Seizures in palliative care

01OverviewDefinition, clinical context and the essential points that orientate the chapter.

Palliative patients may have focal aware episodes, impaired-awareness seizures, bilateral convulsions or non-convulsive status. Ask witnesses what happened before, during and after rather than accepting the word fit. Focal twitching, forced head or eye deviation, speech arrest, sensory experience and postictal focal weakness can localise disease. Document duration from a clock because perceived time is unreliable during a frightening event.

During a convulsion, protect rather than restrain. Move dangerous objects, cushion the head, loosen tight clothing and maintain privacy. Do not place fingers or objects in the mouth. Position laterally when convulsion stops, suction visible material if needed and assess airway, breathing, circulation, glucose, temperature and injury. Give oxygen when hypoxaemic and call for trained help early.

Five minutes is the operational treatment threshold for convulsive status. In the community, buccal midazolam is usually the fastest practical adult route, with rectal diazepam as an alternative. In hospital with intravenous access, lorazepam is standard. Record each dose and time and proceed to the next protocol step if seizure persists; repeated small uncoordinated benzodiazepine doses waste time and compound respiratory depression.

After termination, identify precipitants. Check glucose immediately, then sodium, calcium, magnesium, renal and liver function, infection, hypoxia and drug history as indicated. Review adherence, vomiting, swallowing and abrupt withdrawal. A first seizure, new focal onset, persistent deficit or severe headache may require urgent CT and later MRI. EEG helps suspected non-convulsive status when results will change care.

Maintenance therapy depends on diagnosis, organ function, interactions and route. Levetiracetam is commonly used in brain tumour because it has few hepatic enzyme interactions, but renal dose adjustment is essential and irritability or mood change occurs. Valproate has hepatic and platelet concerns. Enzyme-inducing agents interact with corticosteroids, anticoagulants and cancer therapy. Neurology, oncology and palliative pharmacy should coordinate changes.

When the oral route fails, do not simply omit maintenance doses. A continuous subcutaneous midazolam infusion can suppress seizures but may cause sedation. Some services use off-label subcutaneous levetiracetam, often converting the established oral total under a local specialist protocol; compatibility, concentration and renal function must be checked. If death is near, discuss whether the goal is wakeful prevention, rapid rescue, or proportional sedation for recurrent refractory seizures.

The emergency plan should reflect preferences without compromising clarity. A person may want home treatment and no hospital transfer for an isolated seizure but still want an ambulance after two rescue doses, injury or failed recovery. State CPR and ventilation decisions separately. Train carers using the actual product, verify expiry and supply and provide after-event support because witnessed convulsions are distressing.

Key points

Time every event and describe onset, awareness, movement, eye and head deviation, colour, injury, duration and recovery; video can help with consent.
First-line seizure aid is safety: cushion the head, remove hazards, do not restrain limbs or put anything in the mouth, and use recovery position afterward.
Treat a convulsive seizure at 5 minutes with the prescribed rescue route and call emergency help according to the individual plan.
In the community, adult buccal midazolam 10 mg is a common first rescue; rectal diazepam 10 mg is an alternative when authorised and acceptable.
In hospital, intravenous lorazepam is first-line when access and resuscitation support are available; do not delay rescue while repeatedly attempting difficult access.
Check glucose immediately and correct reversible electrolyte, infection, hypoxia, medicine, withdrawal and intracranial causes in line with goals.
If swallowing fails, specialist options include subcutaneous midazolam infusion or off-label subcutaneous levetiracetam with pharmacy-supported compatibility and conversion.
Levetiracetam is commonly used for tumour-related seizures because interaction burden is low, but dose follows renal function and mood or behavioural effects need review.
The gold-standard plan states seizure threshold, first and repeat rescue, maximum doses, emergency call, airway support, maintenance route and what differs if admission is not wanted.

02AetiologyUnderlying causes, associations and risk factors, with why each one matters.

Intracranial tumour

Primary brain tumour, metastasis, leptomeningeal disease, oedema and haemorrhage disrupt cortex and create focal or generalised seizures.

Metabolic and systemic illness

Hypoglycaemia, sodium or calcium disturbance, uraemia, hepatic failure, hypoxia, sepsis and fever substantially lower seizure threshold.

Medication and withdrawal

Tramadol, some antidepressants and antipsychotics, drug interactions and abrupt alcohol, benzodiazepine or antiseizure withdrawal provoke seizures.

Pre-existing epilepsy and injury

Established epilepsy can destabilise through missed oral doses, vomiting, malabsorption, sleep loss, brain injury or disease progression.

03PathophysiologyThe causal sequence from the underlying abnormality to symptoms and harm.

1
Hypersynchronous cortical discharge
Imbalance between excitation and inhibition recruits neuronal networks, producing focal motor, sensory, cognitive or bilateral convulsive activity.
2
Tumoural excitability
Cortical infiltration, oedema, haemorrhage, gliosis and altered extracellular ions around tumour lower the threshold for abnormal firing.
3
Systemic threshold reduction
Hypoxia, glucose deprivation, electrolyte disturbance and toxin accumulation destabilise neuronal membranes and multiple inhibitory brain networks.
4
Status self-perpetuation
Prolonged seizure internalises inhibitory receptors, increases excitotoxic signalling and becomes less responsive to initial benzodiazepine over time.
5
Postictal suppression
Transient network exhaustion causes reduced awareness, weakness, confusion and headache that can resemble stroke, delirium or terminal decline.

04Clinical features and red flagsSymptoms, examination findings, patterns of presentation and time-critical warnings.

Focal aware seizure

Stereotyped motor, sensory, autonomic or experiential symptoms occur with retained awareness and may precede bilateral convulsion.

Impaired-awareness seizure

Behavioural arrest, staring, automatisms and unresponsiveness followed by confusion suggests focal seizure affecting awareness networks.

Bilateral convulsion

Tonic stiffening, rhythmic jerking, cyanosis and postictal unresponsiveness define a generalised convulsive emergency when prolonged.

Non-convulsive status

Persistent confusion, subtle twitch, eye deviation or unexplained reduced consciousness after a seizure may represent ongoing electrical activity.

Postictal weakness

Transient focal weakness can follow seizure, but persistent or atypical deficit needs urgent stroke, bleed or tumour assessment.

Convulsive statusRed flag

Convulsion lasting 5 minutes or recurrent seizures without recovery requires immediate benzodiazepine and escalation.

Red flags requiring action

A first seizure, focal onset, new weakness, severe headache, trauma or anticoagulation requires urgent intracranial assessment when treatment is appropriate.
A convulsion lasting 5 minutes or serial seizures without recovery requires immediate rescue and status pathway activation.
Persistent impaired awareness with subtle twitching, eye deviation or automatisms may be non-convulsive status and needs urgent neurological review.
Hypoglycaemia, hyponatraemia, hypercalcaemia, uraemia, hepatic failure, infection or hypoxia can precipitate seizures and requires targeted correction.
Abrupt withdrawal of benzodiazepine, alcohol, gabapentinoid or antiseizure medicine can cause recurrent seizures and must be identified.
Midazolam and opioid combinations can depress breathing; record every dose, observe ventilation and have a clear maximum and escalation step.
Valproate is hazardous in significant hepatic disease, while levetiracetam requires renal adjustment and behavioural adverse-effect review.

05InvestigationsWhat to request, why it matters and how to interpret it.

Investigation order

Read from the initial assessment onwards. Tests may run in parallel in urgent care; first-line, preferred, confirmatory, definitive and gold-standard labels appear only when the chapter explicitly states them.

01
First-line witnessed-event historyFirst stepFirst line
Why
Document trigger, focal onset, awareness, movements, colour, injury, timed duration, rescue response and postictal recovery.
Interpretation and limitations
A stereotyped ictal sequence and postictal phase support epilepsy; video can improve expert classification when safely and consensually obtained.
02
ABCDE and capillary glucose
Why
Identify airway compromise, hypoxia, haemodynamic instability, fever, trauma and immediately reversible hypoglycaemia during or after the event.
Interpretation and limitations
Resuscitation and glucose correction occur before detailed diagnosis; normal glucose does not exclude other metabolic triggers.
03
Targeted metabolic and infection tests
Why
Assess sodium, calcium, magnesium, renal and liver function, full blood count, inflammation, drug levels and cultures as indicated.
Interpretation and limitations
Correct identified causes and adjust antiseizure and rescue medicines for renal or hepatic clearance and interactions.
04
CT head and contrast MRI
Why
Investigate first focal seizure, trauma, haemorrhage, tumour progression, oedema, infarct or infection when results alter treatment.
Interpretation and limitations
CT addresses immediate bleed or mass concern; MRI better defines tumour and cortical pathology after stabilisation.
05
Electroencephalography
Why
Detect non-convulsive status, clarify recurrent unexplained impaired awareness or support uncertain event classification.
Interpretation and limitations
Obtain urgently for suspected ongoing non-convulsive seizure; a normal interictal study does not exclude epilepsy.
06
Medicine and route reconciliation
Why
Check missed doses, swallowing, vomiting, formulation, interactions, renal adjustment, rescue supply and withdrawal from alcohol or sedatives.
Interpretation and limitations
A practical route failure can explain recurrence and requires immediate maintenance replacement, not just another diagnostic label.

06Differential diagnosisRealistic alternatives and the features that help distinguish them.

Syncope

Prodrome, pallor, brief arrhythmic jerks and rapid recovery suggests cerebral hypoperfusion rather than an epileptic seizure.

Psychogenic non-epileptic event

Variable prolonged movements, eye closure and preserved physiology may suggest a functional event, but diagnosis needs positive expert evidence.

Rigors or myoclonus

Fever-related shivering and opioid neurotoxicity cause repetitive movement without the typical ictal sequence and require different treatment.

Metabolic encephalopathy

Fluctuating consciousness, tremor or asterixis from organ failure can include seizures but often has broader non-ictal neurological features.

Stroke or raised pressure

Persistent focal deficit, headache, vomiting or reduced consciousness after a first event requires urgent imaging rather than assuming postictal change.

07ManagementImmediate care, first-line treatment, alternatives and escalation.

01Convulsive statusTreat at five minutes and escalateFirst stepEscalationA convulsive seizure reaches 5 minutes or recurs without recovery.

1Call emergency help, protect airway and patient, give oxygen as indicated, check glucose and administer authorised buccal, rectal or intravenous benzodiazepine without delay.
2Time and record the dose, repeat only under the current status protocol and prepare airway support because cumulative benzodiazepine and opioid can depress ventilation.
3First lineSecond lineEscalationIf seizure continues, progress promptly to second-line intravenous antiseizure treatment and critical-care or goal-concordant palliative escalation rather than repeating first-line indefinitely.

02Post-seizure reviewFind the trigger and rebuild preventionThe seizure has stopped and the patient is recovering or remains unexpectedly impaired.

1Use recovery position, assess airway, injury, focal deficit and postictal trajectory and check glucose, oxygen and selected metabolic or infection causes.
2Review brain disease, adherence, swallowing, interactions, renal or hepatic function and whether imaging or EEG will change treatment.
3Adjust maintenance and rescue route with neurology or palliative input, update driving and safety advice and debrief patient and witnesses.

03Oral route failureMaintain seizure control without unsafe omissionVomiting, dysphagia, obstruction or reduced consciousness makes oral antiseizure treatment unreliable.

1Confirm the established daily regimen, seizure risk, renal and hepatic function, desired arousal and expected duration of route failure.
2Use a specialist local protocol for continuous subcutaneous midazolam or off-label subcutaneous levetiracetam, with independent dose, concentration and compatibility checks.
3Prescribe separate rapid rescue, monitor seizure and sedation and reverse the temporary route carefully if swallowing returns.

04Home seizure planMake rescue deliverable under stressA patient at risk of recurrent seizure wishes to remain outside hospital when clinically feasible.

1Agree which event and duration triggers rescue, ambulance or no transfer and document CPR and ventilation choices separately.
2Train identified carers with the actual buccal or rectal product, written dose, repeat rule, recovery position and emergency number.
3Check supply, expiry, storage and accessibility regularly and review the plan after every seizure, medicine change or carer concern.

Key medicines and prescribing safety5 treatments · regimens, roles and cautions

Provides rapid community first-line benzodiazepine rescue when intravenous access is unavailable.

Buccal midazolam for adult prolonged seizure

Give 10 mg into the buccal cavity once when an adult convulsive seizure reaches the individual plan threshold, commonly 5 minutes; call emergency help and repeat only when the prescribed local protocol explicitly authorises it.

Monitor airway and breathing, record the time, avoid uncoordinated repeat dosing and account for opioid, alcohol, frailty and hepatic impairment; use the prescribed product and technique.

First-line hospital benzodiazepine when intravenous access and resuscitation support are immediately available.

Intravenous lorazepam for status epilepticus

Give 4 mg intravenously over 2 minutes in monitored adult convulsive status, repeating once after 5 to 10 minutes if seizure persists according to the current hospital protocol before second-line escalation.

Respiratory depression, hypotension and prolonged sedation occur; do not let repeated access attempts delay buccal rescue or exceed the protocol while airway support is prepared.

An alternative community rescue when buccal midazolam is unavailable, unsuitable or ineffective under the agreed plan.

Rectal diazepam as alternative rescue

Give 10 mg rectally for an adult prolonged convulsive seizure when this route is prescribed and acceptable, with any repeat dose and emergency escalation determined by the individual seizure protocol.

Maintain dignity, record administration and monitor breathing and sedation; accumulation is greater in frailty and hepatic impairment and repeated dosing requires clinical supervision.

Controls focal and bilateral tonic-clonic seizures with relatively few hepatic enzyme interactions, making it useful in many tumour pathways.

Levetiracetam maintenance

A common adult starting dose is 500 mg orally twice daily, increased under neurology guidance according to seizure response to a usual maximum of 1.5 g twice daily, with mandatory dose reduction in renal impairment.

Monitor somnolence, dizziness, irritability, aggression, depression and suicidal thinking and verify renal dose after dehydration or acute kidney injury.

Provides non-oral anticonvulsant treatment and rapid rescue capability when wakefulness may be reduced by the necessary benzodiazepine exposure.

Continuous subcutaneous midazolam

When the oral route fails near end of life, specialist palliative protocols commonly begin 20 to 30 mg over 24 hours by continuous subcutaneous infusion for seizure prevention, with separate 5 to 10 mg rescue and response-led titration.

Respiratory depression, tolerance and sedation increase with opioids and hepatic dysfunction; define the arousal goal, check pump compatibility and seek specialist oversight.

08ComplicationsImportant consequences, why they occur and why they matter clinically.

Hypoxic brain injury

Prolonged convulsion impairs ventilation and raises metabolic demand, causing irreversible neuronal injury when termination is delayed.

Aspiration and trauma

Loss of airway protection, vomiting, falls, fractures, tongue injury and pressure damage occur during or after seizures.

Respiratory medicine toxicity

Repeated benzodiazepine doses, especially with concurrent opioid treatment, produce hypoventilation, airway obstruction, hypotension, aspiration and delayed recovery.

Recurrent emergency attendance

Absent rescue supply, unclear carer instructions and loss of oral maintenance routes cause avoidable ambulance calls and unwanted admissions.

Loss of independence

Driving restriction, falls fear, cognitive adverse effects and unpredictable episodes affect mobility, work, family roles and preferred place of care.

09Monitoring and follow-upTreatment response, safety checks and longer-term review.

Record seizure type, exact duration, recovery, injuries, rescue dose and effect after every event.
After benzodiazepine monitor airway, respiratory rate and effort, oxygenation, pressure and consciousness until recurrence and toxicity risk has passed.
Trend glucose, sodium, calcium, renal and liver function and infection markers when they can change seizure treatment.
Review antiseizure adherence, swallowing, vomiting, interactions and supply during every transition and acute illness.
During levetiracetam monitor seizure frequency, renal dose, mood, irritability, somnolence and suicidal thinking.
During continuous subcutaneous treatment inspect the site and pump, record rescue use and assess whether sedation exceeds the agreed goal.
Recheck carer technique, product, expiry, written repeat rule and emergency contact after each seizure or plan revision.
Review driving, bathing, heights, cooking, sleep and supervision safety while preserving independence proportionately.

10Special situationsVariants, exceptions and circumstances that change the usual approach.

Five minutes changes the label

At that threshold spontaneous termination becomes less likely and treatment delay increases resistance and harm.

Do not chase intravenous access

Buccal rescue can stop ongoing seizure sooner than multiple failed cannulation attempts while hypoxia continues.

Postictal does not mean safe

Persistent deficit, subtle twitching or failure to recover may represent stroke, bleed or non-convulsive status.

Route failure is predictable

A patient with dysphagia needs replacement maintenance and rescue plans before the final oral dose is missed.

Rescue training reduces admissions

Carer confidence depends on practising the exact product and knowing when home care ends and emergency escalation begins.

Sedation may be a trade-off

Near death, recurrent seizures may require benzodiazepine exposure that reduces wakefulness, which should be discussed and reviewed proportionately.

11Common pitfallsFrequent interpretation and management errors.

01
Failing to time a convulsion and delaying rescue beyond five minutes.
02
Putting an object or fingers into the patient's mouth.
03
Restraining limbs during tonic-clonic activity.
04
Giving repeated undocumented benzodiazepines without advancing the status protocol.
05
Waiting for intravenous access when buccal rescue is available.
06
Calling persistent reduced awareness postictal without considering non-convulsive status.
07
Omitting oral maintenance medicines when swallowing fails without providing another route.
08
Using standard levetiracetam doses through acute renal decline.
09
Choosing valproate without hepatic and platelet review.
10
Sending rescue medicine home without carer training, expiry and repeat instructions.