challenge for research, with modification of existing guidelines for end-of-life care and accountability to regulatory bodies to ensure compliance.

APS, NCCN, and AHRQ guidelines clearly delineate the principles of effective pain management, providing algorithms for the management of nociceptive and neuropathic pain of varying severity and chronicity (Rischer and Childress, 1996) (see Table 7-2). Identification of the cause and type of pain, use of repeated standardized assessment tools to assess pain severity and response to treatment, evaluation of the effect of pain interventions on mental alertness, and flexibility in revising treatment regimens are the mainstays of effective care. The use of around-the-clock fixed dosing with patient or caregiver “rescues” provides a means of avoiding withdrawal symptoms and preventing delays in dosing and resulting pain crises (Bottomly and Hanks, 1990). Clinician education about appropriate dosing and medication combinations facilitates better care as well as treatment of depression and anxiety. Use of psychotropic drugs as adjuncts to pain medications and behavioral interventions are effective.

Continuing misconceptions about dependence and addiction, the risks of oversedation, and regulatory problems of opiates have contributed to inadequate implementation of clinical guidelines. In addition, there is a need to educate doctors about the use of opiates and other medications whose use is restricted by Drug Enforcement Agency (DEA) guidelines, in order to resolve the problems of inadequate dosing and reluctance to prescribe. Identifying the barriers that have delayed implementation of effective pain management is a continuing research question.

Fatigue

Fatigue is a major end-of-life symptom described as tiredness, heaviness, weakness, lack of energy, poor stamina, sleepiness, and poor strength. In the Study to Understand Prognoses and Preferences for Outcomes and Risks of Treatment (SUPPORT), 80 percent of patients complained of fatigue in the final three days of life (Phillips et al., 2000). Whether a result of the primary disease process, metabolic abnormalities due to organ failure, treatment side effects, or malnutrition, fatigue limits functional capacity and quality of life. Treatment guidelines have been developed for the management of anemia-related fatigue, but none have addressed fatigue at the end of life. The fatigue related to depression also must be considered in seeking an etiology and choosing an intervention. Despite all efforts, fatigue is often an intractable symptom in the final days of life.

Clinical practice guidelines for this important symptom must build on recent studies documenting the high incidence of fatigue in chronic and terminal illness and its impact on quality of life. Research in the use of stimulants and other new alternatives may offer the potential for future



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