Supportiveeducative interventions

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Patients can be distressed by the manifestation of fatigue during treatment. They may interpret this symptom as an ominous sign, if they perceive it as an indication that their disease has progressed or that their treatment is ineffective (Ream and Richardson 1997). These perceptions, at times inaccurate, can lead to feelings of despondency if patients are unprepared for fatigue and are unaware that it is a common side-effect of treatment. Furthermore, if they are unaware of measures they can take to manage fatigue, they are likely to feel distressed and frustrated when they experience it.

A number of pilot studies have been conducted recently to determine the feasibility and acceptability of a range of different supportive/educative programmes for patients with cancer to enable them to manage fatigue more effectively. Barsevick et al. (2002) developed and evaluated an energy conservation and activity management (ECAM) intervention. The ECAM intervention was conducted over the telephone. It comprised of 3 sessions which sought to provide information about fatigue, develop an energy conservation plan, and evaluate that plan's effectiveness. It was evaluated through the conduct of a single group pre-test/post-test study (n = 80). Data were compared with those attained from a non-equivalent control group (n = 182). The study determined that the programme was suitable for, and relevant to, the target population; the completion rate for the sessions being 100%. This conclusion was endorsed by participants' favourable comments, and assertions that they would continue the plan on their completion of the study. The outcome data were likewise promising; they suggested that the programme moderated the expected rise in fatigue associated with cancer therapy (radio and chemotherapy). However, these pilot data need to be augmented by a larger RCT before firm conclusions can be drawn.

Holley and Borger (2001) developed and evaluated an 8-week rehabilitative group intervention, known as Energy for Living with Cancer, in the south-eastern United States. This programme entailed weekly, structured 90-minute sessions which incorporated educational elements and facility to share experiences of fatigue with others. Whilst the group was facilitated by nurses, a physiotherapist, occupational therapist, and Tai Chi master contributed to the educational sessions. Outcome data have been collected from 20 individuals who have completed the programme to date. These pre-test/ post-test data indicated a significant decrease in fatigue (p = 0.00). In the absence of a control group it is difficult to conclude that this was due solely to this intervention, but the participants' comments regarding the programme have endorsed its utility. They alluded to the manner in which the intervention allowed them to focus on fatigue, gain needed information about the symptom and accept and adapt to it.

A further intervention programme for patients undergoing chemotherapy has been developed and evaluated in the United Kingdom (Ream et al. 2002; Ream 2002). Known as 'Beating Fatigue', this programme entailed provision of investigator-designed written information prior to treatment, and monthly in-depth assessment of the symptom and coaching in effective self-care for its relief. The intervention was conducted over a 3 month period, and evaluated through the conduct of an RCT (n = 103). Preliminary pilot data (n = 8) identified the benefits of the approach at the outset, not only in terms of reducing fatigue, but in the psychological benefits it afforded participants. These findings were corroborated in the main study where those in the intervention group reported significantly less fatigue over time (p < 0.05) and notably less distress from it (p < 0.01) than those in the control group. In addition, they reported that they were more able to engage in hobbies and pastimes (p < 0.05).

Two further initiatives have addressed the management of fatigue. One focused on managing fatigue alongside pain (Grant et al. 2000), and the other on managing fatigue along with troublesome symptoms more widely (Given et al. 2002). The former initiative, the 'I Feel Better Programme', was conducted in the community and entailed a double session educational group workshop taught by masters-prepared oncology nurses. Each session lasted 2.5 hours and provided participants with general information about each symptom, advice on methods for their assessment and management, and strategies for communicating effectively with health professionals. This programme was piloted at 4 sites in Southern California, USA, with 73 patients with a variety of diagnoses. Participants' responses to a simple evaluation tool about the effectiveness of the programme indicated that its objectives were met. Their evaluations were positive and supported the content and format of the trialled intervention. However, despite these favourable reports, attendance at the second session was low. Only 31 of the 73 that enrolled on the programme were present at the follow-up session. The reason for this attrition is unclear, as data were not collected from those that did not attend. However it is probable that this occurred where individuals were unable to attend through ill health or fatigue, or where they felt that the programme did not meet their needs or expectations. Conversely, individuals may not have attended if their health and energy levels had improved. In the absence of confirmatory data, one can only surmise. Clearly, further research needs to be conducted to evaluate this approach to managing fatigue and pain, and to determine factors which may hinder its success.

The second programme was developed to assist patients newly diagnosed with cancer to cope with symptoms, notably fatigue and pain, on commencement of chemotherapy. It was evaluated by Given et al. (2002) through the conduct of a randomized controlled trial. The intervention entailed nurses' utilization of intervention software loaded onto a laptop computer. During 10 contacts over a 20-week period, 6 in person and 4 by telephone, the nurse and patient identified problematic symptoms. On their identification, the software was used to select problem-specific, evidence-based interventions which patients could implement on their own behalf to help resolve their symptoms. This approach was evaluated in 4 chemotherapy outpatient departments in the United States (n = 113). Findings from this study were encouraging; on its completion, more patients in the experimental group reported neither fatigue nor pain (n = 10) than those in the control group (n = 3). However, logistic regression failed to identify the effect of the intervention over other factors. The researchers attributed this to lack of study power due to inadequate sample size. Given this, although preliminary findings are favourable, further research needs to be undertaken to enable the benefits of this approach to be clearly determined.

In conclusion, there is a growing body of research that has evaluated different non-pharmacological approaches to managing cancer-related fatigue. Initially, individual strategies were tested, including exercise and distraction. However, most recently clinicians and researchers have tended to adopt programmes incorporating a variety of complementary strategies for the relief of fatigue. Given the multi-causal and multidimensional nature of fatigue this would seem more apt. Certainly, the pilot findings reported in the studies above appear most favourable.

Providing patients with the time and the opportunity to discuss fatigue and the meaning that it holds for them could prove a key aspect of any fatigue intervention strategy. Patients' worries and fears are frequently channelled through discussion of fatigue (Krishnasamy 1997). Discussion can be especially important when a patient has recently been diagnosed as having cancer, and can become increasingly important as the patient's disease advances and more active strategies requiring either physical or mental effort become more difficult. Patients could be assisted with prioritizing their daily activities and hobbies, and with pacing their energies, to ensure that valued activities remain possible. Patients' self esteem, confidence, and overall psychological well-being can be enhanced when patients achieve realistic and valued goals, thereby boosting their morale.

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