Palliative Nursing Care of the Patient With Cancer-Related

Palliative Nursing Care of the PatientWith Cancer-Related Fatigue

Cynthia Ellis Keeney, MSN, RN ƒ Barbara A. Head, PhD, RN, CHPN, ACSW

Cancer-related fatigue is a common debilitatingsymptom experienced by nearly all cancer patients. It ismultifactorial in nature, with physical, emotional, andcognitive aspects. Cancer-related fatigue can limitpatient involvement in social interactions, self-careactivities, and the important work of closure at the endof life. It has been described as the most troublesomeof symptoms for palliative care patients. This articleaddresses the phenomenon of cancer-related fatigueand presents an actual case illustrating palliativemanagement of fatigue throughout the cancercontinuum. Palliative management of fatigue in otherlife-threatening illnesses is also discussed.

KEY WORDScancer-related fatigue, case study, fatigue, palliativecare, symptom management

You are the nursing coordinator of the Thoracic Oncology

Clinic at a large outpatient cancer center. In your role, you

oversee the symptom management of patients at all

stages of their illness including the initiation and continuation

of palliative care throughout the cancer trajectory.

Anna, a 58-year-old woman with limited-stage small-cell

lung cancer, presents to the thoracic oncology clinic for a

follow-up visit after completing three cycles of cisplatin and

etoposide. She is scheduled to receive her fourth cycle

immediately following today’s visit. After checking her vital

signs, the clinical assistant informs you thatAnnawould like

to talk to you about discontinuing her chemotherapy.

When you enter the room and ask Anna how she is doing,

she responds, ‘‘I don’t think I want to go on with these

treatments. I’m not sure it is worth it to feel like this every

day.’’ When you ask Anna to explain, she hesitates, but her

husband responds, ‘‘She has no energy. We used to go to

the lake every weekend; now, she can’t do it. She can’t

even tolerate a visit with our granddaughter. Some days she

doesn’t even get out of bed.’’

Cancer-related fatigue (CRF) is defined by the Na-tional Comprehensive Cancer Network (NCCN)as ‘‘a distressing, persistent, subjective sense of

physical, emotional, and/or cognitive tiredness or exhaus-tion related to cancer or cancer treatment that is not pro-portional to recent activity and interferes with usualfunctioning.’’1 Cancer-related fatigue is a complex, multi-factorial phenomenon with physical, emotional, and cog-nitive effects and is described by the patient as feelingsof tiredness, lack of energy, weariness, loss of vigor, andphysical and mental exhaustion.2 It differs from tirednessin the general population as it is not associated with in-creased or decreased physical activity, nor is it relievedby rest. Subjective descriptions of the symptom, its effectson daily activities, and its resistance to rest can serve todifferentiate CRF from normal tiredness experienced inthe general population.3

Anna is not alone in her battle with fatigue. Cancer-related fatigue is the most commonly reported cancer-related symptom, occurring in more than 90% of patientswith the disease.4-8 Cancer-related fatigue can have a de-vastating effect on quality of life and is considered themostdistressing of all symptoms experienced by cancer patients,even surpassing pain and nausea.9 Some evidence sug-gests that CRF has been associated with decreased survi-val.10 While CRF can occur in any cancer patient, severalstudies have demonstrated that the incidence and severityof CRF are greatest in patientswho receive aggressive inter-ventions including chemotherapy, biological therapy, ra-diation therapy, bone marrow transplantation, surgery, ora combination of treatments.7,11-15 Cancer-related fatiguecan become so bothersome to patients that chemotherapyregimens are decreasedVor in some instances discontin-ued altogetherVin an effort to mitigate the intensity ofthe symptom.5,16 A higher incidence of fatigue has beenfound with specific cancers9; patients with cancer of thelung17,18 or prostate are more likely to report CRF lasting

Cynthia Ellis Keeney, MSN, RN, is Clinical Research Nurse, Universityof Louisville Interdisciplinary Program for Palliative Care and Chronic Ill-ness, KY.

Barbara A. Head, PhD, RN, CHPN, ACSW, is Assistant Professor, Uni-versity of Louisville Interdisciplinary Program for Palliative Care andChronic Illness, KY.

Address correspondence to Cynthia Ellis Keeney, MSN, RN, Universityof Louisville Interdisciplinary Program for PalliativeCare andChronic Illness,MDR Bldg, Ste 110, 511 South Floyd St, Louisville, KY 40202 ([email protected]).

*This paper is part of our series which partners a new author with a seniorauthor to provide an evidence based paper on a clinical topic in palliativenursing.

DOI: 10.1097/NJH.0b013e318221aa36

270 www.jhpn.com Volume 13 & Number 5 & September/October 2011

Research and Practice: Partners in Care*

longer than 6months and resulting in some level of disabil-ity.17 Cancer-related fatigue is often clustered with othersymptoms19-21 including pain, changes in sleep patterns,and emotional distress, making it even more devastatingto the patient. Left unchecked, CRF can result in significantdisability,22,23 leading to financial losses due to decreasedemployment and increased dependency,7,24 role loss, andrelated decline in meaningful family relationships.22

Cancer-related fatigue is a multidimensional syndromethat can be affected by physiologic, psychological, and/orsituational factors.25 While not clearly understood, causalmechanisms are thought to include factors directly relatedto or induced by the tumor, cachexia, anemia, dehydra-tion, decreased oxygen saturation, insomnia or othersleep-related disturbances, neurological alterations, psy-chological disorders, metabolic disorders, liver metasta-sis, and the adverse effects of anticancer treatments.26

While CRF has received more attention in the researchliterature, cancer is not the only disease accompanied byfatigue. In a literature review of symptom prevalence inend-stage chronic disease, Solano et al27 found that fatiguealso occurred in patients with AIDS (54%-85%), heart dis-ease (69%-82%), chronic obstructive pulmonary disease(68%-80%), and renal disease (73%-87%). Almost all pa-tients with multiple sclerosis experience fatigue to somedegree, and as many as 40% have described it as the sin-gle, most debilitating symptom, even more troublesomethan the neurosensory deficits commonly associated withthe disease.28 Fatigue is also associated with systemiclupus erythematosus and rheumatoid arthritis.25 The fre-quency of fatigue in elderly persons with chronic diseaseranges from 47% to 99%,29 and in palliative care, the pre-valence ranges from 48% to 78%.30,31 The symptom offatigue in these other disease states is similar to that ex-perienced by cancer patients and should be assessed andmanaged accordingly.

For Anna, CRF has led her to consider refusing thetreatments that could prolong her survival. She wouldrather have energy so she can enjoy life. While CRFcan significantly impair a patient’s quality of life, not alldisease-related fatigue is detrimental. In some chronic in-fectious states, fatigue is thought to be a beneficial adap-tive response that facilitates needed rest. At the end oflife, fatigue is considered a natural stage of the dyingprocess and may serve to protect the patient against suf-fering.32 A thorough assessment is therefore essential todetermine any treatable causes.

Anna frowns at her husband and says, ‘‘I told you not

to bring that up. The doctors and nurses have more

important things to do than listen to my complaints.

There’s nothing anyone can do about it anywayVit’s just

part of the disease and its treatment. It is much worse

than I expected.’’

BARRIERS

Despite the prevalence of CRF and the availability of prac-tice guidelines issued more than a decade ago33 and up-dated annually1 by the NCCN, it is rarely addressed in theclinic setting. Patient-, clinician-, and system-related bar-riers can result in failure to report, diagnose, or treat fatigue.

Like Anna, many cancer patients do not voluntarily re-port the presence or impact of fatigue on their dailylives.1,33 Patients’ reasons for not communicating abouttheir fatigue include not wanting to divert the oncologist’sattention away from primary cancer treatment, perceptionthat fatigue is a ‘‘normal’’ adverse effect of cancer and itstreatment and must be endured, personal association offatigue with depression, lack of awareness of availabletreatments, fear the presence of fatigue may indicate dis-ease progression, and fear of having to take additionalmedication.34

Clinicians who do not inquire about fatigue are oftenunaware of its presence or significance for the patient.1

Other clinician-related barriers to diagnosis and treatmentof fatigue include a view of fatigue as a ‘‘normal’’ adverseeffect of the disease and treatment, a belief that it wouldtake too much time to assess and treat fatigue, a focus onsymptoms perceived as being more important or havingmore clinical impact, and lack of knowledge about inter-ventions to mitigate CRF. While most oncologists believetheir patients suffer from fatigue, they tend to give it lessattention than other symptoms, that is, pain.14

System barriers, including an absence of fatigue (or itsdescriptors) as components of documentation forms orcomputer programs and a related lack of policies or pro-cedures addressing the phenomenon, also contribute toinadequate assessment and management of CRF.35-38

This lack of practice standards and accountability mea-sures has limited focused quality improvement efforts.

‘‘It is true that cancer patients often experience fatigue,’’

you tell Anna. ‘‘But there may be something we can do to

help. First of all, I need you to tell me more. I want to

know about your tirednessI. I understand that it is

keeping you from the activities you usually enjoyI. Is it

always present?...What seems to help relieve it? How

does it affect your day-to-day activities? What does it

mean to you?’’

Using active listening skills and allowing ample time

between questions for Anna to respond, you learn that

Anna has been having increasing difficulty performing

self-care. She tells you she must complete her bath in

stages and rest before she can dress herself. ‘‘It’s unlike

anything I have ever experienced. I do nothing, and yet,

I have never felt so exhausted.’’ She states she must

‘‘plan ahead’’ to go to the bathroom as she doesn’t have

the energy. ‘‘Even thinking about it wears me out.’’ She is

Journal of Hospice & Palliative Nursing www.jhpn.com 271

able to stand but reports, ‘‘My legs feel like rubber. I

don’t know how much longer they will hold me up.’’ She

spends nearly all of her time in a recliner because she

does not want to be in the bed any more than necessary.

She states it has become difficult to focus on a television

program or a book: ‘‘I know it sounds crazy, but I am too

tired to even read the newspaper.’’ She also reports she

has trouble focusing on conversations with family and

friends and frequently loses her train of thought. ‘‘It’s just

as well; the visits wear me out anyway.’’ Her husband

reports she sleeps nearly all of the time, even dozing off

while sitting up in a chair at the kitchen table.

ASSESSMENT

As CRF is primarily a subjective, complex, whole-bodyexperience, most experts agree the patient self-reportprovides the best evidence of the intensity and severityof the symptom as well as its impact on a patient’s qual-ity of life.1,32,33,39,40 Individualized characteristics of thefatigue experience should be assessed and include tim-ing, exacerbating and relieving factors, impact on routinedaily activities, meaning to the individual, and any culturalfactors that may affect descriptions.33,40 Assessment toolsuseful for evaluation include a complete medical history,physical examination, laboratory testing, and family andcaregiver reports.33 Since fatigue is not stable, but proneto variations, it should be assessed as a condition or a phe-nomenon2,41,42 and not a one-time symptom that could beeasily addressed.

You note what Anna is telling you about the personal

impact of her fatigue. As you continue, you ask her, ‘‘On

a scale of 0 to 10, with 0 being not fatigued at all and 10

being the most fatigued you can imagine, can you rate

your fatigue?’’ Anna is thoughtful for a minute and then

replies, ‘‘I would rate it around a 9. I guess it could get

worse, but I can’t imagine how! My whole body feels

heavy, and some days it takes all my energy just to sit up

on the side of the bed.’’

According to the NCCN’s practice guidelines for CRF,all patients should be initially screened for the presenceof fatigue at the first clinical visit and routinely thereafter,well into the survivorship period.28,29 If fatigue is identi-fied, the severity of the fatigue should then be deter-mined. The NCCN guidelines suggest that the use of asimple 0- to 10-point numerical rating scale (NRS) is fea-sible and sufficient to determine initial severity. If the in-tensity level is moderate or severe (a score of 4 on theNRS), a focused history and physical examination are in-dicated, and additional measurement is recommended.If fatigue is not present at the initial visit or is reportedto be mild (a score of 0-3 on the NRS), patients and fam-ilies should receive education about fatigue manage-

ment. Rescreening and evaluation should then occur atregular intervals.

There are several tools available for measuring CRFwhen measurement beyond intensity level is warranted(as with a score of 4 on the NRS). Minton and Stone43

reviewed 14 scales previously validated in cancer popu-lations. Based on their study, they recommended threescales: two unidimensional scales measuring physicalfunctioningVEuropean Organization for Research andTreatment of Cancer Quality of Life Questionnaire (EORTCQLQ-C30) and Functional Assessment of Cancer Ther-apy Fatigue (FACT-F)Vand one multidimensional scalemeasuring physical and mental functioningVthe ChalderFatigue Scale or Fatigue Questionnaire. Of the three, theunidimensional scales were considered the easiest toadminister and the most feasible for a clinic setting. In ad-dition, both could be used to monitor the effects of treat-ment.43 The EORTCQLQ-C30 and the FACT-F have 3- and13-item fatigue-specific subscales, respectively, whichhave been independently validated for use with CRF,43,44

making them less burdensome for the patient and attractivetools for the busy clinician.

‘‘In order to further understand your fatigue and what

might be causing it, I need to ask you more questions

about how you’ve been feeling. I think the doctor will

also want to evaluate your lab work,’’ you inform Anna.

You proceed to ask her about her pain, how she’s been

sleeping, what she eats during a normal day, and how

much time she is spending in bed.

Once fatigue is detected, the first assessment priorityis to identify treatable underlying causal or contributingfactors,25 sometimes called the ‘‘gang of 7’’38Vanemia,pain, altered sleep cycles, nutritional deficits, physicaldeconditioning, emotional distress (depression/anxiety),and the presence of comorbidities (hypothyroidism,pulmonary or heart disease, diabetes, etc). A thoroughmedication history should be conducted to determinethe presence of any medications, especially those knownto produce sedation,1 which may contribute to fatigue.Causative factors should be assessed and managedwhenever possible. However, prior to initiating anytreatment, consideration should be given to the patient’sphysical condition and prognosis.32 Balancing thebenefitsand risks of any treatment will guide the nurse to identify atreatment plan that is individualized to the patient.

When assessing Anna’s fatigue, you consider her

chemotherapy regimen. You understand fatigue is more

prevalent with certain chemotherapy agents, such as

cisplatin. However, based on Anna’s treatment goalVto

try and beat the diseaseVand her cell histology and

prognosis, it is in Anna’s best interest to try and remain at

her current dose.


According to Anna’s verbal responses, her pain is well

managed on a low dose of oxycodone; she is eating a

well-balanced diet, which is supplemented by a protein

shake twice daily, and her weight has remained stable

since starting treatment. You realize that she is sleeping

excessively, spending much of the day in bed, which is

probably deconditioning her body. You think a little

exercise might help but decide to proceed with your

assessment before recommending any interventions.

‘‘Have you been feeling unusually sad?’’ you ask the

patient. Anna responds, ‘‘I am sad. I don’t know what

this means. I’m afraid it is a sign that my cancer is

growing and that I am getting worse every day. It means

I can’t be a good wife, mother, or grandmotherVthe

very things that have meant so much to me.’’ Her

husband adds that he often finds her in tears. ‘‘She cries a

lot, but I guess anyone in this situation would.’’

Because some of the manifestations of depression arealso present in fatigue, it is possible to misdiagnose fa-tigue as depression. While depression can occur as a co-morbid condition along with fatigue, it is not necessarilyso. Care must be taken to differentiate the diagnosis.40,45

Depressed patients often present with complaints oftiredness; patients with fatigue often complain of feelingdown. Depression, however, may also present with feel-ings of intense sadness, hopelessness, loss of self-worth,and, possibly, recurrent thoughts of dying. These lattersymptoms are not present in patients suffering from fa-tigue. In addition, fatigued persons suffer from postexer-tional malaiseValso not present in depression.45

After completing your assessment, you excuse yourself

to confer with the oncologist. A review of Anna’s

laboratory work reveals her serum chemistry, complete

blood count, and thyroid function tests are within

normal limits. The two of you agree that further

evaluation for depression is indicated. Anna might

benefit from psychostimulants, education, and a physical

exercise program.

You and her medical oncologist meet with Anna and her

husband and agree on the following treatment plan:

& Refer to the psycho-oncologist for further evaluation of

possible depression

& Begin on methylphenidate (Ritalin) 5 mg PO twice a

day; increase until desired effect is achieved or until

adverse effects prohibit.

You educate Anna and her husband regarding fatigue

and possible management strategies. She is sent home

with an informational brochure and a written plan that

includes a teaching sheet on fatiguemanagement (Figure 1)

and suggestions for light exercise.

MANAGEMENT

According to the Hospice and Palliative Nurses Associa-tion, fatigue treatment interventions fall into one of threecategories: reduction of causative factors and pharmaco-logical and nonpharmacological.46

Reduction of Causative FactorsIf feasible, treatment should focus first on alleviating anyidentified causal factor or comorbidity.1,33 As causal ther-apy may require time before the patient notices improve-ment, symptomatic treatment should also be initiated.25

Looking back at the ‘‘gang of 7,’’ anemia, pain, nutri-tional deficits, and comorbid conditions such as hypothy-roidism and infection are ruled out as causes of Anna’sfatigue. Anna requires only a small dose of oxycodonehydrochloride (OxyContin) to manage her pain; there-fore, this is not likely to contribute to her fatigue. Physicaldeconditioning, hypersomnia, emotional distress, and,possibly, depression are identified as treatable causes tobe addressed in her plan of care (Table 1).

When no identifiable cause is found, symptomatictreatment becomes the primary focus. Because fatigue islikely to be related to multiple factors, most patients suf-fering from fatigue benefit from a combination of pharma-cological and nonpharmacological interventions.32

Pharmacological InterventionsA variety of medications have been studied to determinetheir effectiveness in managing symptoms associatedwith CRF. Donepezil, a centrally active, acetylcholines-terase inhibitorVgenerally prescribed to treat dementiain patients with Alzheimer diseaseVhas been tested inCRF, butwas not shown to be better than placebo in lessen-ing fatigue.47 Early research on psychostimulants has de-monstrated their ability to counteract the manifestationsof CRF as well as alleviate some contributing factors. Theseeffects are attributed to their stimulatory effects on thecentral nervous system.48 Modafinil, a nonamphetaminethat increases wake-time in patients with narcolepsy, hasbeen used successfully to mitigate fatigue in patients withmultiple sclerosis28 and to a limited degree in cancer.49

In Anna’s case, the physician prescribed methylpheni-date. This amphetamine-like drug, commonly prescribedfor attention-deficit/hyperactivity disorder and the symp-tomatic management of narcolepsy,50 has been supportedby research as reducing fatigue in cancer patients.51 It in-creases dopamine concentrations in the brain by blockingdopamine transport or carrier proteins.52 Hanna et al51 re-ported that methylphenidate significantly reduced fatiguein patients receiving aggressive treatment for breast cancer.Methylphenidate has demonstrated efficacy in reducing thesomnolence and mental clouding associated with opioiduse53 and may enhance the analgesic effects of opioids.54

Methylphenidate has also been associated with increased


physical activity55 and has shown promise as a short-actingantidepressant,26,56 making this especially attractive forusewith someone likeAnna,who is possibly experiencingdepression, which is contributing to her fatigue.

Use of corticosteroids, that is, methylprednisolone anddexamethasone, has been anecdotally supported to im-prove fatigue symptoms in cancer patients.32,57 A fewclinical trials have associated corticosteroid administrationwith increased appetite,58 strength,59 sense of well-being,60 and quality of life60,61 in cancer patients. How-ever, the positive effects are reportedly short lived.58

Long-term use of corticosteroids has been associated withmuscle wasting.62 Therefore, use of corticosteroids is re-commended only for brief periods, such as to allow a pa-tient to get through an important holiday or event.32

Nonpharmacological InterventionsA number of nonpharmacological interventions havebeen studied to determine their effects on fatigue andits associated symptoms in cancer and other chronic ill-

nesses. While the results have varied among studies, thereis a growing body of evidence supporting efforts that aimto increase a patient’s knowledge63-65 and/or to increaseor enhance a patient’s physical mobility.32,33

Educational and counseling interventions offered at theoutset of cancer treatment have been associated with bet-ter health outcomes, including reduction of fatigue65 andsymptom burden,66 and improved quality of life.66,67 Ac-cording to the NCCN guidelines,1 all patients and theirfamilies should receive preparatory educational and coun-seling interventions. These interventions should informpatients about the probability of developing fatigue1 andcounsel them regarding self-management strategies likelyto improve coping, such as energy conservation tech-niques, and stress and activity management.64,65 Any edu-cation program should reassure patients that fatigue mayoccur as an adverse effect of treatment, and its presenceneed not indicate that the cancer is progressing.1 Educat-ing patients about fatigue and arming them with self-management strategies allow more control over their

FIGURE 1. Home guide to fatigue management.


disease and provide accurate expectations, thereby re-ducing the stress response.1,2

Three weeks later, Anna returns to the clinic for

follow-up. She states her energy level is starting to

return. She is not sleeping as much as before and is

getting by with a daily nap. She has also begun to enjoy

her television programs and is looking forward to having

dinner with her daughters on Sunday. The

psycho-oncologist’s report indicates that Anna is not

clinically depressed and recommends continued use of

methylphenidate as tolerated.

You suggest that she might now enjoy a light exercise

program sponsored by the clinic’s resource center.

She refuses, saying she is now taking a short walk with

her husband each evening. You encourage her to

continue, as exercise is important to her conditioning

and rebuilding her energy level. You suggest she might

try using some light weights and doing strengthening

exercises.

While intuition may lead patients like Anna to believethat resting more will alleviate their fatigue, the opposite isactually true. Rest will often neither restore nor increaseenergy levels; rather, prolonged physical inactivity andthe resulting muscular deconditioning will actually pro-mote fatigue.32 Fatigue is thought to occur because of se-dentary movement (patient lying around ill) coupled with

TABLE 1 Assessment and Treatment of Causal Factors and Comorbid ConditionsAssociated With Cancer-Related Fatigue

Causal/ComorbidConditions Assessment

PharmacologicalManagement

NonpharmacologicalManagement

Anemia Hemoglobin/hematocrit Erythropoietic growth factors EducationMean corpuscular volume Blood transfusionRed blood cell distribution width Iron transfusionErythropoietinFerritinIronTransferrin saturation

Infection White blood cell Antibiotics EducationC-reactive protein Antipyretics

Nutrition/metabolic Albumin Hydration EducationSodium SteroidsElectrolytes (calcium, magnesium,phosphorus)

Hypothyroidism Thyroid-stimulating hormone Hormone substitution EducationFree T3 and T4

Organ dysfunction:cardiac/endocrine/hepatic/pulmonary/renal

Laboratory values associated withspecific organ

Supportive medicationsReplacement therapy

Education

Pain Self-report AnalgesicsOpioids/nonsteroidalanti-inflammatory drugs

Education;Stress reduction and relaxationtechniques;Activity and exercise

Depression/anxiety Self-report Antidepressants/antianxietyagentsPsychostimulants

Education; counseling; activity andexercise; attention-restoringactivities; stress reduction, andrelaxation techniques

Physical deconditioning Strength testing Steroids (short term) Education; activity and exerciseSelf-report

Sleep disturbances Self-report Psychostimulants Education;Sedatives/hypnotics Sleep therapy;

Activity and exercise;Stress reduction and relaxationtechniques


the toxic effects of therapies, resulting in lost capacityfor physical functioning.68 As a result, greater effort andenergy must be utilized to perform routine activities. Ex-ercise training decreases functional loss and improvesfunctional capacity, thereby decreasing the amount ofphysical effort needed to do everyday tasks.68

Exercise interventions have been studied in a variety ofpopulations, including patients at the end of life, and ap-pear to be the most promising of all nonpharmacologicalinterventions at improving levels of fatigue.1,69 Severalstudies have reported the level of physical activity to beinversely related to the level of fatigue.70 Exercise, particu-larly aerobic exercise, has been reported to reduce fatiguein cancer patients receiving treatment,71,72 in palliativecare patients with a short life expectancy,73 and in cancersurvivors.74 Studies have also supported the use of resis-tance training or ‘‘anabolic’’ exercise to improve muscleand bone tissue in cancer patients.75

If exercise is initiated, muscle strength may improve in amatter of days.76 Any recommended exercise programshould be individualized to the patient, taking into consid-eration the patient’s physical capabilities, disease status,and any comorbid conditions.1,42,68 In Anna’s case, walkingwith her husband is more appealing than attending a class.

Anna continues on her methylphenidate with slight

increases every few weeks. She continues to exercise.

Eight weeks after her last chemo treatment, she contacts

the clinic stating she has begun experiencing shortness

of breath and coughing up blood. Subsequent scans

demonstrate growth and expansion of the tumor, and

she is now diagnosed with extensive-stage small-cell

lung cancer. Administration of topotecan (Hycamtin)

was started. She completes two doses of chemotherapy,

but misses the third and does not call to reschedule.

When you call Anna’s home, her husband informs you

that Anna is ‘‘just too tired to come in to the clinic.’’ ‘‘She

says she just wants to rest.’’ He reports Anna quit taking

the methylphenidate last week, because it was making

her too jittery, and she was having trouble sleeping. He

states Anna called a family meeting and told them she

was ready to stop the chemo. He says his daughters are

taking turns staying with them.

‘‘Will it hurt her to stop the methylphenidate?’’ he asks you.

‘‘She seems so content to just sleep now. I think we should

let her rest. She has fought so hard, and she says she is now

ready to die.’’ You respond, ‘‘No, stopping the medicine

won’t hurt her in any way. If she seems uncomfortable, be

sure to call me, and we’ll see whatmight be helpful to her.’’

You suggest that he consider a referral to the local hospice

program as they can visit, assess her condition, manage

her symptoms, and provide support to the family.

‘‘That might be helpful. I know they were a big help to

my brother,’’ replies her husband. You assure him that

you will make the referral, and they should call him soon

to set up an admission visit.

As with all symptom management in palliative care,treatment goals for fatigue should be based on the stageof the patient’s illness and the patient’s wishes. Other im-portant factors to consider include extent of the disease,other symptoms, age, and emotional ‘‘place’’ of the pa-tient.77 Identifying the point at which aggressive manage-ment of fatigue should be ended is important to thepatient’s comfort and quality of life. As death approaches,fatigue is a natural occurrence and may protect the patientfrom further distress.32 Providing aggressive treatmentduring this time could force the patient to experienceanew the effects of her disease, leaving her to cope withthe intense suffering associated with an advanced stage ofdisease in an even more frail and progressively weakenedphysical and emotional state.32 Anna’s preference for nofurther treatment for her fatigue coupled with diseaseprogression and a shortened prognosis are signs that ag-gressive management is no longer indicated.

Anna receives hospice care for the next month. The hospice

nurse calls the clinic to report that she had a peaceful

death and was comfortable for the last weeks of her life.

CONCLUSION

Cancer-related fatigue is a serious problem for many pal-liative care patients with cancer. Cancer-related fatiguecan limit communication, prevent patient involvement insocial interactions, disrupt daily life, and prevent the impor-tant work of closure at the end of life.78,79 It can be themosttroublesome of symptoms for palliative care patients.78 Be-cause it is a subjective experience and is often thought tobe an unavoidable symptom in chronic illness, it may goignored. Therefore, assessing and treating fatigue shouldbe an essential component of all palliative nursing care.

AcknowledgmentsThe authors thank Anne Elizabeth Small, BSN, RN, OCN, forher expertise and valuable suggestions to our case study.

References1. Berger AM, Abernethy AP, Atkinson A, et al. Cancer-related

fatigue. J Natl Compr Canc Netw. 2010;8(8):904-930.2. Ahlberg K, Ekman T, Gaston-Johansson F, Mock V. Assessment

and management of cancer-related fatigue in adults. Lancet.2003;362:640-650.

3. Piper B, Cella D. Cancer-related fatigue: definitions and clinicalsubtypes. J Natl Compr Canc Netw. 2010;8(8):958-966.

4. Servaes P, Verhagen C, Bleijenberg G. Fatigue in cancerpatients during and after treatment: prevalence, correlatesand interventions. Eur J Cancer. 2002;38(1):27-43.


5. Hofman M, Ryan JL, Figueroa-Moseley CD, Jean-Pierre P,Morrow GR. Cancer-related fatigue: the scale of the problem.Oncologist. 2007;12(1 suppl):4-10.

6. Lawrence DP, Kupelnick B, Miller K, Devine D, Lau J. Evidencereport on the occurrence, assessment, and treatment of fatiguein cancer patients. J Natl Cancer Inst Monogr. 2004;(32):40-50.

7. Curt GA, Breitbart W, Cella D, et al. Impact of cancer-relatedfatigue on the lives of patients: new findings from the FatigueCoalition. Oncologist. 2000;5(5):353-360.

8. Hartvig P, Aulin J, Hugerth M, Wallenberg S, Wagenius G. Fatiguein cancer patients treated with cytotoxic drugs. J Oncol PharmPract. 2006;12(3):155-164.

9. Butt Z, Rosenbloom SK, Abernethy AP, et al. Fatigue is the mostimportant symptom for advanced cancer patients who havehad chemotherapy. J Natl Compr Canc Netw. 2008;6(5):448-455.

10. Mormont MC, Waterhouse J, Bleuzen P, et al. Marked 24-h rest/activity rhythms are associated with better quality of life, betterresponse, and longer survival in patients with metastaticcolorectal cancer and good performance status. Clin CancerRes. 2000;6(8):3038-3045.

11. Hickok JT, Morrow GR, Roscoe JA, Mustian K, Okunieff P.Occurrence, severity, and longitudinal course of twelve commonsymptoms in 1129 consecutive patients during radiotherapy forcancer. J Pain Symptom Manage. 2005;30(5):433-442.

12. HofmanM,Hickok JT,MorrowGR, Roscoe JA,Gillies J, RansonSL.Cancer treatment side effects in breast cancer patients receivingradiation therapy. J Clin Oncol. 2005;23(suppl):705.

13. Nail LM. My get up and go got up and went: fatigue in peoplewith cancer. J Natl Cancer Inst Monogr. 2004;(32):72-75.

14. Vogelzang NJ, Breitbart W, Cella D, et al. Patient, caregiver, andoncologist perceptions of cancer-related fatigue: results of atripart assessment survey. The Fatigue Coalition. SeminHematol. 1997;34(3 suppl 2):4-12.

15. Hartvig Honore P. Molecular mechanisms in cytotoxic druginduced fatigue. Ann Pharm Fr. 2010;68(2):76-81.

16. Morrow GR. Cancer-related fatigue: causes, consequences, andmanagement. Oncologist. 2007;12(1 suppl):1-3.

17. Forlenza MJ, Hall P, Lichtenstein P, Evengard B, Sullivan PF.Epidemiology of cancer-related fatigue in the Swedish twinregistry. Cancer. 2005;104(9):2022-2031.

18. Hung R, Krebs P, Coups EJ, et al. Fatigue and functionalimpairment in early-stage non-small cell lung cancer survivors.J Pain Symptom Manage. 2011;41(2):426-435.

19. Donovan KA, Jacobsen PB. Fatigue, depression, and insomnia:evidence for a symptom cluster in cancer. Semin Oncol Nurs.2007;23(2):127-135.

20. Walsh D, Rybicki L. Symptom clustering in advanced cancer.Support Care Cancer. 2006;14(8):831-836.

21. Theobald DE. Cancer pain, fatigue, distress, and insomnia incancer patients. Clin Cornerstone. 2004;6 suppl 1D:S15-S21.

22. Hamilton J, Butler L, Wagenaar H, et al. The impact andmanagement of cancer-related fatigue on patients and families.Can Oncol Nurs J. 2001;11(4):192-198.

23. Kwon YC, Yun YH, Lee KH, et al. Symptoms in the lives ofterminal cancer patients: which is the most important? Oncology.2006;71(1-2):69-76.

24. Spelten ER, Verbeek JHAM, Uitterhoeve ALJ, et al. Cancer,fatigue and the return of patients to work-a prospective cohortstudy. Eur J Cancer. 2003;39(11):1562-1567.

25. Yennurajalingam S, Bruera E. Palliative management of fatigueat the close of life: ‘‘it feels like my body is just worn out’’.JAMA. 2007;297(3):295-304.

26. Neuenschwander H. Fatigue. In: Michael J, Fisch EB, ed.Handbook of Advanced Cancer Care. New York: CambridgeUniversity Press; 2003:374-381.

27. Solano JP, Gomes B, Higginson IJ. A comparison of symptomprevalence in far advanced cancer, AIDS, heart disease, chronic

obstructive pulmonary disease and renal disease. J PainSymptom Manage. 2006;31(1):58-69.

28. Bakshi R. Fatigue associated with multiple sclerosis: diagnosis,impact and management. Mult Scler. 2003;9(3):219-227.

29. Stone P, Richards M, A’Hern R, Hardy J. A study to investigate theprevalence, severity and correlates of fatigue among patients withcancer in comparison with a control group of volunteers withoutcancer. Ann Oncol. 2000;11(5):561-567.

30.Donnelly S, Walsh D, Rybicki L. The symptoms of advanced cancer:identification of clinical and research priorities by assessmentof prevalence and severity. J Palliat Care. 1995;11(1):27-32.

31. Stone P, Hardy J, Broadley K, Tookman AJ, Kurowska A,A’Hern R. Fatigue in advanced cancer: a prospective controlledcross-sectional study. Br J Cancer. 1999;79(9-10):1479-1486.

32. Radbruch L, Strasser F, Elsner F, et al. Fatigue in palliative carepatientsVan EAPC approach. Palliat Med. 2008;22(1):13-32.

33. Mock V, Atkinson A, Barsevick A, et al. NCCN practiceguidelines for cancer-related fatigue. Oncology (WillistonPark). 2000;14(11A):151-161.

34. Passik SD, Kirsh KL, Donaghy K, Holtsclaw E, Theobald T,Cella D. Patient-related barriers to fatigue communication:initial validation of the Fatigue Management BarriersQuestionnaire. J Pain Symptom Managem. 2002;24(5):481-493.

35. Borneman T, Koczywas M, Sun V, et al. Effectiveness of aclinical intervention to eliminate barriers to pain and fatiguemanagement in oncology. J Palliat Med. 2011;14(2):197-205.

36. Borneman T, Ppiper BF, Sun VC, Koczywas M, Uman G, FerrellB. Implementing the fatigue guidelines at one NCCN memberinstitution: process and outcomes. J Natl Compr Canc Netw. 2007;5(10):1092-1101.

37. Borneman T, Koczywas M, Sun VC, Piper BF, Uman G, Ferrell B.Reducing patient barriers to pain and fatigue management. J PainSymptom Manage. 2010;39(3):486-501.

38. Piper BF, Borneman T, Sun VC, et al. Cancer-related fatigue: roleof oncology nurses in translating National Comprehensive CancerNetwork assessment guidelines into practice. Clin J Oncol Nurs.2008;12(5 suppl):37-47.

39. Von Roenn JH, Paice JA. Control of common, non-pain cancersymptoms. Semin Oncol. 2005;32(2):200-210.

40. WinninghamML, Nail LM, Burke MB, et al. Fatigue and the cancerexperience: the state of the knowledge.Oncol Nurs Forum. 1994;21(1):23-36.

41. WinninghamML. The puzzle of fatigue: how do you nail puddingto the wall? In: Winningham ML, Barton-Burke M, eds. Fatigue inCancer: A Multidimensional Approach. Sudbury, MA: Jones &Bartlett; 2000:31-53.

42. Winningham ML. Strategies for managing cancer-related fatiguesyndrome: a rehabilitation approach. Cancer. 2001;92(4 suppl):988-997.

43. Minton O, Stone P. A systematic review of the scales used for themeasurement of cancer-related fatigue (CRF). Ann Oncol. 2009;20(1):17-25.

44. Yellen SB, Cella DF, Webster K, Blendowski C, Kaplan E.Measuring fatigue and other anemia-related symptoms with theFunctional Assessment of Cancer Therapy (FACT) measurementsystem. J Pain Symptom Manage. 1997;13(2):63-74.

45. Jacobsen PB, Donovan KA, Weitzner MA. Distinguishing fa-tigue and depression in patients with cancer. Semin Clin Neuro-psychiatry. 2003;8(4):229-240.

46. Campbell ML, Happ MB, Hultman T, et al. The HPNA ResearchAgenda for 2009-2012. J Hosp Palliat Nurs. 2009;11(1):10-18.

47. Bruera E, El Osta B, Valero V, et al. Donepezil for cancer fatigue: adouble-blind, randomized, placebo-controlled trial. J Clin Oncol.2007;25(23):3475-3481.

48. Escalante C. Cancer-related fatigue: treatment. In: Hesketh PJ,Savarese D, eds. UpToDate. Watham, MA: UpToDate, Inc; 2010.


http://www.uptodate.com/contents/cancer-related-fatigue-treatment?source=search_result&selectedTitle=10%7E71.

49. Spathis A, Dhillan R, Booden D, Forbes K, Vrotsou K, Fife K.Modafinil for the treatment of fatigue in lung cancer: a pilotstudy. Palliat Med. 2009;23(4):325-331.

50. Methylphenidate: drug information.UpToDate (onlinedatabase).Updated 2011. ht tp://www.uptodate.com/contents/methylphenidate-drug-information?source=search_result&selectedTitle=1%7E71. AccessedMarch 3, 2011.

51. Hanna A, Sledge G, Mayer ML, et al. A phase II study ofmethylphenidate for the treatment of fatigue. Support CareCancer. 2006;14(3):210-215.

52. Methylphenidate. Elsevier, Inc; 2011. http://www.mdconsult.com.echo.louisville.edu/das/pharm/body/235332037-4/0/full/391. Accessed February 11, 2011.

53. Portenoy RK, Mehta Z, Ahmed E. Cancer pain managementwith opioids: prevention and management of side effects. In:Hesketh PJ, Savarese D, eds. UpToDate. Watham, MA: UpToDate,Inc; 2010.

54. Homsi J, Walsh D, Nelson KA. Psychostimulants in supportivecare. Support Care Cancer. 2000;8(5):385-397.

55. Bruera E, Chadwick S, Brenneis C, Hanson J, MacDonald R.Methylphenidate associated with narcotics for the treatmentof cancer pain. Cancer Treat Rep. 1987;71(1):67-70.

56. Harris J-D. Fatigue in chronically ill patients. Curr Opin SupportPalliat Care. 2008;2(3):180-186.

57. Breitbart W, Alici Y. Pharmacologic treatment options for cancer-related fatigue: current state of clinical research.Clin J Oncol Nurs.2008;12(5 suppl):27-36.

58. Bruera E, Roca E, Cedaro L, Carraro S, Chacon R. Action of oralmethylprednisolone in terminal cancer patients: a prospectiverandomized double-blind study.Cancer Treat Rep. 1985;69(7-8):751-754.

59. Moertel CG, Schutt AJ, Reitemeier RJ, Hahn RG. Corticosteroidtherapy of preterminal gastrointestinal cancer. Cancer. 1974;33(6):1607-1609.

60. Della Cuna GR, Pellegrini A, Piazzi M. Effect of methylprednisolonesodium succinate on quality of life in preterminal cancer patients: aplacebo-controlled, multicenter study. The MethylprednisolonePreterminal Cancer Study Group. Eur J Cancer Clin Oncol. 1989;25(12):1817-1821.

61. Popiela T, Lucchi R, Giongo F. Methylprednisolone as pallia-tive therapy for female terminal cancer patients. The Methylpred-nisolone Female Preterminal Cancer Study Group. Eur J CancerClin Oncol. 1989;25(12):1823-1829.

62. Ohnuma T. Complications of cancers and their treatment.In: Kufe DW, Frei III E, Holland JF, et al, eds. Holland-FreiCancer Medicine. 8th ed. Shelton, CT: People’s Medical Pub-lishing House-USA; 2010.

63. BarsevickA, Beck SL, DudleyWN, et al. Efficacy of an interventionfor fatigue and sleep disturbance during cancer chemotherapy. JPain Symptom Manage. 2010;40(2):200-216.

64. Barsevick AM, Dudley W, Beck S, Sweeney C, Whitmer K, Nail L.A randomized clinical trial of energy conservation for patientswith cancer-related fatigue. Cancer. 2004;100(6):1302-1310.

65. Yates P, Aranda S, Hargraves M, et al. Randomized controlled trialof an educational intervention for managing fatigue in womenreceiving adjuvant chemotherapy for early-stage breast cancer.J Clin Oncol. 2005;23(25):6027-6036.

66. Given B, Given CW, McCorkle R, et al. Pain and fatiguemanagement: results of a nursing randomized clinical trial.Oncol Nurs Forum. 29(6):949-956.

67. Johnson JE, Nail LM, Lauver D, King KB, Keys H. Reducing thenegative impact of radiation therapy on functional status.Cancer. 61(1):46-51.

68. Durstine JL, Moore GE, Painter PL, Roberts SO, eds. ACSM’sExercise Management for Persons With Chronic Diseases andDisabilities. Champaign, IL: Human Kinetics; 2009.

69. Mock V. Fatigue management: evidence and guidelines forpractice. Cancer. 2001;92(6 suppl):1699-1707.

70. Dimeo F, Schwartz S, Wesel N, Voigt A, Thiel E. Effects of anendurance and resistance exercise program on persistent cancer-related fatigue after treatment. Ann Oncol. 2008;19(8):1495-1499.

71. Schmitz KH,Holtzman J, CourneyaKS,Masse LC,Duval S, Kane R.Controlled physical activity trials in cancer survivors: a systematicreview and meta-analysis. Cancer Epidemiol Biomarkers Prev.2005;14(7):1588-1595.

72. Mock V. Evidence-based treatment for cancer-related fatigue. JNatl Cancer Inst Monogr. 2004;(32):112-118.

73. Oldervoll LM, Loge JH, Paltiel H, et al. The effect of a physicalexercise program in palliative care: a phase II study. J PainSymptom Manage. 2006;31(5):421-430.

74. Speck RM, Courneya KS, Masse LC, Duval S, Schmitz KH. Anupdate of controlled physical activity trials in cancer survivors:a systematic review and meta-analysis. J Cancer Surviv. 2010;4(2):87-100.

75. Galvao DA, Newton RU. Review of exercise intervention studiesin cancer patients. J Clin Oncol. 2005;23(4):899-909.

76. Davis MP, Walsh D. Mechanisms of fatigue. J Support Oncol.2010;8(4):164-174.

77. Dean GE, Anderson PR. Fatigue. In: Ferrell BR, Coyle N, eds.Textbook of Palliative Nursing. Oxford: Oxford University Press;2001:91-100.

78. Ream E. Fatigue in patients receiving palliative care. Nurs Stand.2007;21(28):49-56; quiz 58.

79. Lindqvist O, Widmark A, Rasmussen BH. Meanings of thephenomenon of fatigue as narrated by 4 patients with cancerin palliative care. Cancer Nurs. 2004;27(3):237-243.

For more than 52 additional continuing education articles related to cancer, go to NursingCenter.com\CE.


Documents

Palliative Nursing Care of the Patient With Cancer-Related