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

A Clinical Guide to Supportive and Palliative Care for HIV/AIDS • Chapter 3: Assessment of Physical Symptomsprescribed for pain. 8 Results indicated that nearly 85% of patients with pain were classified asreceiving inadequate analgesic therapy and fewer than 8% of the 110 patients who reported“severe” pain were prescribed a “strong” opioid (e.g., morphine), as would usually be suggestedin published26guidelinespicasfor treatment of severe pain. 8Thus it is clear that many symptoms are prevalent in persons with HIV-related illness, especiallyin persons with advanced HIV-related disease. In addition, there is evidence to suggest that thehigher the number of symptoms, the greater the experience of distress. It is common for manysymptoms to be present concurrently. Finally, the distress from symptoms related to HIV infectionis often undertreated. It is within this context that symptom assessment must be undertakenand each of these factors must be taken into consideration within the symptom assessmentprocess.IIISymptoms and Quality of Life in Advanced HIV InfectionSeveral studies have specifically considered quality of life in people with HIV disease. 9-14 Theimpact of symptoms on quality of life was explored in the large prospective cross-sectional surveydone by Vogl, et al. discussed above. 5 In this survey, symptoms were assessed and characterizedusing a validated symptom scale and it was demonstrated in this population that both thenumber of symptoms and the symptom distress were highly associated with psychological distressand poorer quality of life. Older age, female sex, nonwhite race, poor social support, andthe presence of intravenous drug use, each have been associated with greater distress and poorerquality of life. In many studies the presence of symptoms is the strongest indicator of poorquality of life. 5, 10, 12, 15 The results of these studies highlight the impact of a broad range of physicaland psychological symptoms on quality of life.THE PRINCIPLES OF SYMPTOM ASSESSMENT■ As discussed above, symptom assessment is a most important aspect of patient care and asignificant component of quality of life assessment. 16,17 When care is being provided for peoplewith HIV-related illness, nearly all clinician interactions with patients require symptom assessmentskills. The following section outlines key points to consider when assessing symptoms.Definition of the Word SymptomSymptoms are Subjective ExperiencesA symptom has been defined as “a physical or mental phenomena [sic], circumstance or changeof condition arising from and accompanying a disorder and constituting evidence for it.... specificallya subjective indicator perceptible to the patient and as opposed to an objective one (cf.sign).” 18 In other words, symptoms are experienced by the patient and signs are observed by theclinician. This is a vital concept; symptoms cannot be seen, although sometimes the physicalmanifestations of a symptom can be detected. Oftentimes a clinician can also observe the distressassociated with a symptom.Symptoms are Different from Pathological Processes or DiagnosesJust as signs are not symptoms, symptoms and signs are not, of themselves, diagnoses. Symptomsand signs can however assist in the diagnostic process. For example, fatigue is a subjectivesensation–-a symptom–-that may occur with the diagnosis of anemia or infection, but fatigueU.S. Department of Health and Human Services • Health Resources and Services Administration • HIV/AIDS Bureau 39