The following Mexican palliateurs have been interviewed in accordance with the IOELC’s Hospice History Programme protocol:

Gustavo Montejo Rosas: interviewed by Silvia Paz on February 24 th 2004.
Interview length: 27 minutes 28 seconds.

Dr Montejo Rosas starts this interview by describing how he became involved in palliative care after working as an anaesthesiologist. In 1989, he got in contact with Dr. Eduardo Bruera, who was then in Canada. They developed together a palliative care project that was presented to the public hospitals’ authorities in the city of Guadalajara. This project was accepted and implemented in 1992. Dr Montejo Rosas goes on to describe barriers to and achievements in the implementation of this comprehensive palliative care initiative, which constitutes one of the earliest to be established in public hospitals in Mexico.

Dr Montejo Rosas describes which opioids were used before 1996 when morphine was made available and gives insights into the availability and use of opioids in Mexico, and into popular and professionals’ perceptions of the use of morphine for severe pain control and in end of life care. He also describes the organization and function of his palliative care team and outlines major achievements, as well as barriers to its development. He describes professional and popular attitudes to dying and death in the community.

Dr Montejo Rosas considers that the insufficient allocation of health resources to end of life care, the futility in medical treatments and the conspiracy of silence between physicians and families holding diagnostic or prognostic information away from patients are the main ethical dilemmas for palliative care in Mexico. He also outlines the role of religion and the family and the use of alternative medicines at the end of life.

Dr Montejo Rosas concludes by remarking on the need for a governmental assessment of the quality of palliative care initiatives that have developed in Mexico, and for standards for future development. Although he is optimistic about the future of palliative care in the country and in Latin America, he thinks that it will take a long time before Mexican palliative care reaches international standards.

Beatriz Montes de Oca: interviewed by Silvia Paz on February 24 th 2004.
Interview length: 48 minutes 12 seconds.

In this interview, Beatriz Montes de Oca talks about her motivations for becoming a nurse, despite having grown up in a family of physicians. She describes her early nursing jobs and her initial involvement in palliative care. During the 1990s, Beatriz Montes de Oca was invited to work with a congregation of Jesuits whose members provided nursing care for old people. She also travelled to the USA to visit a relative who had metastatic breast cancer and who was looked after at an American hospice. From this experience in the USA and from doing her job with the Jesuits, she realized she was providing some sort of palliative care in Mexico. Yet back home, she found that very few people were doing palliative care in Mexico. The first congress of the Latin American Palliative Care Association, however, was about to take place in 2000 in Guadalajara. This represented an opportunity for Beatriz Montes de Oca to meet and make contacts with other palliateurs and to get to know about the provision of palliative care in Mexico. She describes challenges and achievements in establishing ‘Hospice Cristina’, which is one of the earliest private initiatives in palliative care in the country.

Ms Montes de Oca goes on to describe issues around the provision and availability of opioids in Mexico, particularly in Guadalajara and talks about the situation of palliative care within the health out care organization in Mexico. She mentions some legislative initiatives developed in Jalisco aiming at regulating end of life care and at guaranteeing palliative care provision for dying patients. She gives an insight into the medical community and Mexican society’s attitudes towards dying and death, and end of life care; she describes families’ attitudes and behaviours in caring for their dying love ones and the role of the hospice care team in facilitating patients’ care in the community. Beatriz describes how the team operates, the professional background of its members, and the educative opportunities in end of life care that it provides.

Ms Montes de Oca describes controversial issues that emerge when considering patients’ sedation, severe pain control, and the discontinuation of active medical treatments. She speaks about professional and popular attitudes towards the use of morphine and the provision of palliative care to terminally ill patients.

Beatriz concludes by outlining her positive thoughts for the future of palliative care in the country. In her view, palliative care will further develop supported by new legislations and a more open dialogue on palliative care issues amongst professionals and within society.

Argelia Lara: interviewed by Silvia Paz on February 24 th 2004.
Interview length: 35 minutes 40 seconds.

Dr. Lara starts this interview by describing what motivated her to study medicine and to become an anaesthesiologist first and a pain specialist later. It was in doing her job as a pain specialist that Dr Lara had to look after advanced cancer patients in pain. She realized that although her team could alleviate the pain, many other medical complaints that patients suffered from could not be properly controlled. She noticed that very little was known about controlling other symptoms apart from pain. Looking for opportunities to get training on a more comprehensive model of care for this group of patients, Dr Lara got in contact with the Palliative Care Unit at the ‘Gregorio Marañón’ hospital in Madrid in 1997. There she spent more than a year as a visitor initially and as a research fellow later, gaining knowledge in palliative care.

Dr. Lara mentions that before palliative care was introduced as a medical discipline, most techniques for cancer pain control relied on invasive methods, such as blocks, probably due to the lack of strong analgesics which would allow alternative therapies to be used. Morphine, for instance, was introduced into the Mexican market for medical use in 1997. Morphine is currently available in oral tablets and parenteral formulations, but no oral liquid solutions exist. Dr. Lara suggests that although alternative formulations of opioids are scarce, their availability has improved over recent years.

Dr Lara goes on to describe health professionals, patients and carers’ perceptions of the use of morphine and her experience as a palliative care practitioner on introducing the idea of using strong analgesics for severe pain relief in terminally ill patients to colleagues, patients and families. She also mentions efforts made by the Mexican Association for the Study of Pain to make morphine available and describes the mechanisms needed to follow when prescribing opioids in Mexico.

Dr Lara describes the palliative care programme that exists at the ‘Instituto Nacional de la Nutrición’ as part of the hospital pain clinic since 1993. She gives some details on the the government approach to the development of this palliative care initiative; and how this discipline has emerged in Mexico, mainly linked to pain clinics. She also speaks about palliative care education in the country.

Dr Lara describes those main ethical dilemmas in caring for terminally ill patients: for instance, the with-holding of diagnostic and prognostic information from patients. She estimates that, in her experience, the ‘conspiracy of silence’ is a serious problem when having to approach patients’ care in more than ninety-five per cent of cases. Another significant dilemma appears when considering sedation as a medical resource because it tends to be related to the practice of euthanasia at the end of life. By describing the dilemma of medical futility, she gives insights into social and medical attitudes towards end of life care, dying and death in Mexico. Regarding palliative care and euthanasia as possible options at the end of life, Dr Lara mentions that her team seeks to differentiate its practice in palliative care from euthanasia as there are many confusing ideas in peoples’ minds about palliative care and euthanasia practices. She describes that in her experience most patients requesting euthanasia are, in fact, in need of help to relieve their suffering. She feels that the job of her team is to bring to these patients the kind of support they need.

Dr Lara briefly describes the role of religion, the family and the use of alternative medicines at the end of Mexican patients’ lives. Finally, she is optimistic on the future of palliative care in Mexico as more health professionals, as well as patients are interested in the discipline. She remarks on the urgent need for more governmental support, less bureaucracy in the prescription of opioids, and for formal palliative care education to be made available in the country.

Gloria Dominguez Castillejos: interviewed by Silvia Paz on April 23 rd 2004.
Interview length: 69 minutes 53 seconds.

Dr Dominguez Castillejos starts this interview describing how she decided to study medicine, to become a pain specialist and then a palliative care physician. There were many medical doctors in her family and this might have strongly influenced her decision to study medicine. Pain control has always interested her very much. She decided to become an anaesthesiologist and later a pain specialist. As part of her training in pain control in Guadalajara, she got to know about palliative care and became interested in the subject. She decided to move to Mexico DF to gain some palliative care experience working alongside Dr Mayer and Dr Allende and undertook a fellowship in Spain, spending a year under the supervision of Dr Antonio Pascual at the San Pau Hospital in Barcelona. Back home, Dr Dominguez Castillejos pioneered a project to introduce pain control and palliative care in the curriculum of medical students at the Universidad Autónoma de Guadalajara.

In 1999, Dr Dominguez Castillejos invited several health professionals from different medical disciplines to form a team to look after terminally ill patients of poor backgrounds, supported by the Universidad Autónoma de Guadalajara. In 2002, a consolidated multidisciplinary pain and palliative care team emerged to operate at the University Centre for the Study and Treatment of Pain at the Universidad Autónoma de Guadalajara in Jalisco. Dr Dominguez Castillejos describes challenges the team faces in looking after seriously ill patients from very poor areas with very little financial resources, with little governmental support and with limited philosophical and structural support from the University. One of the main concerns is guaranteeing the availability of medicines and analgesics free of charge to patients. She mentions that, in order to obtain donations and financial aid from the private sector and pharmaceutical companies, they created a non-profit, civil association named Grupo Transición (Transition Group).

Dr Dominguez Castillejos goes on to describe the educational programme for undergraduates they offer at the University; other medical colleagues’ perception of the palliative care initiative; the palliative care provision at the centre that offers outpatient, inpatient and home care, and other palliative care groups existing in the region and in the country.

Dr Dominguez Castillejos also speaks about health professionals’, patients’ and families’ attitudes towards end of life care, dying and death; myths and controversies in the use of strong opioids, and opioid availability and prescription. She mentions several ethical dilemmas in palliative care, such as the misconception of seeing palliative care as an equivalent to the practice of euthanasia amongst health professionals and families; misunderstandings on the scope of sedating terminally ill patients dying in distress which has been an issue extensively debated amongst palliative care physicians and bioethicists and which is discussed amongst ‘palliateurs’ and patients’ families; the futility of active treatments prescribed to terminally ill patients; and the ‘conspiracy of silence’ which leads to the withholding of diagnostic and prognostic information from patients.

Dr Dominguez Castillejos describes her experience in researching the situation and management of pain and terminal illnesses amongst indigenous tribes in Mexico. Out of this experience, she promoted a project named Mexico sin dolor ( Mexico without pain) that aims to teach the principles of pain management and palliative care in rural areas and to support rural physicians on these issues. Finally, she concludes with a positive view on the future of palliative care in Mexico and in Latin America. She feels that international support from the more developed and experienced countries would be of much benefit for Latin America in terms of palliative care training and education, and thanks the many people who contribute to developing her palliative care programme.

Francisco Mayer: interviewed by Silvia Paz on June 1st 2004.
Interview length: 54 minutes 30 seconds

Dr Francisco Mayer starts this interview by describing how he was granted his medical qualifications at the Universidad Nacional Autónoma de Mexico (National Autonomous University of Mexico). He was very much attracted by the humanitarian aspects of the medical profession. In the 1980s, he was looking for jobs as an internist or general physician, but these positions were scarce as a result of Mexican economic inflation at the time; only specialist carers were available. He decided to get into anaesthesiology and was offered a position in neuro-anaesthesia, a job he accepted and did for two years. He was interested in doing pain management as this represented a way of being closer to patients. Dr. Mayer completed a postgraduate training course on pain management at the Instituto Nacional de la Nutrición (National Institute of Nutrition), and got a job at the Insitituto Nacional de Neurologia (National Institute of Neurology) where he later helped organize its pain clinic. He left the Institute to work in the private sector. During the 1990s, he was offered a position at the pain and palliative care clinic at the Instituto Nacional de Cancerologia (National Cancer Insititute) where he currently works as a pain and palliative care specialist. He has also undertaken other post-graduate courses on palliative care, hospital administration and health policies, such as a one year distance course Avances en Cuidados Paliativos (Advances in Palliative Care) offered by the Gabinete de Asesoramiento y Formación Sociosanitaria de las Palmas de Gran Canaria, Spain in association with the Universidad Nacional Autónoma de Guadalajara, México (Autonomous National University of Guadalajara, Mexico), and a Master Degree in Health Sciences focused on Health Systems at the Escuela de Salud Pública de México ( Public Health School of México) at the Instituto Nacional de Salud Pública (at the National Institute of Public Health)

He has actively promoted palliative care and the need for better and more flexible availability of opioids amongst national health authorities and has been involved in euthanasia and end of life care debates at the parliamentary level in the Mexico.

Dr Mayer goes on to describe the situation of palliative care within the national health care system in terms of service provision and reimbursement for service; opioid availability; and health professionals’, patients’ and families’ attitudes and behaviours towards the use of morphine and other strong opioids. He also mentions other palliative care teams working in the country and speaks about the main opportunities for developing palliative care in Mexico, such as the need among the public to know how to manage caner pain and deal with terminally ill patients; support from the WHO; more recent policies that have improved the availability of opioids; support from the IAHPC; the encouragement and support of Dr. Eduardo Bruera and Ms Liliana de Lima; and the interest of ‘palliateurs’ in looking for and attending training and education opportunities abroad to bring back home new experiences. He tells about the situation of palliative care education in Mexico and illustrates the way of working of palliative care teams in Mexico by describing how the hospital palliative care team at the National Cancer Institute operates.

Dr Mayer mentions several ethical dilemmas in palliative care, such as lack of ability in many health professionals for recognizing the terminal phase of a disease; the futility of active treatments for dying patients; health professionals’ paternalism that may violate patients’ autonomy; the poor debate on the ethical and legal aspects of terminal sedation and euthanasia; the support of some sectors in the government of initiatives in favour of euthanasia without knowing the existence of palliative medicine, and the ‘conspiracy of silence’ amongst physicians and families. He also speaks about the importance of religious beliefs in shaping the meaning for pain and suffering of dying patients, and about the use of folk medicines by terminally ill patients.

Finally, Dr Mayer concludes with a positive view on the future development of palliative care in Mexico, which is very much favoured by newly emerging political initiatives and by a growing interest amongst health professionals. He briefly describes the emergence of a new discipline linked to palliative care practitioners in Mexico named tanatología (thanatology). Its practitioners are formally trained to specifically discuss dying and death matters with patients and families and have become “fashionable” in Mexico.