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  • 1. Advance Care Planning
  • 2. Communicating Bad News
  • 3. Whole Patient Assessment
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  • 5. Assisted Suicide Debate
  • 6. Anxiety, Delirium
  • 7. Goals of Care
  • 8. Sudden Illness
  • 9. Medical Futility
  • 10. Common Symptoms
  • 11. Withholding Treatment
  • 12. Last Hours of Living
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    Back to Module 10: Common Physical Symptoms
    Specific Symptoms

     
    Breathlessness (Dyspnea)
    Nausea and Vomiting
    Constipation
    Diarrhea
    Anorexia/Cachexia
    Fatigue/Weakness Fluid Balance/Edema
    Skin
    Odors
    Insomnia

    Fatigue/Weakness

    Case Example

    TL is a 97 year old woman with osteoarthritis, hypertension, and breast cancer metastatic primarily to bone. She lives independently, but complains about not having enough energy to go to the store.

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    Definition/Description

    • Fatigue/weakness is one of the most frequent distressing symptoms
    • Patients and families will frequently focus on the symptom rather than its underlying cause
      • Many believe that a person’s strength is under his or her control
      • Feel that the patient is "giving up" or "not fighting"
    • Education of patient and family crucial
      • Giving the patient "permission" to rest
      • Decrease the pressure from family or others exhorting the patient to be more alert, energetic, and conversant

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    General Management of Fatigue/Weakness

    • Adapt activities of daily living
      • Promote energy conservation
      • Physiotherapy and occupational therapy can help with assessment, teaching, and assistive devices
    • Evaluate medications
      • Discontinue routine medications that are no longer appropriate near the end of life
      • May be making the fatigue worse
      • Particularly antihypertensives, cardiac medications, diuretics, etc
    • Optimize fluid, electrolyte intake
      • best possible hydration
      • consistent with goals of care and the patient’s ability to maintain intravascular hydration
      • Based on the degree of hypoalbuminemia
    • Permission to rest
    • Clarify role of underlying illness
    • Educate, support patient, family
    • Include other disciplines

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    Specific Management of Fatigue/Weakness

    • While fatigue/weakness is not easily treated pharmacologically, some patients respond to a few of the following approaches
    • Steroids may have a beneficial effect
      • Dexamethasone

        • Doses of 2–20 mg PO daily is favored because of its long half-life (permitting once-daily dosing) and relative lack of mineralocorticoid adverse effects

        • Dose in the morning for its activating effect

        • Associated with feeling of well-being, increased energy

        • While it can be continued until death, the effect may wane after 4 to 6 weeks

        • As long-term adverse effects are not a factor for patients who are at the end of their lives, there is not need to taper the dose if it remains effective
    • Psychostimulants may also be useful
      • Most experience has been gained with methylphenidate

        • Also, dextroamphetamine and pemoline have been used

        • Begin methylphenidate at 2.5–5 mg po q am and q noon and titrate to effect (usually 10–30 mg po q am and q noon, but sometimes higher)

        • Extended-release formulations permit once-daily dosing

        • Methylphenidate can be used safely even in the debilitated patient

        • Adverse effects, including tremulousness, anorexia, tachycardia, and insomnia should be monitored
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