Ultrasonographic Evaluation of Systemic Venous Congestion in Maintenance Hemodialysis Patients During Fluid Removal.

INTRODUCTION: Fluid overload is a frequent and serious complication in hemodialysis patients. The combination of multiple point of care ultrasound (POCUS) measurements can identify significant venous congestion but its usefulness to determine ultrafiltration (UF) requirements and dry weight is unknown. Therefore, we evaluated prospectively patients in maintenance hemodialysis to establish the correlations between changes in venous congestion parameters and fluid removal. METHODS: This was a prospective, single-center, observational study. POCUS venous congestion measurments were performed in 22 patients during 32 online post-dilutional hemodiafiltration sessions and findings were correlated with UF volume, central venous pressure and body water composition determined by multifrequency bioelectric impedance analysis (BIA). RESULTS: The pre dialysis weight was on average 1.9 kg above the BIA estimated dry weight, the average initial IVC diameter was <2 cm. An initial abnormal Hepatic Vein (HV) waveform was present in 26% (8) of the measurements. The average UF volume was 2084 ± 655 ml and correlated with changes in inferior vena cava (IVC) diameter (R= 0.34, CI 95% (0.18, 0.56) p < 0.05) but not with any other POCUS venous congestion parameters. Normalization of the IVC diameter and HV waveform was observed during the first UF hour in all initially altered measurements. Diameter reduction in the IVC correlated with total body water volume reduction estimated with BIA when measured immediately after fluid removal (R= 0.34, CI 95% (0.08, 0.56) p<0.05) Conclusion. Reduction in IVC diameter had a modest but significant correlation with UF volume in our patients on maintenance hemodiafiltration. POCUS may be used to monitor patients during UF.

Identification of right coronary artery ectasia with echocardiography and confirmation with multimodal imaging.

We present the case of a patient with myocardial infarction due to coronary ectasia. A transthoracic echocardiogram showed a unique image of a cystic-like mass in the right atrium corresponding to the ectatic right coronary artery (arrows), which was confirmed with computed tomography.

[Non-therapeutic hysterectomy in Mexican young females with intellectual disability: a problematized reality]. / Histerectomía no terapéutica en jóvenes mexicanas con discapacidad intelectual: una realidad problematizada.

Background: Non-therapeutic hysterectomy in girls and adolescents with intellectual disability (ID) is an acceptable practice, even when there is a lack of prescriptive ethical reason. Objectives: To determine the magnitude of the practice of hysterectomy in girls and adolescents with ID, and explore the emic factors associated with this procedure. Material and methods: Multicenter, intersectoral study with a mixed methods design. Results: The quantitative results showed that 50 of 234 reported hysterectomies corresponded to females with ID. Average age at the time of surgery was 15 ± 2.9 years. Prophylactic abdominal hysterectomy was the most common procedure, and the justifications for it were "fertility control", "menstrual hygiene management", and "risk of sexual abuse". A qualitative analysis of 15 focus groups revealed that parents' main concern was how to manage their daughters' index disease and reproductive health; they perceived menstruation positively; they expressed their fear of dying and leaving them without support, and emphasized fertility control; none of them approved hysterectomy. Conclusions: The bodies that define health policies need to create a new philosophy that avoids the reductionist approach of current biomedical model, which separates (in the health-disease process) our interdependence with other humans.

Antecedentes: La histerectomía no terapéutica en niñas y adolescentes con discapacidad intelectual (DI) es una práctica aceptable, aun cuando se carece de razón ética prescriptiva. Objetivos: Determinar la magnitud de la práctica de la histerectomía en niñas y adolescentes con DI, y explorar los factores emic asociados a esta práctica. Material y métodos: Estudio multicéntrico e intersectorial con método mixto. Resultados: Los resultados cuantitativos mostraron que 50 de 234 histerectomías reportadas correspondieron a mujeres con DI. El promedio de edad a la cirugía fue de 15 ± 2.9 años. La histerectomía abdominal profiláctica fue el procedimiento predominante y las justificaciones fueron control de fertilidad, manejo de la higiene menstrual y riesgo de abuso sexual. El análisis cualitativo de 15 grupos focales reveló que la principal preocupación de los padres fue cómo manejar la enfermedad índice y la salud reproductiva de sus hijas; percibieron positivamente la menstruación, expresaron su miedo a morir y dejarlas sin ayuda, resaltaron el control de la fertilidad y ninguno aprobó la histerectomía. Conclusiones: Los organismos que definen políticas de salud necesitan crear una nueva filosofía que evite el enfoque reduccionista del actual modelo biomédico, el cual separa (en el proceso salud-enfermedad) la interdependencia entre los seres humanos.

Changes in the Inferior Vena Cava Are More Sensitive Than Venous Pressure During Fluid Removal: A Proof-of-Concept Study.

BACKGROUND: Congestion is central to the pathophysiology of heart failure (HF); thus, tracking congestion is crucial for the management of patients with HF. In this study we aimed to compare changes in inferior vena cava diameter (IVCD) with venous pressure following manipulation of volume status during ultrafiltration in patients with cardiac dysfunction. METHODS AND RESULTS: Patients with stable hemodialysis and with systolic or diastolic dysfunction were studied. Central venous pressure (CVP) and peripheral venous pressure (PVP) were measured before and after hemodialysis. IVCD and PVP were measured simultaneously just before dialysis, 3 times during dialysis and immediately after dialysis. Changes in IVCD and PVP were compared at each timepoint with ultrafiltration volumes. We analyzed 30 hemodialysis sessions from 20 patients. PVP was validated as a surrogate for CVP. Mean ultrafiltration volume was 2102 ± 667 mL. IVCD discriminated better ultrafiltration volumes ≤ 500 mL or ≤ 750 mL than PVP (AUC 0.80 vs 0.62, and 0.80 vs 0.56, respectively; both P< 0.01). IVCD appeared to track better ultrafiltration volume (P< 0.01) and hemoconcentration (P< 0.05) than PVP. Changes in IVCD were of greater magnitude than those of PVP (average change from predialysis: -58 ± 30% vs -28 ± 21%; P< 0.001). CONCLUSIONS: In patients undergoing ultrafiltration, changes in IVCD tracked changes in volume status better than venous pressure.

"Bronchogenic cyst impersonating a pericardial lesion": A case report.

A 32-year-old female presented with palpitations and chest discomfort. The patient had a history of pericardiotomy due to pericardial effusion. Multimodal imaging, including echocardiography, cardiac magnetic resonance (CMR), and coronary computed tomography angiography (CCTA) showed a single mass in the pericardium as the cause of the symptoms. Furthermore, its location and potential complications were accurately defined. The patient underwent a successful surgical resection of the pericardial cyst, microscopic histopathological examination was compatible with a bronchogenic cyst, a very rare congenital malformation. The article discusses the rarity of bronchogenic cysts in the pericardium and the importance of accurate diagnosis and appropriate treatment.

Mitral valve prolapse in patients with atrial septal defect: A quantitative three-dimensional echocardiographic analysis.

INTRODUCTION AND OBJECTIVES: Mitral valve (MV) prolapse is highly prevalent in patients with atrial septal defect (ASD). Abnormal left ventricular geometry has been proposed as the main mechanism of MV prolapse in ASD, however, the changes in the morphology of the MV apparatus remain to be clarified. Our aim was to assess the MV geometry in patients with ASD and MV prolapse. METHODS: We evaluated 99 patients (73% female, median age 40 years) with ASD who underwent a three-dimensional transesophageal echocardiogram. Three-dimensional analysis of the MV was done using dedicated automated software. Transthoracic echocardiographic parameters were assessed post ASD closure in 28 patients. RESULTS: MV prolapse was found in 39% of patients. Although smaller left ventricular dimensions and greater interatrial shunt were found in patients with MV prolapse compared with those without prolapse, there was no difference in the subvalvular parameters. MV prolapse was associated with larger mitral anterior-posterior diameter, anterolateral-posteromedial diameter, anterior perimeter, posterior perimeter, total perimeter, and anterior leaflet area (all p < 0.05). Mitral regurgitation was more frequent in patients with MV prolapse (80 vs. 48%, p = 0.002). CONCLUSIONS: In patients with ASD, the main mechanism of MV prolapse is the presence of an organic primary process of the MV apparatus (excessive anterior mitral leaflet tissue and mitral annular enlargement).

Postoperative intermittent dysfunction of mitral valve prosthesis of unclear etiology identified by three-dimensional echocardiography.

A 56-year-old patient with rheumatic heart disease and atrial fibrillation underwent mitral valve replacement with a mechanical prosthesis. The 3D perioperative echocardiogram showed an intermittent immobile medial disk without hemodynamic repercussion in the intensive care unit. The patient was taken back to the operating room and surgeons could not identify the cause. An enlarged left atrium and the size of the prosthetic valve was thought to have precipitated this condition. The heart team decided a biological prosthetic valve replacement would be performed. This case emphasizes the important role of the perioperative 3D echocardiogram in the detection of immediate surgical complications.

Donor notification of permanent deferral: a qualitative study on the perceptions and practices of notifier and blood donor in Mexico.

BACKGROUND: Informing about permanent deferral requires a process that links the notifier with the donor in a particular way. Little is known about the type of information and how it is disclosed to the donors. The current study aimed to examine perceptions and practices of notifier and blood donor within the framework of the notification process of permanent deferral and from the perspective of the notifier-blood donor relationship. METHODS: A qualitative study with in-depth interviews. The participants were 13 notifiers and 25 permanently deferred donors. Participants were recruited from a national blood bank and a state's blood bank. The entire dataset/narratives were analysed using the method of thematic analysis. RESULTS: The disclosure of permanent deferral was understood as a matter of disclosing the serological test results and their medical meaning along with a concise explanation of the deferral status with regard to future blood donation and the plan to be followed. The notifiers preferred to act in accordance with the standard protocol despite acknowledging the adverse psychological and social effects to which donors are exposed when they are informed of the possible disease and the consequent permanent deferral. Donors described a variety of psychological and social affectations. They valued honesty in the communication, the clarity of the information provided and a greater involvement of the notifier. CONCLUSION: Even though the notification process does not imply that medical care is being offered to donors, the notifier is the administrator of the well-being of the donor. Notification must not be considered as something apart from care, since it is intimately related to the health of each of the donors and their medical care.

Acute changes of left ventricular function during surgical revascularization by 3D speckle tracking.

BACKGROUND: Detecting early impact of coronary artery bypass grafting (CABG) on left ventricular (LV) function is important because such measures may contribute to meaningful improvement in clinical outcomes. We aimed to gain knowledge about acute changes of LV performance during surgical revascularization using three-dimensional speckle tracking echocardiography (3D STE). METHODS: Thirty-five patients scheduled for CABG surgery who underwent intraoperative transesophageal echocardiography (TEE) were enrolled (mean age 68.9 ± 7.3 years). TEE was performed before and after surgery, as well as before and after grafting. 3D LV ejection fraction (LVEF), tissue motion annular displacement (TMAD) of the mitral valves, 3D global longitudinal strain (GLS), global circumferential strain (GCS), twist, and torsion were quantified. Regional longitudinal strain (LS) was calculated based on coronary perfusion territories in a 16-segment LV model. RESULTS: Despite the absence of change in TMAD and 3D LVEF, 3D GLS (-18.6 ± 4.3% at baseline vs -16.0 ± 4.0% after surgery, P = .01) was significantly decreased, followed with no significant effect on GCS, twist, and torsion during surgery. 3D GLS correlated significantly with 3D LVEF (r between -0.34 and -0.51, P < .05 for all) under the whole operation. Territorial LS did not increase immediately after surgery. CONCLUSION: 3D speckle tracking imaging allows for detailed and direct evaluation of myocardial deformation, though impaired LV longitudinal function is still apparent immediately after surgery. GLS is more sensitive to an acute reduction in LV function than conventional parameters, which can be potentially useful for serial monitoring of functional recovery.

Right Ventricular Longitudinal Strain Predicts Low-Cardiac- Output Syndrome After Surgical Aortic Valve Replacement in Patients With Preserved and Mid-range Ejection Fraction.

OBJECTIVES: The aim of this study was to analyze whether right ventricular free wall longitudinal strain (RVFWSL) could be a predictor of low-cardiac-output syndrome (LCOS) after surgical aortic valve replacement (SAVR) in patients with left ventricular ejection fraction ≥40%. DESIGN: Prospective, observational study. SETTING: The study was conducted at a third level university hospital. PARTICIPANTS: The study comprised 75 patients with severe aortic stenosis and LVEF ≥40% who underwent SAVR. The primary outcome was the occurrence of LCOS, and secondary outcomes were in-hospital mortality, hospital stay, or vasoplegic syndrome. INTERVENTIONS: Patients were divided into two groups (LCOS and no LCOS), and RVFWSL was analyzed to determine whether it is a predictor for LCOS. In addition, a receiver operating characteristic curve also was constructed, and the best cutoff value to predict LCOS was found. Furthermore, the reproducibility of RVFWSL measurements was evaluated. MEASUREMENT AND MAIN RESULTS: The incidence of LCOS was 20% in the present study's cohort. After multivariate analysis, cross-clamp time (odds ratio 1.06, 95% confidence interval 1.02-1.11; p = 0.002) and RVFWSL (odds ratio 1.41, 95% confidence interval 1.07-1.87; p = 0.015) were the only predictors of LCOS. However, RVFWSL did not show association with secondary outcomes (p > 0.05 for all). The area under the curve of RVFWSL to predict LCOS was 0.75, and the best cutoff value was -17.3%, with a sensitivity of 86.7% and specificity of 61.7%. CONCLUSIONS: RVFWSL seems to be a predictor of LCOS in patients with severe aortic stenosis and LVEF ≥40% undergoing SAVR. RVFWSL less than -17.3% may identify patients at increased risk for LCOS.

Informed consent: its importance for retrolective research and medical science progress.

In retrolective research, the information necessary to answer the research question is directly generated from medical records and other clinical-documentary sources. This article analyzes the waiver of informed consent and privacy notice when research is retrolective, from which two lines of argument emerge: one is the physician's duty to protect patient dignity, integrity, right to self-determination and privacy, as well as the confidentiality of the information obtained from him; the other is retrolective research contribution to the control of diseases and society's health improvement. Waiver of informed consent or privacy notice documented in the medical record is important for retrolective research, but it has ethical implications for researchers who do not comply with the rationality and personal responsibility they have before society.

En la investigación retrolectiva, la información necesaria para responder la pregunta de investigación se genera directamente de expedientes clínicos y de otras fuentes clínico-documentales. Este artículo analiza la dispensa del consentimiento informado y el aviso de privacidad cuando la investigación es retrolectiva, de lo cual emergen dos líneas de argumentación: una es el deber del médico de proteger la dignidad, la integridad, el derecho a la autodeterminación, la intimidad del enfermo y la confidencialidad de la información obtenida de él; la otra es la contribución de las investigaciones retrolectivas al control de las enfermedades y a la mejora de la salud de la sociedad. La dispensa del consentimiento o el aviso de privacidad en el expediente clínico es importante para la investigación retrolectiva, pero tiene implicaciones éticas para los investigadores que no cumplan con la racionalidad y responsabilidad personal que tienen ante la sociedad.

Research and research ethics committees and the obligation for them to operate in accordance with the principle of the social covenant.

The relationship between the social covenant, ethics and scientific research is highly important for society. Economic prosperity and better health are two of the main reasons why society supports science, without society itself being able to determine the nature of the research that is to be implemented; this is decided by Research Committees (RCs) and Research Ethics Committees (RECs). This article analyzes how the work of RCs and RECs must have a social covenant and represent the interests of society in order to promote its trust in research.

La relación entre alianza social, ética e investigación científica es extremadamente importante para la sociedad. La prosperidad económica y la mejor salud son dos de las principales razones por las cuales la sociedad apoya a la ciencia, sin que la sociedad misma pueda determinar la naturaleza de las investigaciones que serán implementadas; esto último lo deciden los comités de investigación (CI) y los comités de ética en investigación (CEI). En este artículo se analiza cómo el trabajo de los CI y CEI debe tener una alianza social y representar los intereses de la sociedad para promover la confianza de esta en la investigación.

Differentiating spontaneous echo contrast, sludge, and thrombus in the left atrial appendage: Can ultrasound enhancing agents help?

The accurate identification of thrombus in the left atrial appendage with transesophageal echocardiogram (TEE) in patients with atrial fibrillation (AF) before cardioversion is essential. Most of these patients have some grade of spontaneous echo contrast (SEC). Severe SEC is often called "sludge," and its prognosis and treatment are still controversial. Current guidelines suggest the use of ultrasound enhancing agents (UEAs) when significant SEC is present. However, little is known about the utility of the UEAs in the differentiation between sludge and less severe SEC.

Los comités de investigación en salud: su autoridad, responsabilidad fundamental y necesidad de que se sometan a auditorías periódicas.

Research ethics must include theoretical and practical dimensions. The first one is structured by regulations and policies, and the second dimension refers to how the committee interprets and applies those regulations and policies. This article analyses the operation of the committees at a practical level. Given that the evaluation and judgement of research protocols is a process that requires full awareness, its omission entails important implications for health research.

La ética de la investigación debe incluir las dimensiones teórica y práctica. La primera la conforman regulaciones y directrices y la segunda alude a la forma cómo los comités de ética y ética de la investigación interpretan y aplican esas regulaciones y directrices. En este artículo se analiza la operación de los comités a nivel práctico. Dado que la evaluación y el dictamen de los protocolos de investigación es un proceso que requiere consciencia plena, la omisión de esta conlleva importantes implicaciones para la investigación en salud.

Coexisting bicuspid aortic and pulmonary valves diagnosed by 3D transthoracic echocardiography.

Coexisting bicuspid aortic and pulmonary valves is an extremely rare condition, and there have been few published cases. Diagnosis of bicuspid aortic valve is straightforward with 2D echocardiography; however, analysis of the morphology of the pulmonary valve is challenging. In this study, we report on a case of a 32-year-old man with bicuspid aortic and pulmonary valves diagnosed by 2D and 3D transthoracic echocardiography. The enlarged pulmonary artery without any obvious etiology led us to suspect a pulmonary valve anomaly; thus, we comprehensively evaluated it with 2D and 3D echocardiography, which confirmed the diagnosis of bicuspid pulmonary valve.

[Legitimidad de la histerectomía para resolver el "problema" de la higiene menstrual en adolescentes con discapacidad intelectual].

Menstrual hygiene in adolescents with intellectual disability (ID) represents an extra burden for parents or primary caregivers, especially in developing countries, where social institutions, including the health system, lack the capability to help this group of teenagers and their families; hence, hysterectomy to eliminate menstrual bleeding is considered a morally acceptable resource. Hysterectomy to solve the "problem" of menstrual hygiene reflects obstacles that affect the care provided by the physician to the adolescent with ID: on one hand, the criterion of social value about a "poor quality of life," and on the other, discrimination when only socioeconomic conditions are considered rather than the lack of a social network of support and special education. In Mexico, current medical support for girls and adolescents with ID for the management of menstrual hygiene is unsatisfactory. The practice of hysterectomy with the single purpose of menstrual hygiene is ethically and morally unfair and maleficent.

La higiene menstrual en las adolescentes con discapacidad intelectual (DI) representa una carga extra para los padres o cuidadores primarios, principalmente en países en desarrollo, donde las instituciones sociales, incluyendo el sistema sanitario, no tienen la capacidad suficiente para ayudar a este grupo de adolescentes y sus familias; de ahí que la histerectomía para eliminar el sagrado menstrual sea considerada como un recurso éticamente aceptable. La histerectomía para resolver el "problema" de la higiene menstrual refleja óbices que afectan la atención que el médico otorga a la adolescente con DI: por un lado, el criterio de valía social sobre una "calidad de vida deficiente" y, por otro, la discriminación, al considerar solo las condiciones socioeconómicas y no la falta de una red social de apoyo y de educación especial. En México, la actual asistencia médica a las niñas y adolescentes con DI para el manejo de la higiene menstrual es insatisfactoria. La práctica de la histerectomía por el solo hecho de higiene menstrual resulta ser ética y moralmente injusta y maleficente.

Mortality of young people with cancer: clinical-epidemiological characteristics of death and emerging ethical aspects / La mortalidad en adolescentes con cáncer: características clinicoepidemiológicas de muerte y aspectos éticos emergentes.

Objective: To describe the epidemiological, clinical, and ethical aspects of the mortality of young people with cancer in Mexico. Methods: 63 medical records from 14 to 18-year-old patients, with cancer, who died between 2011 and 2014, were reviewed to obtain epidemiological and clinical characteristics of their death. The study sites were three tertiary referral hospitals in Mexico City. Results: Of 40 young people in terminal phase, 16 (40%) continued to receive curative treatment; of the 51 whose place of death was known, 45 (88%) died in hospital. Of the 41 who died within 30 days of their last hospitalization, deaths were due to complications (51%), progression of the disease (41%), and deaths of those in palliative care (7%). Conclusions: Oncological practice rests on what is known as a biomedical model. The results of this study suggest the urgent need for, and support the implementation of, true palliative-care services. More importantly, these findings underscore the necessity of putting the ethics of clinical practice into action, such that best practice in medicine is reinforced.

Objetivo: Describir los aspectos epidemiológicos, clínicos y éticos de la mortalidad de los adolescentes con cáncer en México. Métodos: Se revisaron 63 expedientes clínicos de adolescentes (de 14 a 18 años de edad) con cáncer, fallecidos entre 2011 y 2014, para obtener información clínica y epidemiológica de su muerte. Los sitios de estudio fueron tres hospitales de concentración en la Ciudad de México. Resultados: De los 40 adolescentes con criterios de fase terminal, 16 (40%) continuaron recibiendo tratamiento con fines curativos. De los 51 cuyo lugar de muerte era conocido, 45 (88%) murieron en hospital. De los 41 que murieron dentro de los 30 días de su última hospitalización, las muertes fueron principalmente debidas a complicaciones (51%), a progresión de la enfermedad (41%) o bien fueron muertes en tratamiento paliativo (7%, 3/41). Conclusiones: La práctica oncológica descansa en lo que es conocido como modelo biomédico. Los resultados del estudio sugieren y apoyan la urgente necesidad de implementar verdaderos servicios de cuidados paliativos, pero más importante que eso, está el ímpetu de poner la ética de la práctica clínica en acción, y de ese modo reforzar la buena práctica de la medicina.

Disminución de la fracción de expulsión del ventrículo izquierdo por estrés con adenosina como predictor de isquemia.

INTRODUCCIÓN: En estudios de medicina nuclear se ha observado que la disminución de la fracción de expulsión del ventrículo izquierdo (FEVI) se asocia con enfermedad coronaria trivascular; en resonancia magnética cardiaca (RMC) no se ha estudiado el papel que desempeña la disminución de la FEVI. OBJETIVO: Evaluar la asociación entre la disminución de la FEVI y la isquemia cardiaca en pacientes con estudios de RMC con adenosina. MÉTODO: Estudio transversal comparativo. Los criterios de inclusión fueron pacientes evaluados con RMC con adenosina entre enero de 2009 y junio de 2015. Se comparó el cambio en la FEVI en pacientes con estudio positivo versus pacientes con estudio negativo para isquemia por este método. RESULTADOS: Se incluyeron 59 pacientes: 41 del sexo masculino (70 %), edad de 59.7 ± 10.9 años; 38 % de los estudios fueron positivos para isquemia. La delta de la FEVI (FEVI postestrés - FEVI reposo) fue de -0.16 ± 5.9 versus 5.3 ± 4.7 (p<0.001) en pacientes con y sin isquemia, respectivamente. CONCLUSIÓN: Los pacientes con estudios positivos para isquemia tuvieron menor delta FEVI que los que tuvieron estudios negativos para isquemia. BACKGROUND: The decrease in left ventricular ejection fraction (LVEF) has been observed to be associated with three-vessel coronary disease in nuclear medicine studies; however, the role played by LVEF decrease has not been studied with cardiovascular magnetic resonance (CMR). OBJECTIVE: To assess the association between LVEF decrease and cardiac ischemia in patients with CMR studies with adenosine. METHOD: Cross-sectional, comparative study. Inclusion criteria were: patients assessed with CMR with adenosine between January 2009 and June 2015. LVEF change was compared between patients testing positive for ischemia versus those who tested negative. RESULTS: Fifty nine patients were included: 41 were males (70%), mean age was 59.7 ± 10.9 years; 38% of the studies tested positive for ischemia. Delta LVEF (post-stress LVEF ­ resting LVEF) was ­0.16 ± 5.9 versus 5.3 ± 4.7 (p < 0.001) in patients with and without ischemia, respectively. CONCLUSION: Patients who tested positive for ischemia had lower delta LVEF than those with negative studies for ischemia.

Decision-making on therapeutic futility in Mexican adolescents with cancer: a qualitative study.

BACKGROUND: The world literature shows that empirical research regarding the process of decision-making when cancer in adolescents is no longer curable has been conducted in High-income, English speaking countries. The objective of the current study was to explore in-depth and to explain the decision-making process from the perspective of Mexican oncologists, parents, and affected adolescents and to identify the ethical principles that guide such decision-making. METHODS: Purposive, qualitative design based on individual, fact-to-face, semi-structured, in-depth interviews. The participants were thirteen paediatric oncologists, 13 parents or primary carers, and six adolescents with incurable cancer. The participants were recruited from the paediatric oncology services of three national tertiary-care medical centres in Mexico City. RESULTS: The oncologists stated that they broach the subject of palliative management when they have determined that curative treatment has failed. Respect for autonomy was understood as the assent of the parent/adolescent to what the oncologist determined to be in the best interest of the adolescent. The oncologists thought that the adolescent should be involved in the decision-making. They also identified the ability to count on a palliative care clinic or service as an urgent need. For the parents, it was essential that the oncologist be truly interested in their adolescent child. The parents did not consider it necessary to inform the child about impending death. The adolescents stated that the honesty of their oncologists was important; however, several of them opted for a passive role in the decision-making process. CONCLUSION: The findings of this study evidence that to achieve good medical practice in low-middle income countries, like Mexico, it is urgent to begin effective implementation of palliative care, together with appropriate training and continuing education in the ethics of clinical practice.