Use and predictors of end-of-life care among HIV patients in a safety net health system

Context Although highly active antiretroviral therapy has improved survival among many HIV patients, there are still those with advanced illness and limited access to care who may benefit from palliative care and hospice. Objectives To examine completion of advance directives, use of palliative care, and enrollment in hospice among HIV patients who receive care at an urban safety net hospital. Methods This was a retrospective cohort study of HIV patients in a large, urban safety net hospital in 2010. Physicians abstracted data from the electronic medical record on patient and clinical factors and end-of-life care use. Logistic regression examined predictors of hospice use. Results Overall, 367 HIV patients identified electronically by International Classification of Disease (ICD)-9 code were hospitalized in 2010. The mean age was 42 years, and 57% were African American. Although 28% died, only 6% of the sample received palliative care consultation, and 6% of the sample enrolled in hospice. Those who received hospice had lower albumin levels (adjusted odds ratio [AOR] 4.53, 95% CI 1.19-17.34) had received palliative care (AOR 9.73, 95% CI 2.10-45.09) and completed an advance directive (AOR 16.33, 95% CI 4.23-61.68). Of those patients who received hospice, the mean time to death after enrollment was 11 days. Conclusion Among an urban cohort of HIV patients, the rates of advance directive completion, palliative care use, and hospice use were low. Despite advancements in the treatment of HIV, many patients with advanced illness may benefit from palliative care and hospice services. Advances should be made in identifying those patients earlier in their disease trajectories.