CONTEXT: Fatigue is the most commonly reported symptom in life-limiting illnesses, though not much is known about the distress it causes patients as they approach death.
OBJECTIVES: To map the trajectory of distress from fatigue reported by an Australian palliative care population in the last 60 days leading up to death.
METHODS: A prospective, longitudinal, consecutive cohort study using national data from the Australian Palliative Care Outcomes Collaboration between 1 July 2013 and 31 December 2018. Patients were included if they had at least one measurement of fatigue on a 0-10 numerical rating scale in the 60 days before death. Descriptive statistics were used to analyse patients by diagnostic cohort and functional status.
RESULTS: A total of 116,604 patients from 203 specialist palliative care services were analysed, providing 501,104 data points. Distress from fatigue affected up to 80% of patients referred to palliative care, with the majority experiencing moderate or severe distress. Malignant and non-malignant diagnoses were equally affected, with the neurological cohort showing the greatest variability. The degree of distress correlated with a patient's functional level; it worsened as a patient's function declined until a patient became bedbound when the reporting of distress reduced.
CONCLUSIONS: Distress from fatigue is high in this cohort of patients. Interventions to reduce this distress need to be a research priority.
Yoga was developed >5,000 years ago as a comprehensive system of health and well-being for the mind, body, and soul. The word is believed to derive from the Sanskrit root "yuj" meaning to bind, yoke, union, and/or to concentrate one's attention. In health care, it often serves as a complementary mind-body practice, and it is increasingly being integrated into cancer care. It can be performed in the privacy of one's home through DVD or web-based programs or through group practices led by instructors who are often experienced working with students with medical issues. Most published evidence regarding yoga for seriously ill patients involves breast cancer survivors or breast cancer (stages I-IV) patients undergoing cancer treatment with a preserved functional capacity (ECOG <3). There is limited data examining its effectiveness or feasibility in children or for those with terminal cancer.
Background: Fatigue is one of the most distressing symptoms in patients with advanced cancer. Previous studies have shown an association between low vitamin D levels and fatigue.
Objectives: The aim of this study was to investigate the association between vitamin D levels and self-assessed fatigue in cancer patients admitted to palliative care, with focus on possible sex differences.
Design: This is a cross-sectional study.
Subjects: Baseline data from 530 screened patients, 265 women and 265 men, from the randomized placebo-controlled trial “Palliative-D” were analyzed.
Measurements: Vitamin D status was measured as 25-hydroxyvitamin D (25-OHD) and fatigue was assessed with EORTC-QLQ-PAL15 and with Edmonton Symptom Assessment System (ESAS).
Results: In men, there was a significant correlation between 25-OHD and fatigue measured with the “Tiredness question” (Q11) in EORTC-QLQ-PAL15 (p < 0.05), where higher 25-OHD levels were associated with less fatigue. No correlation between 25-OHD and fatigue was seen for women. Fatigue measured with ESAS did not show any significant association with 25-OHD levels neither in men nor in women.
Conclusion: Low vitamin D levels were associated with more fatigue in men but not in women. The study underscores the importance of subgroup analysis of men and women when evaluating the effect of vitamin D in clinical trials since the effect may differ between the sexes. The ongoing “Palliative-D study” will reveal whether vitamin D supplementation may counteract fatigue in both men and women.
Background: Patients with cancer-related pain use opioids for nociceptive pain, while gabapentinoids are common to treat neuropathic pain. The simultaneous use of opioids with gabapentinoids has been associated with an increased risk of opioid-related death.
Objectives: Determine the frequency of combined use of gabapentinoids among patients receiving opioids for cancer-related pain. We also examined if concomitant use of opioids and gabapentinoids together was associated with increased scores of fatigue and drowsiness on the Edmonton Symptom Assessment Scale (ESAS) compared to patients on opioids.
Design: Retrospective study of patients on opioids and opioids plus gabapentinoids at their third visit to the outpatient Supportive Care Center.
Results: We found that 48% (508/1059) of patients were on opioids. Of these patients, 51% (257/508) were on opioids only, and 49% (251/508) were on opioids plus gabapentinoids. The median (interquartile range [IQR]) morphine equivalent daily dose for patients on opioids was 75 (45, 138) mg, and opioids plus gabapentinoids was 68 (38, 150) mg (p = 0.94). The median (IQR) gabapentinoid equivalent daily dose was 900 (300, 1200) mg. The median (IQR) for ESAS-fatigue in patients on opioids was 5 (3, 7), and opioids plus gabapentinoids was 5 (3, 7) (p = 0.27). The median (IQR) for ESAS-drowsiness in patients on opioids was 3 (0, 5), and opioids plus gabapentinoids was 3 (0, 6) (p = 0.11).
Conclusion: Almost 50% of advanced cancer patients receiving opioids for pain were exposed to gabapentinoids. Maximal efforts should be made to minimize potential complications from the concomitant use of opioids with gabapentinoids.
Un engagement dans la durée pose des questions et mobilise des énergies. La fatigue, voire l'épuisement, s'invite. On peut explorer la question de la fatigue en cherchant à discerner les critères d'une "bonne" et d'une "mauvaise" fatigue, puis essayer de repérer des racines à cette "mauvaise fatigue". Enfin, s'inspirer d'un certain type de repos issu du Shabbat de la tradition biblique.
Hospice volunteers are a high-risk group for anxiety and depression owing to their frequent exposure to patients at the end of life and their subsequent deaths. Resilience is known to be a powerful factor that affects the occurrence of anxiety and depression; however, research on this subject is scarce. We investigated the relationship of resilience with anxiety or depression in hospice volunteers. A total of 145 volunteers were included in the analysis. Participants completed self-reported scales, including the Korean version of the Connor-Davidson Resilience Scale, the State-Trait Anxiety Inventory, Patient Health Questionnaire-9, and the Professional Quality of Life Scale version 5. Pearson correlation coefficients were analyzed to identify the relationship of compassion satisfaction and compassion fatigue with anxiety or depression. A PROCESS macro mediation analysis was used to investigate the mediation effects of compassion satisfaction and compassion fatigue on the relationship between resilience and anxiety or depression. There were significant associations of compassion satisfaction and compassion fatigue with anxiety and depression. The relationship between resilience and anxiety/depression was mediated by compassion fatigue, which had indirect effects on anxiety and depression. Efforts to reduce compassion fatigue and increase resilience could help prevent anxiety and depression in hospice volunteers.
Background: In order to counteract fatigue, physical activity (PA) is recommended for all stages of cancer. However, only few advanced cancer patients (ACP) are physically active. Quantitative data with high numbers of ACP reporting barriers to PA are missing. This study aimed to identify barriers to PA in ACP with tiredness/weakness and investigate their motivation towards it.
Methods: Outpatients with metastatic cancer receiving cancer care at a German Cancer Center reporting moderate/severe tiredness/weakness during self-assessment (MIDOS II) were enrolled. We assessed Fatigue-(FACF-F) and Depression (PHQ8) Scores, demographics, cancer-specific parameters, motivation for PA, physical, psychological and social barriers.
Results: 141 of 440 eligible patients (32.0%) with different diagnoses agreed to participate. Patients frequently reported “I feel weakened due to my tumor therapy” (n = 108; 76.6%), physical symptoms (tiredness, weakness, dyspnea, joint-problems, pain, nausea [n = 107; 75.9%]) and fatigue (n = 99; 70.2%) as barriers to PA. However, no significant group differences regarding these barriers were found between physically active and inactive patients. Social barriers were rarely chosen. Motivated patients were 5.6 times more likely to be physically active (p < 0.001), also motivation turned out to be the strongest predictor for a physically active behavior (ß = 1.044; p = 0.005). Motivated attitude towards PA was predicted by fatigue (ß = - 2.301; p = 0.008), clinically relevant depression (ß = - 1.390, p = 0.039), knowledge about PA and quality of life (QoL) (ß = 0.929; p = 0.002), PA before diagnosis (ß = 0.688; p = 0.005 and Interest in exercise program (ß = 0.635; p = 0.008).
Conclusion: “I feel weakened due to my tumor therapy” is the most reported barrier to PA among both, physically and inactive patients. Motivation for PA is the strongest predictor of performing PA. Interest in PA, knowledge about PA/QoL and PA before diagnosis are main predictors of a motivated attitude. Absence/presence of social barriers did not associate with motivation, fatigue and depression proved to be a negative predictor. Programs including information, motivational counseling and individualized training should be offered for ACP to overcome barriers and reduce fatigue.
Trial registration: German Register of Clinical Trials DRKS00012514, registration date: 30.5.2017.
BACKGROUND: Hospice workers are required to regularly use emotional regulation strategies in an attempt to encourage and sustain terminally ill patients and families. Daily emotional regulation in reaction to constantly watching suffering patients may be intensified among those hospice professionals who have high levels of compassion fatigue. The main object of this study was to examine the relationship between daily exposition to seeing patient suffering and daily emotional work, and to assess whether compassion fatigue (secondary traumatic stress and burnout) buffers this relationship.
METHODS: We used a diary research design for collecting daily fluctuations in seeing patients suffering and emotional work display. Participants filled in a general survey and daily survey over a period of eight consecutive workdays. A total of 39 hospice professionals from two Italian hospices participated in the study.
RESULTS: Multilevel analyses demonstrated that daily fluctuations in seeing patients suffering was positively related to daily emotional work display after controlling for daily death of patients. Moreover, considering previous levels of compassion fatigue, a buffering effect of high burnout on seeing patients suffering - daily emotional work display relationship was found.
CONCLUSIONS: A central finding of our study is that fluctuations in daily witness of patients suffering are positively related to daily use of positive emotional regulations. Further, our results show that burnout buffers this relationship such that hospice professionals with high burnout use more emotional display in days where they recurrently witness patients suffering.
Good symptom management in oncology is associated with improved patient and family quality of life, greater treatment compliance, and may even offer survival advantages. With population growth and aging, the proportion of patients with multiple symptoms-both related and unrelated to their cancer-is anticipated to increase, supporting calls for a more routine and integrated approach to symptom management. This article presents a summary of the literature for the use of symptom assessment tools and reviews the management of four common and distressing symptoms commonly experienced by people with advanced cancer: pain, breathlessness, nausea and vomiting, and fatigue. We also discuss the role of palliative care in supporting a holistic approach to symptom management throughout the cancer trajectory.
CONTEXT: There is little evidence of the effectiveness of aromatherapy massage in palliative care despite its popularity.
OBJECTIVES: This study aimed to investigate the effects of a 30-minute single session of aromatherapy massage at night-time on quality of sleep and fatigue in palliative care.
METHODS: A randomized controlled trial from January 2018 to March 2019. After being stratified by sex, participants were randomly assigned to an aromatherapy massage group and a control group. The effects of aromatherapy massage were evaluated on the massage day and the next day using the Richards-Campbell Sleep Questionnaire (RCSQ) and the Brief Fatigue Inventory (BFI).
RESULTS: Of the 74 participants, data of 27 participants in the treatment group and 30 in the control group were analyzed. ANCOVA indicated that quality of sleep and fatigue did not improve owing to the aromatherapy massage, although usual fatigue in preceding 24 hours and enjoyment of life subscales of the BFI showed signs of contribution (p = 0.07 and p = 0.09, respectively). Post hoc analyses indicated that higher age and performance status were factors with moderate correlation with better sleep (p = 0.03, r = 0.45, and p = 0.03, r = 0.40, respectively), and that older patients tended to experience greater improvement in fatigue (p = 0.02, r = -0.47).
CONCLUSION: A single aromatherapy massage session is no more effective than not having a massage in improving sleep quality in palliative care settings. However, older patients and those in poor health conditions may benefit from aromatherapy massage.
BACKGROUND: Compassion fatigue refers to the emotional and physical exhaustion felt by professionals in caring roles, whereas compassion satisfaction encompasses the positive aspects of helping others. Levels of compassion satisfaction and fatigue have been found to be inconsistent in palliative care professionals, which could have serious implications for patients, professionals and organisations.
OBJECTIVES: This study explored the experiences of clinical psychologists working in palliative care, all worked with adults with cancer, to gain an understanding of the impact this work has on their self and how they manage this.
METHODS: A qualitative approach was taken, using semi-structured interviews and interpretative phenomenological analysis.
RESULTS: Three superordinate themes were identified: commitment, existential impact on the self and the oracle. The participants' experiences were characterised by the relationship between themselves and their patients, the influence of working in palliative services on their world view and the impact of organisational changes. Differences between working as a clinical psychologist in palliative care versus non-palliative settings were considered.
CONCLUSIONS: Professionals working in palliative care should be supported to reflect on their experiences of compassion and resilience, and services should provide resources that facilitate staff to practice positive self-care to maintain their well-being.
INTRODUCTION: Almost all patients with end-of-life cancer experience cancer-related fatigue; however, there are only a few known effective coping methods.
OBJECTIVES: We will conduct a prospective, multi-center, single-blinded randomized controlled study to evaluate the efficacy of acupuncture for cancer-related fatigue in patients with end-of-life cancer.
METHODS: We will enroll 120 patients with cancer hospitalized in a palliative care unit or receiving consultation from a palliative care team in four hospitals. We will add acupuncture treatment; specifically, contact needle therapy (CNT), consisting of an intervention per week period to the usual care. The primary outcome measure will be the Cancer Fatigue Scale (CFS) score while the secondary outcome measures will be the Numerical Rating Scale (NRS) score for fatigue, pain, and salivary amylase levels.
CONCLUSION: We will evaluate the possibility of using acupuncture therapy, that is, CNT, in relieving fatigue sensation in patients with advanced cancer.
TRIAL REGISTRATION: UMIN000028304, registered on July 21st, 2017; https://upload.umin.ac.jp/cgi-open-bin/ctr_e/ctr_view.cgi?recptno=R000032401.
OBJECTIVE: Oncologists are exposed to suffering, loss, and death, which can potentially lead to grief reactions. Although grief over patients may be a natural consequence of the close and longstanding oncologist-patient relationship, the empathy that oncologists feel towards their patients may put them at risk for compassion fatigue (CF). This study examined the mediating role of the two components of CF - secondary traumatic stress (STS) and burnout - in the relation between empathy and grief among oncologists.
METHOD: Participants included 71 Israeli oncologists. Measures consisted of a demographic questionnaire, the Texas Revised Inventory of Grief-Present, the Interpersonal Reactivity Index, and the Professional Quality of Life questionnaire.
RESULTS: Oncologists reported moderate levels of grief, and relatively high levels of both STS and burnout. In addition, they reported high levels of the three components of empathy: perspective-taking, empathic concern, and personal distress. The PROCESS SPSS macro revealed support for the mediation model. The mediators (STS and burnout) fully accounted for the relationship between the following two components of empathy - perspective-taking and personal distress - and grief.
CONCLUSIONS: Oncologists commonly experience grief over patients. We found that oncologists' grief was related to their empathy, and that this association was explained by their levels of CF. The current research may mark a step toward recognizing oncologists' grief as well as understanding the processes associated with it.
BACKGROUND: Fatigue is a common symptom experienced by people with cancer and other long-term, non-malignant conditions. It can be disease-related or caused by treatments such as chemotherapy or radiotherapy. Patients frequently report this as a distressing symptom and, while some international guidelines for its management exist, evidence suggests that these are not always implemented.
METHOD: This article reviews the evidence basis for fatigue management, looking at exercise, education, psychological interventions, complementary therapies and pharmacological therapy, and finds that a one-size fits all approach to fatigue management is unrealistic.
FINDINGS: Research appears to support different interventions at various points in the disease trajectory and this is of importance for service design as palliative care is increasingly introduced earlier in the patient's pathway.
CONCLUSION: Although the body of research is growing, management of fatigue caused by non-malignant conditions remains poorly evidenced, making comprehensive recommendations for these patient groups even more challenging.
Novel immune-based cancer therapies such as programmed death 1 (PD-1) inhibitors continue to emerge for both curative and palliative intent. Post-market data of PD-1 inhibitors indicate that there are a wide range of side effects associated with these drugs, including ones that have relevance to symptom control and represent a diagnostic challenge at the end of life. We present a case of pembrolizumab-induced hypothyroidism causing extreme fatigue and persistent hypoglycemia.
BACKGROUND: People with metastatic cancers experience poor quality of life (QoL), fatigue, and decreased physical function. Exercise improves these symptoms in the curative setting, but the efficacy and safety of exercise in the metastatic setting is uncertain.
METHODS: Prospective, randomized trials of moderate/high intensity aerobic exercise or resistance training versus control in patients with advanced / metastatic solid cancers were identified from prior reviews and updated using a search of PubMed. The mean and standard deviation (SD) for validated outcome measures (QoL, physical function, and fatigue) were extracted for intervention and control groups at baseline and post-intervention. The Mann Whitney test was used to evaluate the effect of exercise on the pooled change between baseline and post-intervention. Safety was evaluated qualitatively.
RESULTS: Sixteen trials were analysed. Among patients with scores at the mean or 2SD above, exercise was not associated with significant or clinical difference in QoL or fatigue. In patients with baseline scores 2SD below mean, exercise was associated with non-significant difference meeting minimal clinical important difference in QoL (-2.8 vs 4.6, p=0.28). For function, patients at the mean had non-statistically significant, but clinically meaningful improvement in the 6-minute walk test (6-MWT) (14.7 vs 29.0 meters, p=0.44). In patients 2 SD below the mean, there was a clinically meaningful difference in two patient-reported functional subscales (0.1 vs 5.3, p=0.076 and 0.44 vs 8.5, p=0.465) and a clinically meaningful difference in the 6-MWT (-7.5 vs 27.0 meters, p=0.34), although none of these associations met statistical significance. There were no differences in falls, fractures, or pain.
DISCUSSION: Exercise is associated with clinically meaningful improvements in QoL, function, and 6-MWT in some patients with metastatic cancer. Despite poor reporting of safety, there was no signal of increased harm from exercise in this setting.
Purpose: To explore the methods through which physicians deliver compassionate care during end-of-life (EOL). Compassionate care provides benefits to patients and providers and is particularly important for patients with serious illnesses, yet its practice remains limited. We aim to qualitatively characterize methods utilized by physicians that facilitate the delivery of compassionate care at EOL.
Methods: We conducted 13 semi-structured interviews with physicians from palliative care and medical oncology subspecialities at a rural academic medical centre in New Hampshire. Interviews were transcribed and analysed using a qualitative research design.
Results: Participants described methods of compassionate care ranging from symptom control to less tangible, non-verbal methods. Primary barriers to the delivery of compassionate care were described as within the broader healthcare system and within the inherent emotional difficulty of EOL care. Physicians from both subspecialities emphasized the importance of successful inter-provider relationships.
Conclusions: Methods for delivering compassionate care at EOL are wide ranging, but barriers on a systemic and individual level should be addressed to make its practice more widespread. This can be accomplished, in part, by the standardization of EOL conversations, training physicians how to have meaningful EOL conversations, and integration of such conversations into electronic medical records.
BACKGROUND: The integration of palliative care into standard oncology care is supported by research to improve quality of life and symptom distress in patients with advanced cancer. In 2016, the American Society of Clinical Oncology (ASCO) released practice guidelines for oncology palliative care that emphasized interprofessional assessment and management of this patient population.
OBJECTIVES: The purpose of this study was to evaluate the effect of clinical guidelines on symptom distress in patients with advanced cancer.
METHODS: In two oncology palliative care clinics, the Edmonton Symptom Assessment Scale (ESAS) scores for pain, fatigue, and anxiety were measured prior to consultation (T1) and at two subsequent visits (T2 and T3). A standardized documentation template was used to measure fidelity for key guideline components.
FINDINGS: Pain, fatigue, and anxiety ESAS scores were statistically lower from T1 to T3. The frequency of patients having a decrease of 2 or more points for all symptoms increased compared to baseline data. There was 100% compliance to the documentation template during the guideline implementation.
Au sommaire de ce dossier sur le ressenti et les émotions des soignants dans leur activité professionnelle : "Les soignants et leurs émotions au quotidien" : les soignants doivent, devant leurs émotions, adoptés des stratégies afin d'empêcher les débordements sans, pour autant, être dans l'évitement. "Fatigue compassionnelle et traumatisme vicariant chez les soignants" : le traumatisme vicariant évoque un état de stress post-traumatique chez le soignant confronté au récit traumatique d'un patient. La fatigue compassionnelle se manifeste par une érosion graduelle de l'empathie, de l'optimisme et de la compassion. Ces troubles nécessitent une prise en compte immédiate et adaptée. "Figures de la souffrance et du deuil des soignants" : le travail de verbalisation et de symbolisation est essentiel dans ce contexte. "L'impact des situations difficiles sur les soignants" : il est important de prendre en compte ces émotions et d'identifier les ressources qui peuvent être proposées aux soignants. La solidarité entre soignants et la cohésion d'équipe sont également essentielles. "Des ressources pour soutenir les soignants" : ces ressources sont les temps d'échanges, formels ou non, les réunions d'équipe, les retours d'expérience et l'analyse des pratiques. "A l'écoute de la souffrance du corps soignant". "Les soignants face aux événements douloureux, témoignages". "Rester soignant malgré l'inconcevable.".
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