Waking Up from Fatigue: the Hidden Burden of Fatigue

In palliative care, the focus is often on treating and managing pain, relieving other physical symptoms, and providing psychological support. Despite this holistic approach, one prominent yet unfortunately often overlooked symptom in both research and clinical practice is fatigue. For many patients, especially those with advanced disease, fatigue is a pervasive and debilitating symptom that interferes with daily functioning and overall quality of life. The implications of this phenomenon deserve closer consideration and underscore the need for increased discourse and dedicated research efforts on the topic of fatigue in palliative care. The recognition of fatigue as a significant symptom in palliative care is a phenomenon that came into the limelight about three to four decades ago. Historically, fatigue was often seen as a side-effect of illness and disease, rather than a problem in its own requiring specific treatment. In ancient medicine, fatigue was often interpreted as the result of an imbalance of bodily fluids (humoral pathology), while in the Victorian era, it was seen as a symptom of “nervous weakness” or “neurasthenia.” In the 20th century, however, medical professionals began to focus more on fatigue, especially in the context of chronic diseases such as cancer. It was the work of pioneers such as Cicely Saunders who brought the concept of “total pain,” of which fatigue is a part, to the fore, highlighting the importance of this symptom in the context of palliative care.1 Since then, the understanding and treatment of fatigue has made significant progress and intensive research continues to understand the mechanisms behind this often debilitating symptom and to develop effective treatment approaches.2 In particular, the Covid pandemic has led to a firing up of research activities also around symptom fatigue. Fatigue is a common consequence of COVID-19 and is often described as part of the “Long-COVID” or “Post-Acute Sequelae of SARS-CoV-2 infection” (PASC) syndrome. As with other disease states that cause fatigue, treatment is often multidisciplinary and may include physical therapy, psychological support, and drug therapy as appropriate. Despite advances in the study and treatment of fatigue in palliative care, we are still far from achieving a comprehensive understanding of this complex phenomenon. The variety of symptoms associated with fatigue, as well as its often, profound impact on patients’ quality of life, underscore the need to further investigate this area. In recent years, we have significantly expanded our knowledge of fatigue. Fatigue is understood to be multifactorial in nature. In the context of palliative care, fatigue can arise directly from the illness itself, or it may be a side effect of treatments such as chemotherapy or radiotherapy. Additionally, psychological factors, such as depression and anxiety, often contribute to feelings of fatigue.2,3 Similarly, the fatigue associated with Long-COVID is also multifactorial. It may be a result of the virus’s direct impact on the body, a remnant of the post-viral syndrome, or an ongoing inflammatory response.4,5 The way we assess fatigue has also improved. Selfreport scales like the Fatigue Severity Scale (FSS) and the Brief Fatigue Inventory (BFI) allow us to measure and monitor fatigue levels in a standardized way.6,7 These tools have proven invaluable in both palliative care and LongCOVID contexts. When it comes to management, non-pharmacological interventions form the foundation of our approach. A blend of physical therapy and psychological support can make a world of difference. Personalized exercise programs have shown promise in enhancing physical function and reducing fatigue levels, all without aggravating other symptoms. Similarly, cognitive-behavioral therapy can equip patients with the skills they need to manage and cope with their symptoms.2 On the pharmacological front, evidence is somewhat limited, especially in the palliative care context. However, some drugs like methylphenidate and modafinil are emerging as potential options. In Long-COVID, treatment largely focuses on managing symptoms, and as yet, no specific drug has been identified as effective against fatigue.3 Waking up from fatigue: The hidden burden of fatigue