Background Many people are living for longer with advanced cancer because of improvements in cancer treatments. Fatigue is the most prevalent and burdensome symptom in this cohort of patients. Thus, many could benefit from any improvements in the management of fatigue. This research explored how fatigue was talked about in advanced cancer care, how oncologists approached it and how patients dealt with it.

Methods A mixed methods design combining video-recordings, questionnaires and interviews was used. The study was divided into three parts: Part A, video-recorded observations of palliative oncology visits; Part B, interviews with patients with fatigue; and Part C, interviews with oncologists. Data from observations were analysed using content analysis and conversation analysis. Data from semistructured interviews were analysed using thematic analysis.

Results In Part A, 60 visits were recorded, and 37 patient participants reported fatigue. Talk connected with fatigue occurred in 82% of consultations and was often sequentially linked with discussions around goals of care and end of life issues. Resistance to treatment recommendations for fatigue was recurrently observed. In Part B, 22 patients were interviewed. The overarching theme ‘interconnectedness’ demonstrated how participants coped with fatigue through an array of interrelated strategies and influences. In Part C, nine oncologists were interviewed. The overarching theme ‘fatigue is perceived as different’ described how fatigue was challenging to assess and challenged the role of the oncologist.

Conclusions The findings showed how fatigue is a complex phenomenon and how it can be integral to the decision-making surrounding palliative cancer treatments. For patients, fatigue is seen as an acceptable trade-off for the prolongation of life, and this was acutely observed when resistance to proposals to adjust cancer treatments occurred. Cancer clinicians may need to consistently reassure patients that alterations to palliative cancer treatments to lessen the burden of fatigue would not reduce survival.