Why neurophysiological monitoring should be included to assess patient comfort during continuous sedation until death

Background: Terminally ill patients may experience refractory symptoms. Continuous sedation until death (CSD) can relieve the intractable suffering. In CSD, behavioral observational scales alone are predominantly used to assess comfort and titrate sedation and analgesia accordingly. Unlike observational scales, neurophysiological monitoring is a nonmotor response–based assessment of consciousness, discomfort, and pain. Aim of the review: The primary aim of this narrative review is to discuss neurophysiological monitoring in relation to behavioral observational scales in CSD. Results: Motor response–based observational scales in CSD are highly unreliable, with a risk of over- and under-medication. Neurophysiological monitoring may contribute to an increased accuracy in assessing consciousness, pain, and comfort. Additional information can lead to more informed decision-making and facilitate patient-tailored treatment approaches. In CSD, processed electroencephalography and analgesic nociception index monitoring may have practical limitations and habitual and cultural reservations. Conclusion: Neurophysiological monitoring during CSD is methodologically superior to the current practice using solely observational sedation or pain scales primarily based on motor responsiveness. An additional neurophysiological monitoring approach to assess consciousness, awareness, comfort, and pain can improve CSD quality. Practical or technological hesitation and reluctance toward clinical acceptability of implementing neuromonitoring should be overcome.