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Fatigue in palliative care patients — an EAPC approach

Department of Palliative Medicine, RWTH Aachen University, Aachen, lradbruch{at}ukaachen.de

Florian Strasser

Department of Internal Medicine, Cantonal Hospital, St. Gallen

Frank Elsner

Department of Palliative Medicine, RWTH Aachen University, Aachen

Jose Ferraz Gonçalves

Department of Palliative Care, Portuguese Institute of Oncology, Porto

Jon Løge

Department of Behavioral Sciences in Medicine, University of Oslo, Oslo

Stein Kaasa

Palliative Medicine Unit, Department of Oncology, St Olavs Hospital, Trondheim

Friedemann Nauck

Department of Palliative Medicine, University of Göttingen, Göttingen

Patrick Stone

Department of Mental Health, St George's Hospital Medical School, London

the Research Steering Committee of the European Association for Palliative Care (EAPC)

Fatigue is one of the most frequent symptoms in palliative care patients, reported in .80% of cancer patients and in up to 99% of patients following radio- or chemotherapy. Fatigue also plays a major role in palliative care for noncancer patients, with large percentages of patients with HIV, multiple sclerosis, chronic obstructive pulmonary disease or heart failure reporting fatigue.This paper presents the position of an expert working group of the European Association for Palliative Care (EAPC), evaluating the available evidence on diagnosis and treatment of fatigue in palliative care patients and providing the basis for future discussions. As the expert group feels that culture and language influence the approach to fatigue in different European countries, a focus was on cultural issues in the assessment and treatment of fatigue in palliative care.

As a working definition, fatigue was defined as a subjective feeling of tiredness, weakness or lack of energy. Qualitative differences between fatigue in cancer patients and in healthy controls have been proposed, but these differences seem to be only an expression of the overwhelming intensity of cancer-related fatigue.

The pathophysiology of fatigue in palliative care patients is not fully understood. For a systematic approach, primary fatigue, most probably related to high load of proinflammatory cytokines and secondary fatigue from concurrent syndromes and comorbidities may be differentiated. Fatigue is generally recognized as a multidimensional construct, with a physical and cognitive dimension acknowledged by all authors. As fatigue is an inherent word only in the English and French language, but not in other European languages, screening for fatigue should include questions on weakness as a paraphrase for the physical dimension and on tiredness as a paraphrase for the cognitive dimension. Treatment of fatigue should include causal interventions for secondary fatigue and symptomatic treatment with pharmacological and nonpharmacological interventions. Strong evidence has been accumulated that aerobic exercise will reduce fatigue levels in cancer survivors and patients receiving cancer treatment.

In the final stage of life, fatigue may provide protection and shielding from suffering for the patient and thus 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. Palliative Medicine 2008; 22: 13—22.

Key Words: fatigue • palliative care • cancer-related fatigue • recommendations

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