Skip to main content
Log in

Bispectral Index monitoring in cancer patients undergoing palliative sedation: a preliminary report

  • Original Article
  • Published:
Supportive Care in Cancer Aims and scope Submit manuscript



Continuous palliative sedation (PS) is currently titrated based on clinical observation; however, it is often unclear if patients are still aware of their suffering. The aim of this prospective study is to characterize the level of consciousness in patients undergoing PS using Bispectral Index (BIS) monitoring.

Patients and methods

We enrolled consecutive patients with refractory symptoms requiring PS. We documented the level of sedation using Ramsay Sedation Scale (RSS) and BIS at 0, 2, 4, 6, 12, and 24 h during the first day of PS and examined their degree of association. Intravenous midazolam or propofol was titrated according to the sedation level.


Twenty patients on PS were recruited and had BIS continuous monitoring. Delirium was the most frequent reason for PS (n = 15, 75%). The median time of sedation was 24.5 h (interquartile range 6–46). The average time to achieve the desired sedation level was 6 h, and dose titration was required in 80% of the cases. At baseline, 14 (70%) patients were considered to be awake according to RSS (i.e., 1–3) and 19 (95%) were awake according to BIS (i.e., >60%). This proportion decreased to 31 and 56% at 4 h, 27% and 53 at 6 h, and 22 and 33% at 24 h. RS and BIS had moderate correlation (rho = −0.58 to −0.65); however, a small proportion of patients were found to be awake by BIS (i.e., ≥60%) despite clinical observation (i.e., RSS 4–6) indicating otherwise.


The BIS is a noninvasive, bedside, real-time continuous monitoring method that may facilitate the objective assessment of level of consciousness and dose titration in patients undergoing PS.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Subscribe and save

Springer+ Basic
EUR 32.99 /Month
  • Get 10 units per month
  • Download Article/Chapter or Ebook
  • 1 Unit = 1 Article or 1 Chapter
  • Cancel anytime
Subscribe now

Buy Now

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Fig. 1
Fig. 2

Similar content being viewed by others


  1. Cherny N (2009) The use of sedation to relieve cancer patients’ suffering at the end of life: addressing critical issues. Ann Oncol 20(7):1153–1155. doi:10.1093/annonc/mdp302

    Article  CAS  PubMed  Google Scholar 

  2. Cherny N, Radbruch L (2009) European Association for Palliative Care (EAPC) recommended framework for the use of sedation in palliative care. Palliat Med 23:581–593. doi:10.1177/0269216309107024

    Article  PubMed  Google Scholar 

  3. Maltoni M, Scarpi E, Rosati M, Derni S, Fabbri L, Martini F et al (2012) Palliative sedation in end-of-life care and survival: a systematic review. J Clin Oncol 30:1378–1383. doi:10.1200/JCO.2011.37.3795 Journal of Clinical Oncology 30, no. 12 (April 2012) 1378-1383

    Article  PubMed  Google Scholar 

  4. Beller EM, van Driel ML, McGregor L, Truong S, Mitchell G (2015) Palliative pharmacological sedation for terminally ill adults. Cochrane Database Syst Rev (1)CD010206.doi: 10.1002/14651858.CD010206.pub2

  5. Gurschick L, Mayer K, Hanson LC (2015) Palliative sedation: an analysis of international guidelines and position statements. Am J Hosp Palliat Care 32:660–671. doi:10.1177/1049909114533002

    Article  PubMed  Google Scholar 

  6. Chamorro C, Martínez-Melgar JL, Barrientos R (2008) Sedación, analgesia y bloqueo neuromuscular en el paciente crítico. Recomendaciones del grupo de trabajo de analgesia y sedación de la SEMICYUC. Monitorización de la sedación. Monitoring of sedation. Med Int 32 Supl 1:45–52 Vol. 32

    Google Scholar 

  7. Jacobi J, Fraser GL, Coursin DB, Riker RR, Fontaine D, Wittbrodt ET, Chalfin DB et al (2002) Clinical practice guidelines for the sustained use of sedatives and analgesics in the critically ill adult. Crit Care Med 30:119–141

    Article  PubMed  Google Scholar 

  8. Ramsay MAE, Savege TM, Simpson BRJ, Goodwin R (1974) Controlled sedation with alphaxalone-alphadolone. Br Med J 2:656–659

    Article  CAS  PubMed Central  PubMed  Google Scholar 

  9. Rosow C, Manberg PJ (2001) Bispectral index monitoring. Anesthesiol Clin North Am 19:947–966

    Article  CAS  Google Scholar 

  10. Punjasawadwong Y, Phongchiewboon A, Bunchungmongkol N (2014) Bispectral index for improving anaesthetic delivery and postoperative recovery. Cochrane Database Syst Rev (6):CD003843. DOI: 10.1002/14651858.CD003843.pub3

  11. Müller JN, Kreuzer M, García PS, Schneider G, Hautmann H (2017) Monitoring depth of sedation: evaluating the agreement between the Bispectral Index, qCON and the entropy module’s state entropy during flexible bronchoscopy. Minerva Anestesiol. doi:10.23736/S0375-9393.17.11262-9

    Google Scholar 

  12. Sathananthan D, Young E, Nind G, George B, Ashby A, Drummond S et al (2017) Assessing the safety of physician-directed nurse-administered propofol sedation in low-risk patients undergoing endoscopy and colonoscopy. Endosc Int Open 5:E110–E115. doi:10.1055/s-0042-121667

    Article  PubMed Central  PubMed  Google Scholar 

  13. Dou L, Gao HM, Lu L, Chang WX (2014) Bispectral index in predicting the prognosis of patients with coma in intensive care unit. World J Emerg Med 5:53–56. doi:10.5847/wjem.j.1920-8642.2014.01.009

    Article  PubMed Central  PubMed  Google Scholar 

  14. Yaman F, Ozcan N, Ozcan A, Kaymak C, Basar H (2012) Assessment of correlation between bispectral index and four common sedation scales used in mechanically ventilated patients in ICU. Eur Rev Med Pharmacol Sci 16:660–666

    CAS  PubMed  Google Scholar 

  15. Faritous Z, Barzanji A, Azarfarin R, Ghadrdoost B, Ziyaeifard M, Aghdaei N, Alavi M (2016) Comparison of bispectral index monitoring with the critical-care pain observation tool in the pain assessment of intubated adult patients after cardiac surgery. Anesthesiology and Pain Medicine 6:e38334. doi:10.5812/aapm.38334

    PubMed Central  PubMed  Google Scholar 

  16. Gélinas C, Tousignant-Laflamme Y, Tanguay A, Bourgault P (2011) Exploring the validity of the bispectral index, the critical-care pain observation tool and vital signs for the detection of pain in sedated and mechanically ventilated critically ill adults: a pilot study. Intensive Crit Care Nurs 27:46–52. doi:10.1016/j.iccn.2010.11.002

    Article  PubMed  Google Scholar 

  17. Gélinas C, Johnston C (2007) Pain assessment in the critically III ventilated adult: validation of the critical-care pain observation tool and physiologic indicators. Clin J Pain 23:497–505. doi:10.1097/AJP.0b013e31806a23fb

    Article  PubMed  Google Scholar 

  18. de Wit M, Epstein SK (2003) Administration of sedatives and level of sedation: comparative evaluation via the Sedation-Agitation Scale and the Bispectral Index. Am J Crit Care 12:343–348 Consulted on line at:, Feb 16, 2016

    PubMed  Google Scholar 

  19. Barbato M (2001) Bispectral index monitoring in unconscious palliative care patients. J Palliat Care 17:102–108

    CAS  PubMed  Google Scholar 

  20. Barbato M, Barclay G, Potter J, Yeo W (2015) Sedation and analgesia in unconscious palliative care patients: can Bispectral Index monitoring adds to our understanding? J Palliat Care 31:57–59

    PubMed  Google Scholar 

  21. Masman AD, van Dijk M, van Rosmalen J, Blussé van Oud-Alblas HJ, Ista E, Baar FP, Tibboel D (2016) Bispectral index (BIS) monitoring in terminally ill patients: a validation study. J Pain Symptom Manag. doi:10.1016/j.jpainsymman.2016.01.011

    Google Scholar 

  22. Barbato M, Barclay G, Potter J, Yeo W, Chung J (2017) Correlation between observational scales of sedation and comfort and Bispectral Index scores (BIS). J Pain Symptom Manag. doi:10.1016/j.jpainsymman.2016.12.335

    Google Scholar 

  23. Mercadante S, De Conno F, Ripamonti C (1995) Propofol in terminal care. J Pain Symptom Manag 10:639–642

    Article  CAS  Google Scholar 

  24. Lundströms, Zachrisson U, Fürst CJ (2005) When nothing help: propofol as a sedative and antiemetic in palliative cancer care. J Pain Symptom Manag 30:570–577

    Article  Google Scholar 

  25. Porzio G, Aielli F, Verna L, Micolucci G, Aloisi P, Ficorella C (2010) Efficacy and safety of deep, continuous palliative sedation at home: a retrospective, single-institution study. Support Care Cancer 18:77–81. doi:10.1007/s00520-009-0632-4

    Article  PubMed  Google Scholar 

  26. van Dishoeck AM, van der Hooft T, Simoons ML, van der Ent M, Scholte op Reimer WJ (2009) Reliable assessment of sedation level in routine clinical practice by adding an instruction to the Ramsay Scale. Eur J Cardiovasc Nurs 8:125–128

    Article  PubMed  Google Scholar 

  27. Cleeland CS, Gonin R, Hatfield AK, Edmonson JH, Blum RH, Stewart JA et al (1994) Pain and its treatment in outpatients with metastatic cancer. N Engl J Med 330:592–596. doi:10.1056/NEJM199403033300902

    Article  CAS  PubMed  Google Scholar 

  28. Avidan MS, Zhang L, Burnside BA, Finkel KJ, Searleman AC, Selvidge JA et al (2008) Anesthesia awareness and the bispectral index. N Engl J Med 358(11):1097–1108

    Article  CAS  PubMed  Google Scholar 

  29. Kelley SD (2007) Monitoring consciousness. Using the Bispectral Index™ during anesthesia. 2nd ed. Aspect Medical Systems, Inc

  30. American Society of Anesthesiology Task Force on Intraoperative Awareness (2006) Practice advisory for intraoperative awareness and brain function monitoring: a report by the American Society of Anesthesiology Task Force on Intraoperative Awareness. Anesthesiology 104(4):847–864

    Article  Google Scholar 

  31. Jacobsohn E, Glick D, Burnside BA, Zhang L, Villafranca A, Karl L et al (2011) Prevention of intraoperative awareness in a high-risk surgical population Eric. N Engl J Med 365:591–600

    Article  PubMed  Google Scholar 

  32. Sigl JC, Chamoun NG (1994) An introduction to bispectral analyses for the electroencephalogram. J Clin Monit 10:392–404

    Article  CAS  PubMed  Google Scholar 

  33. Hui D, Dev R, Bruera E (2016) Neuroleptics in the management of delirium in patients with advanced cancer. Curr Opin Support Palliat Care 10:316–323

    Article  PubMed  Google Scholar 

  34. Dean MM, Cellarius V, Henry B, Oneschuk D, Librach L, Canadian Society Of Palliative Care Physicians Taskforce SL (2012) Framework for continuous palliative sedation therapy in Canada. J Palliat Med 15:870–879. doi:10.1089/jpm.2011.0498

    Article  PubMed  Google Scholar 

  35. McWilliams K, Keeley PW, Waterhouse ET (2010) Propofol for terminal sedation in palliative care: a systematic review. J Palliat Med 13:73–76. doi:10.1089/jpm.2009.0126

    Article  PubMed  Google Scholar 

  36. Kirk TW, Mahon MM (2010) Palliative Sedation Task Force of the National Hospice and Palliative Care Organization Ethics Committee. National Hospice and Palliative Care Organization (NHPCO) position statement and commentary on the use of palliative sedation in imminently dying terminally ill patients. J Pain Symptom Manag 39:914–923. doi:10.1016/j.jpainsymman.2010.01.009

    Article  Google Scholar 

  37. Deschepper R, Laureys S, Hachimi-Idrissi S, Poelaert J, Distelmans W, Bilsen JL (2013) Palliative sedation: why we should be more concerned about the risks that patients experience an uncomfortable death. Pain 154:1505e1508. doi:10.1016/j.pain.2013.04.038

    Article  Google Scholar 

  38. Sanders RD, Tononi G, Laureys S, Sleigh JW (2012) Unresponsiveness not equal unconsciousness. Anesthesiology 116:946e959

    Article  Google Scholar 

  39. De Jonghe B, Cook D, Appere-De-Vecchi C, Guyatt G, Meade M, Outin H (2000) Using and understanding sedation scoring systems: a systematic review. Intensive Care Med 26:275. doi:10.1007/s001340051150

    Article  CAS  PubMed  Google Scholar 

  40. Reschreiter H, Maiden M, Kapila A (2008) Sedation practice in the intensive care unit: a UK national survey. Crit Care 12:R1521–R1528. doi:10.1186/cc714

    Article  Google Scholar 

  41. Martin J, Parsch A, Franck M, Wernecke KD, Fischer M, Spies C (2005) Practice of sedation and analgesia in German intensive care units: results of a national survey. Crit Care 9:R117–R123 De

    Article  PubMed Central  PubMed  Google Scholar 

  42. Brinkkemper T, van Norel AM, Szadek KM, Loer SA, Zuurmond WWA, Perez RSGM (2013) The use of observational scales to monitor symptom control and depth of sedation in patients requiring palliative sedation: a systematic review. Palliat Med 27:54–67. doi:10.1177/0269216311425421

    Article  PubMed  Google Scholar 

  43. Olson D, Lynn M, Thoyre SM, Graffagnino C (2007) The limited reliability of the Ramsay Scale. Neurocrit Care 7:227. doi:10.1007/s12028-007-0069-x

    Article  PubMed  Google Scholar 

  44. Lennmarken C, Bildfors K, Enlund G, Samuelsson P, Sandin R (2002) Victims of awareness. Acta Anaesthesiol Scand 46:229–231

    Article  CAS  PubMed  Google Scholar 

  45. Tonner PH, Paris A, Scholz J (2006) Monitoring consciousness in intensive care medicine. Best Pract Res Clin Anaesthesiol 20:191–200. doi:10.1016/j.bpa.2005.08.011

    Article  PubMed  Google Scholar 

  46. Sandin R, Enlund G, Samuelsson P, Lennmarken C (2000) Awareness during anaesthesia: a prospective case study. Lancet 355:707–711

    Article  CAS  PubMed  Google Scholar 

  47. Moerman N, Bonke B, Oosting J (1993) Awareness and recall during general anesthesia. Facts and feelings Anesthesiology 79:454–464

    Article  CAS  PubMed  Google Scholar 

  48. Bruera E, Bush S, Willey J, Paraskevopoulos T, Li Z, Palmer J, Elsayem A (2009) The impact of delirium and recall on the level of distress in patients with advanced cancer and their family caregivers. Cancer 115:2004–2012. doi:10.1002/cncr.24215

    Article  PubMed Central  PubMed  Google Scholar 

  49. Gambrell M (2005) Using the BIS monitor in palliative care: a case study. J Neurosci Nurs 37:140–143

    Article  PubMed  Google Scholar 

  50. Myles PS, Leslie K, McNeil J, Forbes A, Chan MTV, for the B-Aware trial group Bispectral index monitoring to prevent awareness during anaesthesia (2004) The B-Aware randomised controlled trial. Lancet 363:1757–1763 Consulted on line at:, April 6, 2016

    Article  CAS  PubMed  Google Scholar 

  51. Coleman RM, Tousignant-Laflamme Y, Gélinas C, Choinière M, Atallah M, Parenteau-Goudreault E et al (2013) Changes in the bispectral index in response to experimental noxious stimuli in adults under general anesthesia. ISRN Pain 1:1–8

    Article  Google Scholar 

Download references


The authors would like to thank Dana Aline Perez-Camargo and Adriana Pena for the support in the statistical analysis of the data, Oscar Rodriguez-Mayoral for the discussion of the manuscript.

Author information

Authors and Affiliations



The authors declare that they have full control of all primary data and agree to allow the journal to review their data if requested.

Conception and design: Edith Monreal-Carrillo, Silvia Allende-Pérez, and Emma Verástegui

Data collection: Maria-Fernanda Garcia Salamanca

Analysis and interpretation of data: Edith Monreal-Carrillo, Emma Verástegui, David Hui, and Silvia Allende-Pérez

Manuscript writing: Emma Verástegui, Edith Monreal-Carrillo, David Hui, and Eduardo Bruera

Approval of final article: Emma Verástegui, David Hui, Edith Monreal-Carrillo, Silvia Allende-Pérez, Maria-Fernanda Garcia Salamanca, and Eduardo Bruera

All authors read and approved the final manuscript.

Corresponding author

Correspondence to Emma Verástegui.

Ethics declarations

Written consent was obtained from the legal representative before palliative sedation and BIS monitoring were initiated. This study was reviewed and approved by the Institutional Review Board of the INCan (Ref. CEI/1006).

Conflict of interest

The authors declare that they have no conflict of interest.


This work received no financial support.

Additional information

Edith Monreal-Carrillo and Silvia Allende-Pérez contributed to the work equally.

Rights and permissions

Reprints and permissions

About this article

Check for updates. Verify currency and authenticity via CrossMark

Cite this article

Monreal-Carrillo, E., Allende-Pérez, S., Hui, D. et al. Bispectral Index monitoring in cancer patients undergoing palliative sedation: a preliminary report. Support Care Cancer 25, 3143–3149 (2017).

Download citation

  • Received:

  • Accepted:

  • Published:

  • Issue Date:

  • DOI: