Objective To explore the effect of demands-directed, multidisciplinary team based transitional care on quality of life and fatigue level of lung cancer patients receiving post-operative chemotherapy. Methods A nursing service demand scale for discharged patients was compiled, and the service contents were evaluated with the Delphi method.A total of 76 patients who met the inclusion standards were randomly and evenly divided into 2 groups.The control group received routine post-discharge nursing care, while the intervention group received interventions based on the their service demands.After 3 and 6 months, patients′ quality of life and fatigue levels were measured using the Functional Assessment of Cancer Therapy-Lung (FACT-L) and Cancer Fatigue Scale. Results After 3 months′ intervention, the lung cancer specificity score and the total score of quality of life in the intervention group were significantly higher than those in the control group （P＜0.01 for both）.After 6 months′ intervention, the social/family well-being scores,emotional well-being scores and the total score of quality of life in the intervention group were significantly higher than the controls （P＜0.01）, while scores of emotional fatigue, cognitive fatigue and the total score of cancerfatigue in the intervention group were lower than those in the control group （P＜0.01）. Conclusion Based on the survey into service demands of lung cancer patients receiving post-operative chemotherapy, continuous nursing intervention could improve patients′ quality of life and lessen cancer-related fatigue level.