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 SymptomsThese core aspects of the history are crucial. Of note, given that injection drug use is a riskfactor for HIV infection and a factor that may interface with many aspects of symptom assessmentand management, it is the most important factor to recognize. (Note: “aberrant” drugrelatedbehaviors26 picasmay be uncovered in the process of eliciting a social history that may suggestproblems with substance abuse or addiction. An approach to these is detailed in the sectionChallenging Clinical Situations and Special Populations.)In patients with advanced disease, for many reasons, the social assessment should usually bebroad. In addition to eliciting the core of the social history, initial historytaking should addressthe following:• Psychosocial assessment should reflect an understanding of the many factorsthat modulate distress, such as personality, coping, and both past and presentpsychiatric disorders. Questions that address the concept of coping andresources can be helpful (e.g., Are there things or people in your life that giveyou strength and help you to cope as you face this illness?). These questionscan also be symptom-specific (e.g., Are there things/people in your life thathave been helping you to cope with fatigue?).• Cultural and spiritual assessment should reflect an understanding of, andrespect for, family cultural and spiritual dynamics and the patient and familyexpectations and preferences for medical care and interactions. This aspect ofassessment is crucial, especially in relation to sensitive issues related totreatment decisions towards the end of life. Practical issues that arise in thisaspect of the assessment can inform the development of treatment plans. Forexample, the clinician may come to understand the cultural or spiritualinterpretation that a patient or family has in relation to interventions such asparenteral feeding or ventilator support near the end of life. In addition, formany patients, cultural and spiritual practices and support can help toalleviate distress.• The clinician should become aware of the patient’s family and socialresources, financial situation, and physical living environment. This point inthe history also provides an important opportunity to ascertain who is likely toassist with the patient’s care in the home. Often, with advanced illness, familymembers are asked to function as health care providers in the home. A familymember who serves as the “front-line” caregiver plays a key role in symptommanagement, administration of medications, and reporting problems;therefore, he or she can be a crucial help in ongoing symptom assessment andmanagement.• Knowledge of the patient’s and family’s previous experience with HIV infectionor other progressive medical disease may provide useful insights into theresponse to physical illness or the genesis of psychological symptoms.The social history provides the clinician with information that can assist in optimizing the careof the patient with advanced illness. It can also identify aspects of the patient’s illness experienceand distress that may be best addressed by others on the health care team or in the community.IIIU.S. Department of Health and Human Services • Health Resources and Services Administration • HIV/AIDS Bureau 53