INTENSIVE-CARE FOR PATIENTS WITH AIDS - CLINICAL AND ETHICAL ISSUES

Pneumocystis carinii pneumonia (PCP) remains a common and morbid infec tion among patients with the acquired immunodeficiency syndrome (AIDS) . Most patients who die of PCP do so because of respiratory failure. T he survival after intubation and mechanical ventilation for PCP and re spiratory failure has gone through three eras: Era I (1981-85), when t he 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%. Pa tients with CD4 counts of less than 50, patients who develop pneumotho races while intubated, and patients spending more than 2 weeks in the ICU receiving mechanical ventilation appear to have very poor (<10% su rvival) prognoses. As the survival rate has fallen in recent years, so too has the cost-effectiveness of ICU care for patients with severe P CP It now costs about $200 000 (U.S.) to save a year of life through t he use of the ICU in PCP, a relatively cost-ineffective intervention. Our present approach is to provide patients information about prognosi s and options and allow them to make an informed choice about whether they would like ICU care should the medical need arise. Whether the hi gh costs and low cost-effectiveness of intensive care should and will be factored into this decision are questions of great clinical and eth ical importance for the future.