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Fatigue: Eduardo Bruera, MD, discusses palliative management of fatigue at the close of life.
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Fatigue: Eduardo Bruera, MD, discusses palliative management of fatigue at the close of life.
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Upload Date:
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Language: EN.
Segment:0 .
>> I'm Joan Stevenson, Editor of JAMA's medical news and perspective section. Today, I have the pleasure of speaking with Dr. Eduardo Bruera about palliative management of fatigue, a topic in Care at the Close of Life discussed in a chapter co-written by today's guest. Dr. Bruera, why don't you introduce yourself to our listeners? >> Thank you. My name is Eduardo Bruera. I'm the Chair of the Department of Palliative Care Rehabilitation Medicine at MD Anderson Cancer Center in Houston, Texas.
>> Dr. Bruera, how would you define fatigue and what different types of fatigue may present in the clinical setting? >> Fatigue is essentially a symptom. So it's a subjective sensation. And it's important to be aware that fatigue is described to us by the patient. It's not so much a reflection of what the patient can do, the function, the activity, the strength. All those contribute to fatigue, but essentially fatigue is a subjective symptom described to us by a patient.
And among the types of fatigue, I think there are predominantly two main contributors, two main types. The physical fatigue in which the person feels the cognitive and emotional willingness to engage in activity but is physical unable, and the emotional fatigue in which there is that sense of no drive or interest in pursuing any activity because of an anticipatory feeling of tiredness or a lack of energy.
>> How does the prevalence of fatigue among palliative care patients compare with the prevalence of fatigue in the general population? >> Unfortunately, fatigue is almost universal among palliative care patients. So this is quite different from what happens in the general population. And fatigue is the most severe symptom consistently reported by patients in palliative care. Not only patients with cancer, but also patients with CHF, patients with COPD, patients with AIDS.
A large number of patients with all sorts of chronic diseases present with severe consistent fatigue that they generally identify as the number one source of distress. >> What challenges do clinicians face in determining the cause of a patient's fatigue? >> One of the problem with fatigue is that the vast majority of our patients have many contributors.
So it's not that it's hard to find a cause for fatigue, it is that there are generally too many potential contributors. And overwhelmingly we need to think about fatigue as a multidimensional construct in which the patient will have at the same time the contribution of deconditioning, lack of muscle mass, medications, depression, and cognitive changes and basically anemia.
And all those contributors are usually together. So part of the challenge in determining the cause is that we need to consider that it is always multi-causal and it's identifying the number of contributors that are present in a given patient so we don't miss one or two or three of those out. >> That sounds pretty challenging. What steps should clinicians take to evaluate fatigue in elderly patients?
>> The first challenge is to determine how much fatigue is bothering the patient. That is easy to do because we can simply ask the patient to tell us from none to very bad, from zero to 10, fingers of a hand, any subjective evaluation by the patient is reasonably good. It is also useful to put that in perspective with other symptoms the patient might be having like pain, like nausea, like shortness of breath, like depression, anxiety, etc. And then we need to move on to what are the main comorbidities the patient might have.
And in the elderly, that is a major problem because elderly patients frequently have multiple comorbidities and multiple medications. So figuring out which of those are contributing to the fatigue in my given patient, and starting to make changes both in the management of the comorbidities and perhaps in the type of medications the patient is receiving, are perhaps the main steps towards starting to resolve the problem.
>> What treatment strategies are available for fatigue? And when the specific cause of fatigue isn't clear, how can clinicians help ease patients' symptoms? >> Yes, that's a very important question because, as your question clearly hints, the strategies in the case of a patient who complains of chronic fatigue are two. The first is to use the treatments that are aimed at a specific identified problem. For example, a patient may have hypogonadism, a patient might have severe anemia.
Mild anemia is usually irrelevant, but severe anemia, six, seven of hemoglobin, the patient might have medications that are clearly causing drowsiness and tiredness, or the patient might have a significant level of depression requiring antidepressant management. So the identification of causes that can be treated specifically is the first step. The second step is what do we do universally in those patients who are complaining of fatigue in which we have not identified one or two reversible or potentially reversible mechanisms.
And there are a number of interventions, including pharmacologically corticosteroids in selected numbers of patients, psychostimulants, particularly methylphenidate. Exercise is an almost universal intervention, and even the very ill patients can engage in walking or other types of exercise. Counseling, natural light, distraction; all those are adjuvant interventions that we can propose that will not only help subjectively, but also will provide the patients with an increased sense of mastery over the symptom distress.
>> Dr. Bruera, is there anything else you would like to tell our listeners about the palliative management of fatigue at the close of life. >> I think one of the points we need to think about is that at the level of fatigue at this point, we are not different from the way we were in the level of pain 20 or 30 years ago. And 20 or 30 years ago, we used to accept pain as a "normal" consequence of having diseases such as cancer or heart failure. And now I think we would not accept that.
We would say that is completely treatable phenomenon. With regards to fatigue, there is still at this present time the consideration that fatigue is "normal" in these patients, and that sometimes leads to a little bit of a neolistic [phonetic] attitude towards assessment and management. And we need to say there are multiple things I can look for and I can try in these patients. And the data from our team and many other teams suggests that simple measures can dramatically reduce the subjective sensation of fatigue at the end of life.
>> Thank you, Dr. Bruera, for your insights into palliative management of fatigue at the close of life. And for additional information about this topic, JAMA Evidence subscribers can consult Chapter 9 of Care at the Close of Life. This has been Joan Stevenson of JAMA talking with Dr. Eduardo Bruera for JAMA Evidence.
