Fatigue in palliative care
from eTG
- Definition: Persistent, distressing tiredness not proportional to activity, not relieved by rest/sleep, impairs functioning.
- Presentation:
- Physical: Weakness, low energy, tiring easily
- Cognitive: Poor memory, concentration
- Affective: Lack of motivation
- Sleep: Non-restorative, disturbed sleep patterns
- Impact: Major contributor to poor QoL, reduced function, impaired adherence to care plans
- More prevalent than pain in advanced cancer; also common in organ failure (e.g. cardiac, respiratory, renal, hepatic)
🔍 Assessment
- Ask proactively—patients may underreport or use vague terms (“no energy”, “tired”, “lethargic”)
- Evaluate:
- Severity
- Functional impact
- Psychological, social, spiritual domains
- Consider treatable causes (especially early in illness)
- Investigations: Judicious—avoid extensive tests in late-stage disease unless reversible causes likely
🔍 Common Contributing Factors (Multifactorial)
- Physical symptoms: Pain, dyspnoea, nausea
- Psychological: Depression, anxiety, distress
- Sleep issues: Insomnia, circadian disruption
- Disease sequelae: Anaemia, dehydration, hypoxia, cachexia, electrolyte imbalance
- Neuromuscular: Deconditioning, steroid myopathy, paraneoplastic syndromes
- Other illnesses: Infection, hypothyroidism
- Medications: Opioids, antihistamines, benzodiazepines, antipsychotics, etc.
- Disease-modifying treatments: Chemo, RT, hormonal therapy
- Progression of underlying illness
🛠️ Management Approach
- Key principle: Provide education and set realistic expectations
- Tailor to prognosis, goals of care, stage of illness
- Fatigue may serve a protective role in terminal stages
✅ General Measures
- Patient/family education
- Emphasise fatigue is part of illness, not a sign of “giving up”
- Energy conservation
- Pacing, prioritising, delegating tasks
- Use of aids and equipment
- Physical activity (where appropriate)
- Moderate aerobic/resistance exercise improves fatigue in cancer, CKD, COPD
- Avoid prolonged bed rest—can worsen fatigue
- Tailor and supervise with physio/exercise physiologist
- Multidisciplinary support
- Involve physio, OT, dietitian, palliative care team
🧠 Psychological & Emotional Management
- Regular psychosocial support (including phone contact if needed)
- Treat depression/anxiety/distress if present
- Consider:
- CBT
- Mindfulness-based stress reduction (MBSR)
- Mindfulness-based cognitive therapy (MBCT)
💊 Pharmacological Therapy (Limited Role)
- Corticosteroids: Limited, inconclusive evidence; short-term use only under specialist direction
- Psychostimulants (e.g. methylphenidate, modafinil, dexamfetamine)
- Evidence weak/inconclusive
- Use restricted in Australia
- Require palliative care specialist oversight
⚖️ Final Considerations
- In end-of-life care, fatigue may:
- Protect from suffering
- Indicate irreversible decline
- Be managed through comfort care rather than active reversal
- Avoid burdensome interventions not aligned with goals of care