Question

A 54-year-old man presents with a 1-year history of pneumonia, visceral Kaposi's sarcoma unresponsive to therapy, and chronic persistent diarrhea. He says that he uses heroin on and off because he is tired of visiting doctors all the time. He has elected to forego antiretroviral medication, chemotherapy, and prophylactic drug therapy. His caregiver mentions that his functional status has declined; he is confined to his bed for most of the day. His mental status is still intact, but activities of daily living (ADL) are notably affected. Physical exam reveals the patient has congestive heart failure. He is very thin, with recent wasting. His lab results show a viral load of 150,000 copies/ml, BUN 19 mg/dl, serum creatinine 1.3 mg/dl, CD4+ count 50 cells/mcL, and his serum albumin is repeatedly 2 mg/dl. His viral load 2 months ago was 140,000 copies/ml.

What is the most appropriate action in this case?

1. Hospice care with the diagnosis of end stage heart disease
2. Hospice care with the diagnosis of end stage renal disease
3. Hospice care with the diagnosis of end stage HIV/AIDS disease
4. Hospice care with the diagnosis of end stage pulmonary disease
5. Hospice is not appropriate

Answer 1

The appropriate action is hospice care with the diagnosis of end stage HIV/AIDS disease because the patient's severe immunodeficiency, opportunistic infections, and refusal of treatment indicate a terminal stage of the illness.

Step-by-step explanation:

The most suitable action in this case is to provide hospice care with the diagnosis of end stage HIV/AIDS disease.

Given the patient's CD4+ count of 50 cells/mcL and the clinical history of opportunistic infections (such as Kaposi's sarcoma and recurrent pneumonia), as well as chronic persistent diarrhea, the patient meets the criteria for a diagnosis of AIDS.

His declining functional status, decrease in activities of daily living (ADLs), and decision to forego antiretroviral medication and other therapies indicate that his disease has progressed to a terminal stage where palliative care is the appropriate response to improve his quality of life during end-stage illness.

The patient's high viral load also reflects the advanced state of the disease and the ineffectiveness or absence of treatment.

While he presents with congestive heart failure and renal insufficiency, these are likely complications from his advanced HIV/AIDS rather than primary diagnoses justifying hospice care.