Fatigue in advanced disease associated with palliative care: A systematic review of non-pharmacological treatments

'Blood transfusions in palliative medicine and symptom control in solid tumours'

INTRODUCTION

Fatigue and breathlessness are among the most distressing symptoms for palliative care patients and may be related to underlying anaemia. Red cell concentrate (RCC) transfusion is a common intervention, yet its efficacy in improving these symptoms in palliative populations remains unclear.

METHODS

This retrospective chart review examined the impact of RCC transfusion on fatigue, breathlessness and functional status in 33 patients admitted to a hospice inpatient unit over 30 months. Symptom and functional scores were assessed pre-transfusion, and at 14 and 30 days post-transfusion, using the Palliative Care Outcomes Collaboration Symptom Assessment Scale, Australian Karnofsky Performance Status (AKPS) and Resource Utilisation Groups-Activities of Daily Living (RUG-ADL) tools.

RESULTS

Results showed that fatigue scores improved in 58% of patients, with sustained improvement at 30 days in 36%. A statistically significant reduction in fatigue was observed at 14 days post-transfusion (p=0.02). However, the impact on breathlessness was limited, with only 18% of patients reporting improvement, and no significant changes in mean breathlessness scores over time. Functional status, measured by AKPS and RUG-ADL, declined in 36% and 27% of patients, respectively, likely reflecting the progressive nature of terminal illness.

CONCLUSIONS

While RCC transfusion demonstrated potential for alleviating fatigue, particularly in the short term, its effects on breathlessness and functional status were limited. The high mortality rate (30% at 30 days) and small sample size highlight the challenges of research in this population. These findings support the role of RCC transfusion in managing fatigue in palliative care, though further prospective studies are warranted.

Top Ten Tips Palliative Care Clinicians Should Know About Diagnosing, Categorizing, and Addressing Fatigue

Fatigue is a multifactorial symptom that is commonly faced by patients with cancer, chronic disease, and other serious illnesses. Fatigue causes suffering across biopsychosocial domains and affects patients and their loved ones. In this article, a consortium of professionals across cancer care, physical therapy, exercise, pharmacy, psychiatry, and palliative medicine offers tips and insights on evaluating, categorizing, and addressing fatigue in the setting of serious illness. The comprehensive approach to managing fatigue underscores the importance of collaborative efforts characteristic of interdisciplinary palliative care. Prioritizing screening, diagnosing, and treating fatigue is crucial for enhancing patients' and families' overall quality of life.

Ensuring quality of life in palliative care physiotherapy in developing countries

Palliative care (PC) focuses on the body, mind, and spirit and can also provide pain and symptom relief, clarifying and focusing the provision of care on the patient's desires and goals, and helping them understand their disease and its treatment plans. Although PC is widely recognized for its applicability near the end of life or during terminal illness, it is also applicable and beneficial for patients with diseases in their earlier stages. Near the end of life, palliative care often focuses on providing continual symptom management and supportive care. Although palliative care has been noted to improve some life expectancy, its primary aim is to improve quality of life via focusing on the comfort of the patient, maintaining dignity, reducing intensive care utilization, and avoidance of expensive hospitalizations. One major challenge to quality of life for patients in PC is the physical and functional decline that occurs with disease progression. These issues can be addressed by specialized PC physiotherapy. Uniform provision of high-quality PC services (and physiotherapy in palliative care) faces substantial challenges in resource-challenged settings, including low- and middle-income countries. When properly integrated into PC teams and adequately supported, physiotherapy within PC can address common symptoms (pain, breathlessness, weakness) and assist patients to remain in an adapted home setting to optimize their quality of life, safety, and dignity.

Fatigue Prevalence Among Palliative Care Cancer Patients in Comprehensive Cancer Center, King Fahad Medical City, Riyadh, Saudi Arabia: A Cross-Sectional Study

Objective: The aims of the current study are to assess the prevalence of cancer-related fatigue, to examine the difference in cancer-related fatigue severity in relation to patients' characteristics (age, gender, type of cancer, and palliative performance status), and to explore the correlation between cancer-related fatigue and pain, dyspnea, insomnia, and depression among palliative care patients. Methods: A cross-sectional descriptive observational study conducted at Comprehensive Cancer Center, King Fahad Medical City, Riyadh, Saudi Arabia. The study included cancer patients who received palliative care services from January 2016 to December 2021. Clinical data of study participants were retrospectively collected from Palliative Care department patient registry. Symptoms were assessed and scored using Edmonton Symptom Assessment Scale. Data analysis was performed using SPSS statistical software. Results: A total of 2616 patients were included in the study, 52.3% were females and 47.7% were males. The median age of study participants was 56 years (range: 2-101 years). Among all study population, the highest reported cancer type was gastrointestinal malignancy (33.5%), while the least was unknown primary malignancy (1.4%). With regards to Edmonton Symptom Assessment Scale, pain (86.4%) and fatigue (83%) were the highest reported symptom in comparison to constipation (17.3%) and insomnia (7.1%). Conclusion: Cancer-related fatigue is a prevalent and concerning issue among palliative care patients. It is essential that healthcare providers recognize the prevalence of fatigue among patients with life-limiting illnesses, assess patients for fatigue routinely, incorporate strategies for managing fatigue, work closely with affected individuals and their families in order to guide the establishment of a personalized care plan that addresses the patient's unique needs and preferences.

Management of Fatigue in Patients with Advanced Cancer

OPINION STATEMENT

Fatigue is a common and distressing symptom experienced by patients with cancer. It is most common in patients with locally advanced or metastatic incurable disease. It can have profound effects on quality-of-life and physical functioning. In addition to general supportive measures (directed at tackling contributory conditions and comorbidities), a variety of specific interventions have been developed which can be broadly categorised as physical therapies, psychological therapies or medication. There is some evidence that each of these approaches can have benefits in patients with earlier stage disease, those undergoing active treatment and in cancer survivors. The best evidence is for aerobic exercise, yoga, cognitive-behavioural therapy (CBT) and psycho-educational interventions. Less strong evidence supports the use of medications such as methylphenidate or ginseng. In patients with advanced disease, it is likely that the mechanisms of fatigue or the factors contributing to fatigue maintenance may be different. Relatively fewer studies have been undertaken in this group and the evidence is correspondingly weaker. The authors recommend the cautious use of aerobic exercise (e.g. walking) in those who are still mobile. The authors advise considering the use of psycho-educational approaches or CBT in those patients who are able to engage in such forms of therapy. In patients near the end-of-life, the authors advise use of dexamethasone (short-term use) and other pharmacological treatments only on the basis of a clinical trial.

Consideration of Symptom Management in Advanced Heart Failure

This work provides an opinion on palliative care for people with heart disease. The work focuses on the management of key symptoms associated with both end stage heart disease, applying a palliative approach and suggesting treatment options. The work also indicates the potential for greater collaboration of specialist teams including specialist palliative care in the assessment and management of patients with complex needs as they progress through their disease trajectory. The practical application of evidence-based guidelines and recommendations is key to the successful individualised management of complex symptoms.

Health-related quality of life and health literacy in patients with systemic mastocytosis and mast cell activation syndrome

BACKGROUND

Systemic mastocytosis is a rare genetic disease characterized by aberrant proliferation and/or activation of mast cells, resulting in multi-organ, allergy-like symptoms. Mast cell activation syndrome (MCAS) is a clinically similar, but more prevalent disease with unclear etiology. In this study, the health-related quality of life (HRQOL) and health literacy of people suffering from SM and MCAS were assessed.

RESULTS

Two validated questionnaires (QLQ-C30/QLQ-INFO25) from the European Organisation for Research and Treatment of Cancer (EORTC) were used to analyze HRQOL and level of information of SM and MCAS patients. In addition, a control group without any health issues was included. Data were analyzed by ANOVA and linear regression to detect significant differences. Questionnaire data from 66 patients with MCAS (83% female, mean 44 years), 32 patients with SM (78% female, mean 53 years) and 52 healthy participants (67% female, mean 48 years) resident in Germany were analyzed. HRQOL as measured by the Global health status was significantly worse in patients suffering from MCAS or SM compared to control group. Individuals with MCAS showed a slightly, but insignificantly lower score on Global health status, and a significantly lower score with respect to role function and fatigue. Patients with the rare disease SM felt significantly better informed on their disease compared to MCAS patients. Linear regression performed separately for both groups showed a direct influence of the level of information on patients' HRQOL.

CONCLUSION

Overall, our study showed a significant negative impact on the HRQOL of both diseases, but only a small difference in quality of life and severity of symptoms between patients with MCAS and the supposedly more severe form, the rare disease SM. Our results demonstrate that the level of information patients receive impacts HRQOL, and that this is not only an issue in rare diseases, but also diseases with unclear etiology and pathology. Our data shows that even slight improvements in the patient's level of information can have a positive effect on their quality of life, further highlighting the importance of gaining more knowledge on rare and incompletely understood diseases and communicating these insights to patients.

Cancer-related fatigue measures in palliative care: A psychometric systematic review

INTRODUCTION

In palliative care, the prevention and relief of fatigue are regarded as crucial goals in patients with cancer.

METHODS

A systematic review was carried out according to the COnsensus-based Standards for the selection of health status Measurement INstruments methodology. Searches were conducted in Medline (through PubMed), Web of Science, Open Gray, Scielo, Cochrane, CINAHL and EMBASE. All instruments found in each study were assessed using the COnsensus-based Standards for the selection of health status Measurement INstruments checklist and Grading of Recommendations, Assessment, Development and Evaluation approach.

RESULTS

A total of 5598 articles were identified in the different databases. In total, 57 studies describing 19 instruments were included in this study. The main properties evaluated were internal consistency, cross-cultural validity, hypotheses testing and responsiveness. All studies were evaluated with the Strobe scale with a score greater than 6 points.

CONCLUSIONS

According to the quality methodological results, Edmonton Symptom Assessment System, Problems and Needs in Palliative Care Questionnaire, European Organisation for Research and Treatment of Cancer Quality of Life 15-item Questionnaire for Palliative Care and Palliative Care Quality of Life Instrument are the recommended instruments used for assessing cancer-related fatigue in palliative care. PROPESRO registration number: CRD42020206783.