Mrs D is an 82-year-old retired nurse with a history of interstitial lung disease, hypertension, coronary disease, osteoporosis, gastroesophageal reflux disease, and anemia, with a recent hospitalization for pneumonia. Her surgical history includes a colectomy secondary to a perforated diverticulum and gastrointestinal bleeding.
Mrs D's most pervasive symptom over the past 3 years has been fatigue—often profound, debilitating fatigue that is functionally and cognitively limiting. Mrs D describes what she experiences as "fatigue," "exhaustion," and "sleepiness." Mrs D lives alone; she is very close to her daughter, who attends most clinic visits and helps her at home. She has a living will, she has asked to not undergo attempted resuscitation, and her daughter is her durable power of attorney for health care. Mrs D's goals of care generally focus on comfort. She will not pursue diagnostic testing unless it will help to identify therapy that improves her quality of life. Her primary care physician, Dr K, who is also a palliative care specialist, suspects that her fatigue stems from a combination of factors. These factors include her underlying diseases: interstitial lung disease; anemia resulting from chronic low-grade blood loss, likely at her prior surgical site (vs an undiagnosed gastrointestinal cancer); depression, increasing social isolation, and a growing sense of apathy; medications, including opioids and antihistamines; deconditioning (increasing weakness resulting from decreased daily activity); and other symptoms, including intermittent pain (related to vertebral and rib fractures due to osteoporosis and intermittent angina), progressive dyspnea, chronic diarrhea, and dizziness. When symptoms worsen, her fatigue seems to worsen. She also has anorexia and weight loss (from 101 to 84 lb in 2 years), which distresses her greatly. Dr K thinks the weight loss might be related to the short bowel syndrome but also harbors some suspicion of an underlying gastrointestinal malignancy.
Pulmonary function tests reveal that Mrs D has severe restrictive lung disease, with a forced vital capacity of 34% of predicted. A previous pulmonary evaluation excluded reversible or modifiable causes. Since having a recent episode of pneumonia, Mrs D has been more dependent on oxygen both for dyspnea and for daily activities. Using the oxygen makes her feel anxious and self-conscious. She also has chronic dizziness resistant to vestibular training (prior evaluation suggested Ménière disease) and vitamin B12 deficiency. Her current daily medications are lisinopril, alendronate, isosorbide, omeprazole, and acetylsalicylic acid; as needed medications are albuterol inhalations, oxycodone or acetaminophen, diphenoxylate, megestrol acetate, nitroglycerin, and meclizine.
A number of symptomatic interventions have been attempted, including exercise or physical therapy, increased socialization, methylphenidate, megestrol acetate, blood transfusions, vitamin B12 replacement, a course of sertraline (25 mg titrated upward to 100 mg) for 1 year and fluoxetine (10 mg titrated to 40 mg) for 8 months for depression, as well as other therapies to control concurrent symptoms (eg, opioids for pain). Each has yielded only partial and short-lasting relief.