Tuesday, January 17, 2006

Prognosis in end-stage HIV AIDS. Supreme court rules on Oregon's PAS law.

The December Journal of AIDS has a paper about predicting prognosis in end-stage HIV-AIDS. It is based in a cohort of 230 patients enrolled in an HIV Palliative Care program in New York. This was a sick cohort--median CD4 count was 39/mm^3; median Karnofsky was 30; and after a median follow up of 4 months 54% had died. After analyzing those who died, only age greater than 65 years and performance status (measured as either Karnofsky score or number of impairments in activities of daily living) independently predicted death. Viral load, CD4 count, and baseline symptom scores were not predictive of death.

This is ongoing evidence that in a multitude of diseases, performance status is the best predictor of mortality. The authors point out that HIV-specific measures (such as viral load, CD4 count, etc.) are good predictors of mortality in healthier people with HIV; however they lose their prognostic power towards the end where pretty much everyone's CD4 counts are in the tubes. It should be noted, of course, that this was a very unique population--a single center's referral population. So the generalizability of this is limited, although it's not the first study to come to this conclusion in HIV.

The Supreme Court ruled in favor of Oregon's physician assisted suicide law today. Specifically, it ruled by a 6-3 margin that the federal government can't use the Controlled Substances Act to crack down on doctors who prescribe drugs to be used in assisted suicide under the Oregon Death with Dignity Act. Chief Justice Roberts dissented, in a block with Justices Thomas and Scalia, in a move that's of interest for those of us who are concerned about the balance of power on the Court. I've noted on this blog before that I'm no fan on assisted suicide, nor am I convinced Oregon's law is the best way of allowing and regulating it. But just because I've yet to be in a situation where PAS seems right--right for a specific patient, in a specific situation, using "close-up" ethics--doesn't mean that I won't someday. And having the DEA scrutinizing decisions, inserting themselves into the doctor-patient relationship at the end of life, is good for no one. See this previous post. I thought NPR's "All Things Considered" coverage today was particularly good.

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