Wednesday, January 24, 2007
JAMA has another Perspectives on Care at the Close of Life piece about fatigue in the dying. It's a nice review; comprehensive, accurate, based in a nice case, etc. I sort of had this weird feeling while reading it though like I was missing something, or that its structure was disjointed--something was wrong. That's when I realized the article kept on veering its discussion from fatigue to depression to pain to weight loss back to fatigue, etc. I then realized that the article, itself, embodied the slug-like epistemological goo surrounding fatigue in the dying/the advanced cancer patient. Is it a discreet disease (or syndrome) with risk factors, treatments, etc.? Or is it just a symptom of other diseases/syndromes (cancer, depression, COPD, etc.) whose treatment is the same as the underlying condition's? Or is it an inevitable, normal part of the human condition, as one's body begins the cascade of dysfunctions which will lead to death--a normal, expected part of dying? The article sort of acknowledges this, but then just jumps around from one version of fatigue to another without warning and it makes for some off-kilter reading.
There is a very welcome section at the end about 'managing expectations' about fatigue which has this quote from the doctor interviewed in the piece:
"I have a number of patients who suffer from fatigue who I think mostly just want...someone to listen to them tell them their story."
This is absolutely the most important sentence in this article. Insofar as our treatments for this thing called fatigue generally suck, and insofar as it is often a inexorable part of the transformation of a patient's life from healthy to sick to dying to dead (and is therefore unfixable), fatigue is frequently not something to be diagnosed and fixed. Instead it is an aspect of suffering, a stigmata of that transformation, and our (clinicians') role is to...well...everyone has their own words they like to use here and I always struggle with the right ones...bear witness to it, offer a presence, listen, and acknowlege the mystery and pain of dying.
There's also a coda for the recent Perspectives on palliative care for homeless patients. The patient is still alive, still homeless/transient, and still receiving palliative care.
And super-briefly--Archives of Internal Medicine has a prospective cohort study further validating the association with SSRI use and osteoporotic fractures in the elderly. Although the study wasn't really designed to look at this fully, the authors postulate that the mechanism of this is not necessarily increased falls (as with tricyclic antidepressants) but via bone density & health. The same issue has an article linking psychologic factors with cardiovascular disease: apparently " cynical distrust" will raise your levels of inflammatory markers. Does this mean all bloggers are destined to die young?