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 SymptomsPortenoy, et al. have developed a validated instrument for the assessment of three key dimensionsof symptoms: frequency, severity and distress. 6 (See Figure 3-1 at the end of this chapter.) Thisinstrument mirrors in part what usually should be explored clinically in relation to each symptom.The three26questionspicasasked of the patient on that instrument address how frequent, severe andbothersome a symptom may be to the patient. A shorter version of this instrument has been usedin studies of patients with advanced HIV infection and has provided useful data. 5, 7Symptom distress relates to the degree of subjective discomfort and the “bothersomeness” ofeach specific symptom. Global symptom distress has also been considered as a subjective conceptthat relates to the impact of all symptoms. Symptom distress can be described and measured.As alluded to above, the overall impact of symptom distress is most important. A largeprospective cross-sectional survey, discussed above, of 504 ambulatory AIDS patients found thatpatients experienced many distressing physical and psychological symptoms and a high level ofdistress. 5 Symptom distress significantly correlated with lower performance status, worse scoreson measures of psychological distress, and a poorer global quality of life.The impact of symptoms may be described and measured in relation to specific issues or globalconstructs. Many of the specific issues form the components of the global concept of quality oflife. The impact of a symptom can be assessed in relation to the following:• Spheres of functioning• Family, social, financial, spiritual and existential issues• Various global constructs such as overall symptom distress or quality of lifeFactors that may modulate symptom distress may in turn be modulated by other components ofthe overall quality of life. Distress can be compounded when it is coming from multiple sources.By the same token, positive aspects of life frequently can mitigate some degree of distress. Themultidimensional construct of quality of life reflects the broad influence of many positive andnegative factors on a patient’s perceived well-being. 30, 31 A diverse array of physical, emotional,social, ethical and spiritual phenomena can increase or temper distress or enhance well-being.Factors from each of these areas have the potential to independently influence quality of life,and to exacerbate or lessen the distress associated with specific symptoms. Each must thereforebe considered in symptom assessment.IIIPRACTICAL ASPECTS OF SYMPTOM ASSESSMENT■ This section focuses on the practical aspects of symptom assessment, discusses some populationsin which symptom assessment can be especially challenging, and reviews available instrumentsfor symptom assessment.The key to symptom assessment is a comprehensive approach as shown in Table 3-3. The healthcare provider should undertake the following tasks:• Develop an understanding of the patient’s current and past illness• Elicit the details of the distress caused by each symptomU.S. Department of Health and Human Services • Health Resources and Services Administration • HIV/AIDS Bureau 45