Fatigue

Fatigue is a feeling of constant tiredness or weakness and can be physical, mental or a combination of both. Fatigue is a subjective feeling and people with advanced illness will experience it in their own way. Some people may describe it as feeling, ‘heavy’, ‘slow’, ‘weak’, ‘light-headed’, or ‘dizzy’.

People may describe mental or emotional fatigue as feeling exhausted, listless, depressed, guilty, or frustrated.

Physical and mental fatigue prevents participation in preferred activities and impedes activities of everyday living.

Cognitive fatigue complicates activities such as reading, driving a car, and making decisions.
Many factors can contribute to fatigue. These include:

• progression of life-limiting illness
• symptoms such as pain, breathlessness, hypoxia (low levels of oxygen in body tissues)
• sleep disturbance
• psychological symptoms such distress, depression, anxiety
• anaemia, dehydration, cachexia
• medications such as opioids, antihistamines, antiemetics, benzodiazepines
• treatments such as chemotherapy, radiotherapy.

People experiencing fatigue with advanced illness may see themselves as ‘lazy’ or ‘not positive enough’. They may also feel a loss of self and meaning. Pay attention to the person’s experience of fatigue. Listen carefully and acknowledge their distress as this can reduce the distress associated with fatigue.

As the life-limiting illness progresses, fatigue can become unavoidable. Generally there is no real ‘cure’ as such, but ways of improving the person’s experience of this symptom or managing underlying causes where possible.

In assessing fatigue, nurses should aim to understand the symptoms, activity level, and challenges from the person’s perspective. This forms the basis for helping them to manage and structure daily activities to optimise their quality of life.

As for pain and dyspnoea, assessment of the whole person, including physical, psychosocial, and spiritual needs is essential for fatigue.

Ask the person about their experience of fatigue: when it occurs, the severity, whether there are better times during the day for them to get things done, their level of distress, and the impact on their function.
Check for reversible contributing factors as listed above.

While fatigue is distressing and common in palliative care patients, it is often inadequately assessed and managed. Screening is important and fatigue is included in the Symptom Assessment Scale and the Edmonton Symptom Assessment Scale.

Tools

Assessment tools specific to fatigue include the Brief Fatigue Inventory (BFI), the Functional Assessment of Cancer Therapy (FACIT-F), the Multidimensional Fatigue Inventory 20 (MFI-20), and the Piper Fatigue Scale

Patients often describe fatigue as one of the most difficult symptoms to manage.

Fatigue is often misunderstood and healthcare professionals can help by encouraging open discussion and validating concerns.

Often patients feel guilty about being no longer able to contribute fully to family life and this feeling should be acknowledged.

For many patients, fatigue will be part of their experience of living with their illness.

Awareness and acknowledgement of the symptoms, and consideration of lifestyle and goals can help to manage fatigue and reduce its impact on daily life.

Strategies may include:

• keeping a fatigue diary to help optimise activity timing and intensity
• activity enhancement / exercise
• energy conservation and provision of aids and equipment
• nutritional assessment and support
• good hydration
• psychosocial support
• distraction and concentration techniques
• addressing sleeping problems.

Modifying the persons’ activity and rest patterns and helping them to prioritise activities can help. As can taking frequent short breaks rather than a long rest period.

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 treatment may be detrimental.

Fatigue is best managed by a multidisciplinary team of health and social care professionals. This may include the person’s GP, nurses, an occupational therapist, physiotherapist, and counsellor or psychologist.
Fatigue can be a side effect of certain medicines. It may help to ask the doctor or pharmacist to review the person’s medicines. Management of fatigue with medicines is controversial.

Certain underlying causes of fatigue can be treated where relevant. These include:

• anaemia via blood transfusion
• infection via antibiotics
• fever via antipyretic drugs
• dehydration via hydration
• poor nutrition via nutritional supplements,
• electrolyte imbalance via bisphosphonates, magnesium, blood sugars.

Sleep disturbance may be a cause or contributing factor and you can read more about this in Sleep disturbance.

This information was drawn from the following resources:

• Ingham G, Urban K. How Confident Are We at Assessing and Managing Fatigue in Palliative Care Patients? A Multicenter Survey Exploring the Current Attitudes of Palliative Care Professionals. Palliat Med Rep. 2020 May 28;1(1):58-65. doi: 10.1089/pmr.2020.0005.
• Mücke M, Kravchenko D. Fatigue. In: MacLeod RD, Van den Block L, editors. Textbook of Palliative Care. Cham: Springer International Publishing; 2018. [cited 2022 Sep 22].
• O’Neil-Page E, Dean GE, Anderson PR. Fatigue. In: Ferrell BR, Paice JA, editors. Oxford textbook of palliative nursing [Internet]. 5th ed. Oxford: Oxford University Press; 2019. [cited 2022 Sep 22].
• Radbruch L, Strasser F, Elsner F, Gonçalves JF, Løge J, Kaasa S, et al. Fatigue in palliative care patients – an EAPC approach. Palliat Med. 2008 Jan;22(1):13-32. doi: 10.1177/0269216307085183.
• Therapeutic Guidelines Limited. Fatigue in palliative care [Internet]. 2016 [cited 2022 Sep 22].