'I Just Have No Motivation Whatsoever!'

The NCCN Guidelines Version 1.2012 defines cancer-related fatigue as "a distressing persistent, subjective sense of physical, emotional, and/or cognitive tiredness or exhaustion related to cancer or cancer treatment that is not proportional to recent activity and interferes with usual functioning" (p. FT-1).

In working with lung cancer patients, one of the most troublesome symptoms related to the cancer and/or treatment is fatigue. Each symptom a patient experiences poses its own obstacle to coping, but fatigue is one of the most irksome. Time after time, patients tell me:

• "I am not motivated to do anything."
• "I just want to sleep all of the time."
• "This is just not me. I'm usually a very active person."
• "My husband [or wife or children] must do everything, because I just don't have the energy to do it."

The list of comments could go on, but you get the point.

I am sure you have heard many of these same comments from your own patients. So what can be done about fatigue? What has been your experience, and what interventions/education have you used with patients that have been helpful?

For one of our studies several years ago, we created pocket-sized cards on different symptoms that the clinicians could use as teaching tools with the patients and then give to the patients as a take-home resource. One of the symptom cards was on fatigue.

What we provided was based on the NCCN guidelines and can be found at the City of Hope Pain & Palliative Care Resource Center. Scroll down to Educational Materials/Curriculum, and look for No. 27: Passport to Comfort: Reducing Barriers to Pain & Fatigue Management. All the pocket cards are there, and many have been translated into Spanish.

Here are some basic definitions and questions to ask your patients regarding fatigue.

What is fatigue?

• An overwhelming sense of exhaustion physically, mentally, emotionally
• Can occur with cancer or cancer treatment
• Can persist over time and interfere with usual activities
• Differs from the tiredness of everyday life, which is usually temporary and relieved by rest
• More distressing and not always relieved by rest
• Can vary in its unpleasantness and severity
• Can make being with friends/family difficult
• Can make it difficult to follow your treatment plan

Common causes of cancer-related fatigue

• Anemia (low red blood cell count)
• Pain
• Emotional distress
• Sleep problems
• Poor nutrition
• Lack of exercise
• Other illnesses such as infection, hypertension, diabetes

Common words used to describe cancer-related fatigue

• Feeling tired, weak, exhausted, weary, worn out
• Having no energy, not being able to concentrate
• Feelings of heaviness in arms and legs, feeling little to no motivation, sadness and/or irritability, and unable to sleep or sleeping too much

What to tell your doctor

• When did the fatigue start?
• Has it progressed over the course of your treatment?
• What makes your fatigue better
• What makes your fatigue worse?
• How has the fatigue affected your daily activities?

Energy conservation principles

• Prioritize your activities in order of importance
• Ask for help and delegate tasks when you can
• Place items you use often within easy reach
• Establish a structured routine
• Balance rest and activities, performing activities during times of higher energy
• Establish a regular bedtime
• Whenever possible, sit instead of standing when performing tasks

Principles of exercise

• Your heart, lungs, and muscles require a daily workout. When you are less active, especially while in bed, your heart, lungs, and muscles have very little work to do. Over time, your heart pumps less forcefully, your lungs expand less fully, and your muscles will become weak and tight. This causes a drop in your energy level, which affects your ability to carry out your daily routine.
• Check with your doctor before exercising
• Do exercises slowly and completely
• If too tired to finish exercises, do what you can
• Always work at your own pace, do not rush
• Work within your own target heart rate (see your doctor for details)
• Remember to breathe while you exercise
• Walk

Rate your fatigue on a scale of 0 (no fatigue) to 10 (severe fatigue).