiretroviral therapy (ART) have all improved survival rates. Despite this, there remain approximately 20,000 AIDS deaths per year in the United States. A viral load of more than 100,000 copies of a CD4 count below 25 cells/mcl may predict a terminal condition if a patient is declining in function, choosing to forgo medication, antiretrovirals are no longer effective, or life-threatening complications have developed. Continue reading “Determining Prognosis: Patients with End-Stage AIDS (Reading & Sharing)”
Alzheimer’s disease and other dementia
- Inability to ambulate without assistance (FAST 7-C)
- inability to speak or communicate meaningfully with speech limited to approximately a half-dozen or fewer intelligible or different words (FAST 7-B)
- Loss of ADL functions including bathing and dressing (FAST 6)
- Incontinence of bowel and bladder (FAST 6)
- one or more of the following comorbid conditions in last 3-6 months
- Aspiration pneumonia
- Pyelonephritis or upper urinary tract infection
- Decubitus ulcers, usually multiple and stages II or IV
- Fever, recurrent after antibiotics
- An altered nutritional status as manifested by:
- difficulty swallowing or refusal to eat such that sufficient fluid or caloric intake cannot be maintained and the patient refuses artificial nutritional support
- If the patient is receiving artificial nutritional support (NG or G-tube or parenteral hyperalimentation), there must be evidence of an impaired nutritional status as defined in the General Guidelines (greater or equal 10% loss of body weight)
The principles for determining when patients with end-stage cardiac disease require end-of -life care, are actually similar to those for determining prognosis of patients with advanced pulmonary disease.
Disabling Dyspnea or Chest Pain
- Dyspnea or chest pain with rest or minimal exertion and can therefore classified as New York Heart Association class IV (NYHA class IV)
- Ejection fraction less or equal 20%, if available
- Persistent symptoms despite optimal medical management with vasodilators and dialectics, or
- Inability to tolerate optimal medical management due to hypotension and/or renal failure
- Dyspnea at rest or with minimal exertion
- Dyspnea poorly responsive or unresponsive to bronchodilator therapy
- Dyspnea results in other debilitating symptoms such as decreased functional activity, fatigue, and cough
- FEV-1< 30% predicted post-bronchodilator, if available
A decline in a patient’s nutritional status is another key indicator of poor prognosis. This is best expressed as an unintentional weight loss of 10 percent of normal body weight over a period of about 6 months, with the loss of weight usually due to the patient’s life-limiting condition.
- Reversible cause of weight loss, such as depression and metabolic disturbances (diabetes, thyroid disease), should be excluded prior to assuming that the weight loss is due to the terminal illness and a true indicator of the patient’s prognosis.
- However, terminally ill patients may still have reversible cause of weight loss. Thus, for terminally ill patients with reversible cause of weight loss, weight loss will be less helpful in determining prognosis.