Nursing Care at the End of Life

Fatigue is defined by the North American Nursing Diagnosis Association (1996) as “an overwhelming sustained sense of exhaustion with decreased capacity for physical or mental activity”. However, it is a very subjective condition with many causes and definitions making it difficult to measure. Fatigue affects nearly all patients with advanced disease, and interferes greatly with quality of life. It makes even the simple pleasures that are left to a patient at the end of life, such as reading or talking to friends, too much of an effort to undertake.

Causes of fatigue are as varied as the many definitions. Anemia, pain, cachexia, cancer or AIDS treatments, grief, depression, electrolyte imbalance, endocrine disorders, fear, dyspnea — alone or in combination — are just some of the risk factors for developing significant fatigue.

Treatment of fatigue, again, is tied to the cause. A holistic assessment that includes all areas of a patient’s life is necessary to understand and treat fatigue.

Pharmacological interventions
Treat the underlying cause of fatigue:

	Anemias: treat based on classification of anemia
	Correct underlying electrolyte or endocrine imbalances
	Opioid therapy induced fatigue and sedation: usually resolves within a few days of onset. Consider adding methylphenidate (Ritalin) to combat the sedation and fatigue that can occur when initiating opioid therapy.

Non-Pharmacological interventions

	Teach the patient to balance activity with rest periods.
	Suggest a personal care aide if needed for ADL’s.
	Encourage exercise, active or passive range of motion, occupational therapy as tolerated.
	Refer to other therapies such as counseling, spiritual counseling, life review, active listening, Therapeutic Touch, music or art therapy to address depression, anxiety or fear issues.
	Physical aids and equipment such as walkers, grab bars, a lift chairs, an over-bed trapeze, a hospital bed with side rails to assist with positioning, etc may be indicated as the disease progresses.