Wednesday, November 30, 2005

Betty Carmack quote

"If the love, compassion and caring weren't so strong, the resulting grief and sorrow wouldn't be so wrenching."

from her book, Grieving the Death of a Pet

Poma Chodron quote

"Compassionate action has to start with ourselves. It is unconditional compassion for ourselves that leads naturally to unconditional compassion for others. If we are willing to stand fully in our own shoes and never give up on ourselves, then we will be able to put ourselves in the shoes of others and never give up on them."

Sunday, November 20, 2005

Symptomatology: Fatigue

I have been slowly making my way through the symptoms experienced at the end-of-life. The next symptom I would like to address is fatigue and an increased need for sleep.

Fatigue is a common symptom for patients at the end-of-life. Of 1000 patients with advanced cancer, 69% reported easy fatigue; 66% reported weakness; and 61% reported lack of energy (Walsh et al, 2000). Although many patients experience fatigue, the intensity and pattern of the fatigue may vary.

Fatigue may be exacerbated by disease progression, sleep disturbances, pain, poor nutrition, depression, anemia, or result from the side effects of many medications. If an underlying cause can be identified, such as sleep disturbance, depression or anemia, and the patient finds the fatigue bothersome, that underlying cause may be treated.

Fatigue at the end-of-life can exacerbate feelings of regret, sadness, and a sense of loss; therefore fatigue should be treated appropriately.

Exercise at the End-of-Life

Exercise has been shown to improve fatigue, decrease anxiety and increase quality of life in patients who are healthy as well as among patients enrolled in hospice(Yoshioka 1994). This treatment option should be considered when medically appropriate.

While exercise may be used to treat fatigue, labor saving devices, such as a bedside commode, walker, raised toilet seat, and energy-saving appliances / grabbing tools, may also be used to enable patients to continue their activities of daily living, even during their periods of lowest energy.


Many patients at the end-of-life experience anorexia; they lose an interest in eating. This is a very normal symptom at end-of-life. However, some patients may be distressed by the fatigue that may result from their decreased caloric intake. These patients may benefit from nutritional supplements such as Ensure.

Pharmacological Interventions at End-of-Life


Since many patients at the end-of-life experience anorexia in conjunction with fatigue, Megace is often used. Megace not only improves appetite, but has also been shown to decrease fatigue, improve energy, and increase a sense of well-being.

Low-dose Corticosteroids

Even for otherwise healthy adults, corticosteroids are usually taken in the morning. This is because they frequently increase energy, making it difficult for patients to sleep. This side effect can be used to an advantage for patients at the end-of-life who are experiencing fatigue. Like Megace, corticosteroids also increase appetite and improve a patient’s sense of well-being. Although corticosteroids have not been studied on fatigue specifically, they have been shown to improve pain, weakness and depression in patients at the end-of-life. Some low-dose corticosteroids that have been used to treat fatigue in this population include Dexamethasone and Prednisone.

As people get closer to the end-of-life, fatigue should no longer be treated as a symptom. Increased sleep is a very normal part of the dying process, especially in the last weeks prior to death.

Most of the information presented in this post came from the National Comprehensive Cancer Network's guidelines on the treatment of cancer-related fatigue.

Friday, November 11, 2005

Film Review of an Oldie but Goodie

Steel Magnolias came out in 1989, so this post is certainly not meant to keep you abreast of what's up and happening in the world of celluloid nor will it send you off to the movie theater, but this film deserves special mention, especially as one of the scenes relates so poignantly to my personal experience with grief.

In the film, Shelby (played by Julia Roberts) dies at a young age due to complications related to diabetes. The scene at her funeral is incredibly powerful.

Shelby's mother stands alone at Shelby's grave. This camera shot alone started to trigger my grief over my grandmother's death in March, providing a visual to the overwhelming feeling of loneliness that buried deep in my chest at the time of her death.

One of Shelby's friends then tries to convince Shelby's mother that she should be happy for her daughter because her daughter is now in heaven. Shelby's mother snaps back something to the effect of, "I'm sorry I'm so selfish that I can't be happy for her!" This reaction mimics my feelings as well. My grandmother lived a very full and exciting life and was fortunate to live into her 90's. My family kept trying to point this fact out to me as if it should make my pain disappear. My grandmother herself had told me on more than one occasion that she didn't want me to cry when she died. And as a result, mourning over my grandmother's death, I felt very much like Shelby's mother - guilty and selfish for feeling sad.

And then finally, one of Shelby's mother's friends says something absolutely absurd in an effort to provide some humor relief to the very strained situation. And although I've watched this movie multiple times before, I laughed just as hard at this scene as I had the first time. However, this time the laughter only brought more tears.

You see, when my grandmother died, a very good friend of mine made me laugh, too. And that laughter meant the world to me. It - and he (the friend) - renewed my appreciation for life. Unfortunately, that friend and I have since become estranged. And that makes me sad now, too.

Watching this scene again, I cried for Shelby' mother; I cried for my grandmother; and I cried for lost friendships. I cried for me.

Well, this wasn't much in terms of a movie review, but if you have an interest in grief, check out this flick on DVD (even if you've already seen it before) and tell me what you think.

Sunday, November 06, 2005

Patrick Overton quote

When we walk to the edge of all the light we have and take the step into the darkness of the unknown, we must believe that one of two things will happen - there will be something solid for us to stand on, or we will be taught to fly.