Table 4 Fatigue equivalents in different European languages
tings) and the NCCN (cancer setting) and is noted in guidelines for palliative care for advanced heart failure [108; 187; 279]. In addition, the Agency for Healthcare Research and Quality has addressed fatigue in the cancer setting, and systematic reviews have been done to help determine effective pharmacologic and nonpharmacologic interventions [281; 290; 291; 292; 293]. Management of fatigue should include treatment of an underlying cause, if one can be identified, but symptomatic relief should also be provided ( Figure 10 ) [108; 187; 279]. When medications are the underlying cause of the fatigue, non- essential medications should be discontinued, and changing medications or the time of dosing may reduce tiredness dur- ing the day. Appropriate management of infection, cachexia, depression, and insomnia may also help reduce fatigue [279; 287]. The patient’s life expectancy and preferences should be considered before carrying out treatment of an underlying cause [279]. Fatigue may provide a protective effect for patients in the last days or hours of life [279]. As such, the patient may be more comfortable without aggressive treatment of fatigue during that period [279]. after chemo- or radiotherapy, only 27% reported that their oncologist had recommended any treatment for fatigue. 1 This is partly due to barriers to reporting fatigue in the patients, but also to inadequate skills and knowledge of physicians. Treatment of the underlying cause should be initiated in patients with secondary fatigue (Figure 2). Disease stage and life expectancy have to be considered to balance possible risks and potential benefits of causal therapy. Taking into account the possible role of cytokines in the pathophysiology of fatigue, there may be a role for pharma- cological approaches directed at targeting excessive cytokine concentrations. Thalidomide as an antagonist of TNF has been suggested as a treatment of cachexia in cancer 4,99 and AIDS. 100 Thalidomide showed a beneficial effect on weight loss and quality of life in a single small randomized trial with cachectic cancer patients. 101 However, the cytokine antago- nist pentoxiphylline had no significant effect on cachexia in randomized trials in HIV 102 or cancer patients. 103 Thalidomide, pentoxiphylline or other drugs interfering with cytokine synthesis such as rolipram have not been used in clinical trials on fatigue yet and sedation as one of the major side effects of thalidomide makes its use for the treatment of fatigue unlikely. No change in fatigue was reported in the randomized trial of thalidomide for cancer cachexia. 101
___________________________________________ Palliative Care and Pain Management at the End of Life
Language
Fatigue
Other translation
An easy-to-use instrument is the Brief Fatigue Inventory, which includes nine items that ask the patient to rate the severity of fatigue on a scale of 0 (no fatigue) to 10 (“as bad as you can imagine”) [289]. The patient is asked to consider the current level of fatigue as well as fatigue experienced within the past 24 hours and to indicate the degree to which fatigue has interfered with activities, mood, walking ability, relations with other people, and enjoyment of life. Assessment should also include a physical examination to detect an underlying cause of fatigue, a focused history-taking, and laboratory tests, as appropriate, to rule out suspected causes ( Figure 9 ) [279]. Management Little evidence is available to support guidelines for the man- agement of fatigue during the end of life. Most of the research on nonpharmacologic and pharmacologic treatment options has been conducted with subjects receiving active cancer treatment or long-term follow-up care after cancer treatment. Fatigue in the palliative care setting is addressed specifically by the European Association for Palliative Care (EAPC) (all set- Most patients will require symptomatic treatment for fatigue with pharmacological and/or nonpharmacological interventions. In the final stage of life, fatigue may provide protection and shielding from suffering for the patient and treatment of fatigue may be detrimental. Identification of the time point where treatment of fatigue no longer is indicated is impor- tant to alleviate distress at the end of life. The vast majority of patients with cancer-related fatigue do not receive adequate treatment. In a survey of patients English (British) Fatigue Fatigue French Italian German Stanchezza Ermüdbarkeit, Tiredness? Exhaustion? Ermattung Swiss Müde, Bedusselt Portuguese Fraqueza, Cansaço, Weakness, Fadiga tiredness, fatigue Norwegian Irish (Gaelic) Trøtt Buibhestas
ALGORITHM FOR THE MANAGEMENT OF FATIGUE IN PATIENTS RECEIVING PALLIATIVE CARE
Figure 2 Algorithm for treatment of fatigue in palliative care patients.
Source: [279] Reprinted, with permission from Radbruch L, Strasser F, Elsner F, et al. Fatigue in palliative care patients—an EAPC approach. Palliat Med. 2008;22(1):13-32. Figure 10
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MDCA1525
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