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To the Editor: In their Perspectives on Care at the Close of Life article, Drs Lo and Rubenfeld¹ rightly state that palliative sedation is an option of last resort for relieving intractable suffering and that all alternatives should be exhausted before proceeding. The authors note that opioid-induced neurotoxicity may manifest with myoclonus, delirium, and hyperalgesia. We assume that the patient in question was not delirious and had no history of chemical dependence or somatization because these are risk factors for increased pain expression and dose escalation.^2-3

The severe pain experienced by the patient (as her dose escalated from 40 mg/h of hydromorphone to 100 mg/h overnight) may have been due to opioid-induced hyperalgesia, which would warrant an opioid rotation as early as possible. According to the authors, treatment of the patient's severe myoclonus by opioid rotation was not considered because she had not responded to fentanyl or morphine in the . . . [Full Text of this Article]

Egidio Del Fabbro, MD
edelfabbro@mdanderson.org

Eduardo Bruera, MD
Department of Palliative Care & Rehabilitation Medicine
M.D. Anderson Cancer Center
University of Texas
Houston

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