Lorraine West, Specialist Palliative Care Occupational Therapist. September 2018.

Cancer related fatigue and the input of supportive and palliative care:

Managing fatigue along the pathway

• Definitions

• Impact of fatigue on the person and care givers in palliative care.

• Maintaining quality of life

• Achieving “ what matters”

• Fatigue at end of life

Objectives

Defenitions

• “Palliative care is an approach to the patient/ family/caregiver- centred healthcare that focuses on optimal management of pain and other distressing symptoms, while incorporating psychosocial and spiritual care according to patient/ family needs values, beliefs and cultures.”

National Comprehensive Cancer Network (NCCN) 2018

• “Supportive care is an ‘umbrella’ term for all services, both generalist and specialist, that may be required to support people with cancer and their carers. It includes self help and support, user involvement, information giving, rehabilitation, complementary therapies, symptom control, spiritual support….”

NICE 2004

Why fatigue?

Palliative care patients identify fatigue as a significant symptom.

Fatigue is one of the most complex symptoms experienced by cancer patients (Potter, 2004).

Has an impact on the quality of life for both patients and their carers, which is not always recognised by health professionals.

Incidences

• The European Association for palliative care describe fatigue as one of the most frequent symptoms in palliative care patients, reported in 80% of cancer patients and in up to 99% of patients following radiotherapy or chemotherapy (Radbruch l et al, 2008)

The impact of fatigue on the patient’s quality of life.

• Fatigue has a strong negative impact on the patient’s daily life (Pederson, et al 2003)

• Coakley et al’s, (2002) study found fatigue influenced many areas of life, for

those with advanced cancer, including mood, relationships, walking ability and enjoyment.

• The participants in Potters (2004) study describe their fatigue as global,

affecting their physical, social and spiritual aspects of their lives, as they struggle to cope

Social consequences

Psychological consequences

Spiritual consequences

Struggling to cope

Physical consequences

FATIGUE

(Potter 2004

Palliative care

• NICE (2004) Guidelines state that the goal of palliative care, is the achievement of the best quality of life for patients and their families.

• NCCN (2018) states the “goal of palliative care is to anticipate, prevent and reduce suffering and to support the best quality of life for patients / families/ carer givers regardless of the stage of the disease or the need for other therapies”

Management of fatigue in palliative care

All patients should be screened for fatigue.

The severity and impact of fatigue on daily life should be assessed in every patient.

Treatable causes of fatigue should be managed appropriately in an effort to reduce levels of fatigue. (Coakley et al, 2002)

Constant treatments, analgesia, hospital trips can have a cumulative effect and impact on a person’s fatigue levels.

Fatigue is sometimes divided into two areas : physical and cognitive.

Physical prevents participation in activities and impedes activities of daily living.

Cognitive complicates activities such as reading, driving a car and thus prevents leisure

activities.

Reversible or treatable causes?

• Consider referral to medical or nursing

• Anaemia Blood transfusion

• Infection Antibiotics

• Fever Antipyretic drugs

• Dehydration Hydration

• Cachexia Nutrition, anabolics (high protein drinks), dietician.

• Sleep disturbances Sleep hygiene education/sedative

• Electrolyte imbalance Biphosphonates, Magnesium, blood sugars

Pharmacological approach

• Steroids -Dexamethasone

• Psycho-stimulants e.g. Methylphenidate. Initially 5mg BD – morning and lunchtime. Caution with cardiac disease.

• Modafinil

• (Seek specialist advice with these medications).

• Antidepressants

Non pharmacological approach (1)

• Patient and care giver education –providing information and support and enabling patients to talk about fatigue, it’s meanings and implications.

Exercise – consider referral to the Physiotherapist.

Fatigue management – consider referral to the Occupational Therapist.

Access complementary therapies

Non pharmacological approach (2)

• Modifying patients’ activity and rest patterns-help patients to prioritise activities. Limit naps to 20-30 minutes, taking frequent short breaks between and within activity rather than a long rest period.

• Psychosocial interventions – to help manage stress.

• Ensure adequate nutrition and hydration – consider dietician referral if appropriate

• Encourage self management. After treatment of reversible causes, the best treatment for fatigue is the person themselves.

Exercise

• Aerobic exercise effectively alleviates fatigue in patients receiving cancer treatment ( Radbruch et al, 2008).

But…

• Exercise may not always be appropriate, or even possible in some palliative care patients (Coakley et al ,2002).

Maintaining physical activity

• In palliative care exercise does not need to be anything extra or different to what a person already does.

• Encourage instead to maintain daily routines.

• Getting up, getting washed, managing stairs, getting dressed are all forms of physical activity which help maintain function, stamina and wellbeing.

Balancing energy and Rechargeable battery.

“Energy” can be gained by activity that gives a sense of wellbeing or

achievement.

Clifford House ( Sheffield)

Cancer related fatigue at Clifford House

Session 1

What is cancer related fatigue? Balancing energy. Mix and match activity. Making change.

Session 2

Personal goal review. Rest. Sleep. Relaxation techniques. Diet. Goal setting.

Session 3

Personal goal review. Mental fatigue. Stress and relaxation. Talking to others. Activity and exercise.

End of Life care

• It is important to remember that in the final stages of life, fatigue may provide protection and shielding from suffering for the patient and therefore its treatment may be detrimental.

• Identification of the time point, where treatment of fatigue is no longer indicated is important to alleviate distress at the end of life Radbruch et al, (2008)

End of Life Care- What matters to you?

• A person centred approach is required, as fatigue may vary not just from day to day, but from hour to hour.

1.Discuss labour saving and assistive devices. These must make a positive impact to the person e.g. a wheelchair to be able to spend the afternoon out with a friend

2.Discuss eliminating and delegating non essential activities

3.Discuss conservation or use energy differently for valued activity

4. Give time to process information and to make decisions.

Thank you for listening. Any Questions?

References • POTTER J (2004) Fatigue experience in advanced cancer: a

phenomenological approach. International Journal of Palliative Medicine 10 (1) : 15-23

• NICE (2004) Guidance on Cancer Services. Improving Supportive and Palliative Care Adults with Cancer. The Manual. London,NICE

• BROWN H (2004)The management of fatigue in advanced cancer – related fatigue. European Journal of Palliative Care 11 (1) : 16 -18

• PEDERSON L, MUNCH T N, GROENVOLD M (2003) The treatment of fatigue in palliative care patients. European Journal of Palliative Care 10 (6): 225-229

• COAKLEY A, HUTHCINSON T, SALTMARSH P, KELLY A, ELLERSHAW J E. MARSHALL E, BRUNSTON H (2002) International Journal of Palliative Nursing 8 (8) 381- 388

• RADBRUCH l et al (2008) Fatigue in Palliative Care Patients – An EAPC approach. Palliative Medicine 2008; 22(1) : 13-32

• NCCN Clinical Practice Guidelines in Oncology (NCCN Guidelines). Cancer Related Fatigue 2018

• NCCN Clinical Practice Guidelines in Oncology (NCCN Guidelines). Palliative Care 2017