Educational Interventions Help Ca Patients Cope With Fatigue

NEW YORK--Fatigue is too often a part of life for cancer patientsand can erode their quality of life. "We need to talk tocancer patients about their energy level and ability to cope,and educate them about how to deal with the treatment and thedisease itself," said Lois Almadrones, RN, MPA, OCN, clinicalresearch associate, Memorial Sloan-Kettering Cancer Center.

Ask patients to do their own fatigue assessment by keeping a logfor a few days or a week to determine when they feel the mostand least fatigued. This could lead to an educational intervention,Ms. Almadrones said at a symposium on fatigue presented by CancerCare, Inc.

Patients on a 3-week cycle of chemotherapy, for example, are likelyto feel most fatigued 7 to 11 days after administration, she said,while patients on radiation therapy will feel most tired towardthe end of therapy. "We need to tell them that that is whenthey need to schedule in more rest periods," she said.

A symptom assessment should also be done, in addition to bloodwork, she said. Questions to ask include: Are you having diarrhea?Do you have difficulty concentrating, reading, or watching TV?Do you have tingling and numbness in your hands and feet? Chestpains? Pains in the arms or shoulders? Rapid heart beat?

A special sleep assessment may also be necessary. Ask patientswhat wakes them up at night, Ms. Almadrones said, and suggestthat they not think about things that bother them right beforegoing to sleep. If pain is waking them up, a long-acting painmedication that could provide even an hour's more rest would beof benefit, she said. If nausea, vomiting, or diarrhea is awakeningthem, taking medication before retiring could help.

Since patients often continue to work, they need to think aboutwhen they are best able to concentrate. "Sometimes they say,I'm only good for 2 hours in the morning," Ms. Almadronessaid. "So all the things that take the most concentrationshould be done in the morning."

Patients should also be advised to eat healthy, high-caloric foodthat goes down easily and does not require a lot of chewing. Theyshould be discouraged from using alcohol, cigarettes, or caffeineto cope with their anxiety or stress, and counseled instead tolearn relaxation techniques or to join support groups.

The Many Causes of Fatigue

Ms. Almadrones painted a harrowing portrait of the factors thatcombine to produce weariness in the cancer patient. "Thefirst is the disease itself," she said. "The tumor burdenmay cause chemical and hormonal changes."

Having to work plays a major role in fatigue, Ms. Almadrones pointedout. "The patient may be the only breadwinner in the family.So not only are they dealing with the treatments, they are tryingto keep up with a full work schedule so that they can keep theirinsurance. A patient who is a homemaker may still be making dinnerevery night."

The fatigue can begin with the diagnostic procedure, which requiresanesthesia, causes tissue damage, and may cause blood loss. Thecancer surgery causes damage to both abnormal and normal tissues.

Pain killers can contribute to overall fatigue levels, as doesthe lack of enteral nourishment that goes with major abdominalsurgery. The patient undergoing laparotomy eats no food for 2or 3 days before the surgery, and does not start eating untilthe third, fourth or fifth postoperative day, Ms. Almadrones said.

To ease these emotional and physical burdens, excess emotionaldrains on the patient have to be removed, she said. "Thepatient has to know that other activities or responsibilitiesmay have to wait. Encourage sleep rituals at night that help thepatient wind down. Recommend a massage, a long weekend, a be-good-to-yourselfday before starting a new round of therapy."

Above all, listen to the way the patient describes the fatigue,"she said. "Then we can treat it appropriately."

'You Have to Cry Sometimes'

Fatigue and stress are common not only among cancer patients butalso among the health professionals who care for them. "Ioften feel I have known intimately more people who have died thanare living," said social worker Carolyn Messner, directorof education and training at Cancer Care, Inc.

"Our challenge is to learn how to re-energize ourselves sowe can continue to do this work," she said at the symposium.

Ms. Messner told of a student who compared working in cancer careto playing a harp. "To play with sensitivity, you have tohave some calluses on your fingers," she said. "Butif the calluses are too thick, your playing will suffer. So youhave to have just the right type of calluses.

"As a practitioner, you have to have just the right copingstrategies. You don't want to cry all the time, but you have tocry sometimes."