Management of Fatigue in Palliative Care
The most effective approach to managing fatigue in palliative care is a comprehensive strategy that includes regular assessment, treatment of underlying causes, and a combination of non-pharmacological interventions (particularly physical activity when appropriate) and targeted pharmacological treatments. 1
Assessment and Screening
- Regular screening and evaluation of fatigue using brief assessment tools should be conducted at each clinical encounter to monitor changes and guide treatment modifications 1
- Assessment should include evaluation of disease status, medication side effects, treatable contributing factors (anemia, pain, emotional distress, sleep disturbances), and impact on quality of life 1
- Fatigue in palliative care is often multidimensional, affecting physical, cognitive, and emotional domains 2
Non-Pharmacological Interventions
Physical Activity
- Physical activity is the non-pharmacological intervention with the strongest evidence (category 1 recommendation) for managing fatigue, even in palliative care settings when appropriate 1
- Exercise should be tailored to the patient's functional status and modified based on disease progression 1
- For significantly deconditioned patients, referral to a physiatrist or supervised rehabilitation program may be indicated 1
- Exercise should be recommended with caution in patients with fever, anemia, neutropenia, or thrombocytopenia 1
Energy Conservation Strategies
- Implementation of energy conservation techniques including:
Psychosocial Interventions
- Cognitive Behavioral Therapy (CBT) and Behavioral Therapy (BT) are category 1 recommendations for managing fatigue 1
- Mindfulness-based stress reduction and supportive expressive therapies can help manage stress and improve coping 1
- Psychoeducational interventions to help patients understand and manage fatigue symptoms 1
Sleep Interventions
- CBT for sleep is a category 1 recommendation for improving sleep quality and reducing fatigue 1
- Structured sleep hygiene practices including limiting naps to 1 hour to avoid interfering with nighttime sleep 1
Pharmacological Interventions
- Treatment should target underlying causes when identified (anemia, depression, hypothyroidism) 1
- For cancer-related fatigue in palliative care:
- Methylphenidate may provide benefit for cancer-related fatigue (standardized mean difference 0.49,95% CI 0.15 to 0.83) 3, 4
- Corticosteroids (methylprednisolone) may be helpful for short-term use in advanced cancer 1, 4
- Limited evidence supports the use of modafinil for fatigue in specific populations 3, 4
Special Considerations for End-of-Life Care
- Fatigue patterns may vary at end-of-life - some patients experience constant fatigue while others have unpredictable patterns 1
- Common contributing factors at end-of-life include anemia, medication side effects, polypharmacy, cognitive impairment, and malnutrition 1
- Nutrition should be tailored to the terminal patient's comfort and not forced, as nutritional decline is expected 1
- At the very end of life, fatigue may provide protection and shielding from suffering, and aggressive treatment may not be beneficial 2
Ongoing Management
- Regular reevaluation of fatigue levels and treatment effectiveness is essential 1
- Treatment approaches should evolve as disease progresses and patient's clinical status changes 1
- Focus should include finding meaning and promoting dignity for the patient throughout the illness trajectory 1
Common Pitfalls to Avoid
- Failing to screen regularly for fatigue, as it is often underreported by patients 1
- Overlooking treatable contributing factors such as medication side effects, anemia, or depression 1
- Applying the same interventions throughout disease progression without adaptation 1, 2
- Focusing solely on pharmacological interventions without incorporating evidence-based non-pharmacological approaches 1, 5