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Robert M. Wachter, MD; John M. Luce, MD; Philip C. Hopewell, MD

JAMA. 1992;267(4):541-547.

Abstract
Objective.
—We sought to review the clinical and ethical issues surrounding critical care for patients with the acquired immunodeficiency syndrome (AIDS).

Data Sources.
—We reviewed published studies and abstracts dealing with the outcome of critical care for patients with AIDS, decision making about life-sustaining treatments in patients with AIDS, and infection control in the intensive care unit. We also consulted with a number of experts in the field.

Study Selection.
—We selected outcome studies in which patients with documented AIDS or infection with the human immunodeficiency virus (HIV) were analyzed. We rejected data concerning patients with suspected or presumed AIDS and data concerning presumed cases of Pneumocystis carinii pneumonia (PCP).

Data Synthesis.
—Most AIDS patients who require critical care do so because of respiratory failure caused by PCP. Although studies early in the epidemic reported survival rates to hospital discharge of 0% to 14%, recent studies demonstrate improved survival rates of 36% to 55%. Treatment for patients with PCP and respiratory failure should include either intravenous trimethoprim-sulfamethoxazole or pentamidine isethionate, as well as adjuvant corticosteroids. Patients with AIDS may require critical care for many other indications, including seizures, sepsis, and hypotension, or reasons unrelated to their immunodeficiency. In general, such patients have a better prognosis than those with respiratory failure.

Conclusions.
—The provision of critical care for PCP and respiratory failure specifically or AIDS generally cannot be considered futile. Therefore, decisions about the use of critical care should be guided by the particular clinical situation and the patient's preferences. More research is needed to elucidate the reasons for the improving survival for patients with PCP and respiratory failure and the predictors of such survival.

(JAMA. 1992;267:541-547)

Author Affiliations
From the Medical Service, San Francisco (Calif) General Hospital Medical Center and the Departments of Medicine (Drs Wachter, Luce, and Hopewell) and Epidemiology (Dr Wachter), University of California, San Francisco.

Footnotes
Reprint requests to the Division of General Internal Medicine, San Francisco General Hospital, Box 0862, University of California, San Francisco, San Francisco, CA 94143-0862 (Dr Wachter).

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