The Clinical Guide to Supportive and Palliative Care for HIV/AIDS

IIIChapter 3.Assessment of Physical SymptomsJane M Ingham, MD, BS, FRACP, and Maria Farooqi, MDINTRODUCTION■ Health professionals caring for people living with HIV will encounter myriad symptoms rangingfrom minor and bothersome problems to problems that are associated with great distress. Incaring for a patient who presents with a symptom, the health professional has two main roles.The first involves defining the etiology of the symptom and implementing an appropriate treatmentstrategy directed towards eliminating or modulating the pathophysiologic process responsiblefor triggering the symptom. The second role involves ensuring that a strategy is developedand implemented that provides timely and effective relief of the distress associated withthe symptom. Usually, these two goals involve two closely interrelated, but different, treatmentstrategies and there may be times, especially towards the end of life, when the first goal isunattainable. At the core of the process required to achieve these goals is symptom assessment,the focus of this chapter.To understand symptom assessment in HIV infection, health care providers must understandsymptoms within the contexts of quality of life and of HIV infection itself. This chapter addressesthe symptoms common in patients with advanced HIV disease, the principles of symptomassessment, and an approach to symptom assessment in advanced HIV including some clinicallyuseful assessment instruments. Although this chapter frequently uses fatigue, pain, andthe symptoms associated with fever as examples to illustrate the process of assessment, thesame general process of assessment applies for all symptoms.Symptoms and Quality of Life in HIVThe overarching goal of palliative care is to relieve or reduce suffering and promote quality oflife. A crucial component of quality of life is the component that relates to symptoms includingfatigue and pain, among many others. Such symptoms can be present throughout the course ofillness from diagnosis through the progression of disease and toward the end of life. Of note,these symptoms may be present even at times when disease markers are improving. The sometimesunpredictable and episodic course of HIV-related illness—especially in the early years ofthis illness when treatment strategies were less clearly outlined—made it difficult to estimatethe likely course of HIV-related disease for an individual. This factor, along with patient advocacyand developments in the field of palliative medicine, prompted an increasing awareness ofthe importance of palliative medicine for those living with HIV infection. These and other factorshave served to promote quality of life itself as an important outcome of all treatments fordisease, regardless of the stage of illness.Health-related quality of life is a multidimensional concept affected by a variety of positive andnegative experiences from a variety of domains. A patient’s health-related quality of life shouldnot be thought of only as a research outcome; rather, in clinical practice it is a vitally importantconcept that reflects the global impact of disease and the impact of related medical interventions.U.S. Department of Health and Human Services • Health Resources and Services Administration • HIV/AIDS Bureau 37