Cancer-Related Fatigue Symptom Management in Palliative Care - Case Study Example

Cancer-Related Fatigue Symptom Management in Palliative Care Cancer is an incurable condition where terminally-ill patients suffer many symptoms in the palliative care setting and fatigue is one of the most common. “An incurable condition is a condition that conventional medicine cannot cure. Usually these conditions are marked by serious suffering from the patient” (Nagel, 2007). In answer to the special type of care needed by these terminally ill patients with incurable diseases, there exist the palliative care facilities that provide comfort and treatment of symptoms to alleviate patient sufferings. According to World Health Organization (WHO, 2009), palliative care improves the quality of life of patients and families who face life-threatening illness, by providing pain and symptom relief, spiritual and psychosocial support from diagnosis to the end of life and bereavement. 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 (Radbruch et al., 2008). The fatigue experienced as a side effect of cancer treatment is differentiated from the fatigue experienced by healthy people in their daily lives. Healthy fatigue is frequently described as acute fatigue that is eventually relieved by sleep and rest; cancer treatment–related fatigue is categorized as chronic fatigue because it is present over a long period of time and is not completely relieved by sleep and rest (National Cancer Institute, 2009). This study aims to identify the treatment modalities and symptom management for cancer-related fatigue including assessment, interventions, and collaborations with multidisciplinary health care professionals, in providing comfort to alleviate the sufferings of breast cancer patients. Concepts and knowledge from related literatures, research, and practice shall be applied to clearly understand its nursing implications taking into consideration the actual management of breast cancer patients during Oncology ward hospital exposure. What is cancer-related fatigue? In a broader sense, fatigue, also known as weariness, tiredness, exhaustion, or lethargy, is generally defined as a feeling of lack of energy (eMedicineHealth, 2009). Cancer-related fatigue is a feeling of debilitating tiredness or total lack of energy that can last for days, weeks, or months; commonly caused by anemia, fatigue is the side effect of chemotherapy that affects patients the most – more than nausea, pain, or depression; symptoms include feeling weak or worn out, having difficulties climbing stairs, walking short distances, and performing simple daily tasks; proper nutrition, light exercise, short naps, and medications may help alleviate the fatigue (CancerSymptoms.org, 2006). Prevalence and causes of cancer-related fatigue Various studies were conducted by researchers regarding fatigue symptom management in cancer patients. De Jong, Candel, Schouten, Huijer Abu-Saad and Courtens conducted a cohort study participated by 157 patients with breast cancer who were interviewed using Rotterdam Symptom Checklist and the Multidimensional Fatigue Inventory, at the first, third and fifth cycle of adjuvant chemotherapy, as well as 4 and 12 weeks after the last cycle of adjuvant chemotherapy. Found out that the prevalence of fatigue increased significantly after the start of chemotherapy. After chemotherapy treatment the prevalence rate seemed to decline. An increase in fatigue was associated with a decrease in daily functioning. At all measurement occasions fatigue was affected by type of operation, such that women with a mastectomy were more fatigued than women that underwent a lumpectomy. Receiving radiotherapy also led to an increase in fatigue. (De Jong et al, 2004). Also, Jacobsen and colleagues of the Moffitt Cancer Center in Tampa, Florida conducted a study examining 221 women with non-metastatic or early stage, breast cancer treated with either radiotherapy (121) or a combination of chemotherapy and radiotherapy (100) and their results were compared with 221 age- and geographically-matched healthy women. The women were observed at two-, four- and six-month intervals after treatment. They found out that breast cancer patients had a significantly greater number of days with reported fatigue at each of the four assessments. Even at the six-month follow-up assessment, the fatigue remained statistically significant and clinically meaningful in the breast cancer patients. Heightened fatigue was more prevalent in those patients, who received both chemotherapy and radiotherapy (HealthImaging.com, 2007). In Bower’s literature review on the prevalence and causes of fatigue after cancer treatment, the findings were: First, fatigue remained stable over the 1-year assessment after completed treatment with chemotherapy and radiation therapy. Second, women treated with standard- and high-dose chemotherapy reported comparable levels of fatigue. Third, approximately 20% of women were classified as fatigued at each assessment point. Fourth, fatigue was strongly correlated with mental health and with muscle and joint pain, but not with hemoglobin or menopausal status (Bower, 2005). Other causes of fatigue in breast cancer patients include abnormalities in energy metabolism related to increased requirements (e.g., due to tumor growth, infection, fever, or surgery); decreased availability of metabolic substrate (e.g., due to anemia, hypoxemia, or poor nutrition); or the abnormal production of substances that impair metabolism or normal functioning of muscles (e.g., cytokines or antibodies). Other proposed mechanisms link fatigue to the pathophysiology of sleep disorders and major depression (Portenoy and Itri, 1999). Assessment, intervention and treatment modalities of cancer-related fatigue The National Cancer Institute presented a comprehensive assessment for cancer-related fatigue that starts with obtaining a careful history to characterize the individual’s fatigue pattern and to identify all factors that contribute to its development (National Cancer Institute, 2009). The following should be included in the initial assessment: Fatigue pattern, including onset, duration, and intensity, as well as aggravating and alleviating factors. Type and degree of disease and of treatment-related symptoms and/or side effects. Treatment history. Current medications. Sleep and/or rest patterns, relaxation habits, customs, and rituals. Nutrition intake and any appetite or weight changes. Effects of fatigue on activities of daily living and lifestyle. Psychiatric evaluation, including evaluation for depression. Complete physical examination, including gait, posture, and range of motion. Compliance with treatment. Job performance. Financial resources. Other contributing factors (e.g., anemia, dyspnea, muscle wasting). Apart from the guidelines listed by National Cancer Institute, The National Comprehensive Cancer Network (NCCN) guidelines recommend that fatigue be monitored on a routine basis in the clinical setting. Despite the ease of using a 0-to-10 visual analog scale (VAS), routine assessment of fatigue is currently not a standard practice in oncology clinics. Fatigue assessment has also been expanded through the development of instruments either designed for, or specifically normed, on particular patient groups. For example, the Fatigue Symptom Inventory (FSI) and the Multidimensional Fatigue Symptom Inventory (MFSI), while appropriate for assessing fatigue in non-patient populations, were also originally normed on breast cancer patients. The 83-item MFSI yields a total fatigue score as well as subscale scores for general, mental, emotional, and physical fatigue, and vigor (Stein, Martin, Hann and Jacobsen, 1998). A 30-item short form of this instrument (MFSI-SF) has also shown excellent psychometric properties and includes the same subscales as the full-version of the MFSI (Stein, Jacobsen, Blanchard and Thors, 2004). The Functional Assessment of Cancer Therapy-Fatigue scale was designed to assess fatigue specifically in cancer patients (Yellen, Cella, Webster, Blendowski and Kaplan, 1997). Interventions in the management of cancer-related fatigue involves specific treatment for potentially reversible causes (i.e., treating anemia or metabolic or endocrine abnormalities, as well as managing pain, insomnia, depression, or anxiety) and symptomatic measures when no obvious etiology or reversible cause can be identified. Nonspecific symptomatic treatment measures include education, counseling, and pharmacologic as well as non-pharmacologic measures (Escalante, 2009). As to pharmacological treatment, medications called psychostimulants (meant to "stimulate" the mind and body of the patient, giving them more energy) were said to relieve fatigue in patients with cancer and other diseases. The medications include: methylphenidate (Ritalin), Modafinil (used to treat Narcolepsy), and Pemoline (Vachani, 2006). Erythropoietic agents in ameliorating fatigue in cancer patients with chemotherapy-induced anemia is still under debate though some studies concluded that patients who responded to erythropoietic agents reported increased energy and activity levels, and improved overall quality of life (Schwartz, 2007). Complimentary therapies are by the use of mind-body interventions in the treatment of fatigue and these include acupuncture, healing touch, hypnosis, massage, yoga, lectin standardized mistletoe extract, levo-carnitine, guided imagery and relaxation (Vachani, 2006). Substantial research supports physical exercise as an intervention for fatigue (Schwartz, 2007). Collaboration with multidisciplinary professionals and agencies Multidisciplinary approach in the management of cancer-related fatigue symptoms is one strategy that promotes optimal patient functioning. In cancer patients undergoing chemotherapy or radiation therapy management, collaborative nursing functions, other than medication administration as prescribed by the physician, include patient (and significant others) referral to supportive group programs and professional counseling (Doenges, Moorehouse, and Geissler-Murr, 2002, p816). The case study of SB, a 60-year old breast cancer patient, shows an effective multidisciplinary treatment approach. Her osteoporotic vertebral compression fracture was referred for orthopedic surgery, and her femur showed a large lytic lesion and was referred to a radiation oncologist who prescribed a definitive dose of radiation to that area. Because the femoral cortex was eroded, which posed a risk of fracture, the orthopedic surgeon performed prophylactic fixation. She was also managed with palliative medicine team including nurses, physicians, and social workers and specialized in aggressive symptom management. Social workers provided resources, assisted with her finances, and encouraged her to participate in a local breast cancer support group. Though SB eventually died because of metastasis, she enjoyed a good quality of her remaining life during her lengthy illness, likely because of the multidisciplinary approach to her treatment, which included medical oncology, radiation oncology, orthopedic surgery, and palliative medicine teams (Faiman, 2008). Treatment/Management regimen proposal Since chemotherapy and radiation therapy are the treatment usually applied to breast cancer patients, fatigue is borne to be experienced by the patient. Thus, intervention in minimizing this discomfort is the nurses’ main objective. Thorough assessment shall be done utilizing scored checklist, keen observation, and entrusting therapeutic communication. Apart from the pharmacological treatment and other collaborative nursing functions, nurses must be skillful in the application of non-pharmacologic and independent functions deemed important as well. Patient education is essential in the Oncology ward patient to make them aware that they will experience fatigue after chemotherapy and/or radiation therapy and this anticipation could help the patients for advance preparation. Also, through patient education, they are encouraged to express what they feel and this information may be useful in developing a management plan utilizing specific activities like periods of rest, sleep hygiene, exercise, relaxation techniques, guided imagery, or exposure to stimulus that can distract their attention and forget the feeling of fatigue (e.g. listening to music, painting, and other non-strenuous activities). Monitoring patient’s diet is also important to provide nutrition and nourishment to the patient. Summary To sum up, the growing interest in the study of cancer-related fatigue symptom has led to the discovery of effective management strategies that benefited cancer patients and improved palliative care. Despite of the few studies already done, the prevalence of this symptom associated with breast cancer patients as a manifestation of the side effects of chemotherapy and radiation therapy treatments is still high indicating its importance for further research and study. This prompts an increasing attention for health care providers about the impact of cancer-related fatigue symptom to the patients so that more comprehensive evaluation and maximization of available treatment and management alternatives shall be discovered and utilized. References Bower, J. (2005). Prevalence and Causes of Fatigue After Cancer Treatment: The Next Generation of Research. American Society of Clinical Oncology, Journal of Clinical Oncology Volume 23, No 33 (November 20), 2005: pp. 8280-8282. 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PubMed May-June;6(3):143-52, U.S. National Library of Medicine and the National Institutes of Health. Internet summary article last accessed on August 20, 2009 at Vachani, C. (2006). Coping with Cancer: Cancer-Related Fatigue. Abramson Cancer Center of the University of Pennsylvania. Internet article last accessed on August 20, 2009 at Yellen, S.B., Cella, D.F., Webster, K., Blendowski, C. and Kaplan, E. (1997). Measuring fatigue and other anemia-related symptoms with the Functional Assessment of Cancer Therapy (FACT) measurement system. PubMed February;13(2):63-74. U.S. National Library of Medicine and the National Institutes of Health. Internet summary article last accessed on August 20, 2009 at Read More