Abstract
Dear Editor:
Various guidelines on palliative sedation (PS) have been published across the globe.1,2 PS is a last resort measure used at the end of life to relieve severe and refractory symptoms. 2 A doctor who initiates PS should perform monitoring to preserve the physiological stability of terminally ill patients who are not imminently dying. This can involve conducting ongoing assessments of sedation levels and monitoring routine cardiovascular and pulmonary parameters. 2 The interdisciplinary health team should recognize the potential for staff distress. All participating healthcare personnel need to understand the rationale for sedation and goals of care.
The Mexican legal system not only allows a patient to refuse care but also conceives of this right as a means of preserving human dignity. A patient's right to decide to discontinue curative treatment will be outlined in a document based on characteristics predetermined under official regulations and patient's wishes, which can be issued and revoked at any time. The first political constitution of Mexico City was approved on January 31, 2017 and will take effect on September 17, 2018. Article 11 subsection “A” refers to a dignified life that implicitly involves the right to a dignified death. 3 This represents a considerable advance in Mexican legislation and in policy making in Latin America.
Bispectral index (BIS) monitoring can be of added value in clinical settings in which PS is considered. Recently, Monreal-Carrillo et al. 4 have described preliminary experiences related to the use of BIS in patients undergoing continuous PS in a comprehensive cancer center located in Mexico City. PS was initiated with initial propofol doses of 0.16 mg/(kg·h) and midazolam 0.08 mg/kg, which were adjusted according to each patient's response. The researchers increased these dosages when the Ramsay Sedation Scale remained at 1–3 or when BIS levels were measured at >60. BIS monitoring was continuously performed from the initiation of PS until death, but it was applied for the first 24 hours. For 75% of the cases (n = 15), PS was used to treat delirium. The continuous infusion rate used ranged from 0.16 to 1.3 mg/(kg·h) for propofol and from 0.08 to 0.5 mg/(kg·h) for midazolam. The median period of sedation used was 24.5 hours and the median survival rate was 19 hours. None of the patients required orotracheal intubation. In their article, the authors 4 suggest that BIS serves as a noninvasive continuous monitoring method used in real time that can be used to provide objective graphic measurements of the levels of consciousness among patients receiving PS.
For Latin America, there are limited data on the PS and end-of-life care of terminal cancer patients, and so data reported by Monreal-Carrillo et al. 4 are of use to physicians who treat patients (both hospital and domiciliary practice) with refractory symptoms daily (pain, dyspnea, anxiety, and delirium). If we have the right to live with dignity, we also have the right to die with dignity.