Palliative MedicineTier 2Approach to a presentation

Seizures

Red flags

Prolonged (>5 minutes) or recurrent seizures without recovery of consciousness between them (status epilepticus) in a palliative patient
New-onset seizure in a patient with known/suspected brain metastases or primary CNS malignancy
Seizure with associated significant distress, injury risk, or airway compromise

By underlying cause in the palliative population

Structural - primary brain tumour or metastases, raised intracranial pressure
Metabolic - hyponatraemia, hypoglycaemia, hypercalcaemia, uraemia, hepatic encephalopathy - all common in advanced illness
Drug-related - opioid neurotoxicity/accumulation (especially with renal impairment), abrupt withdrawal of benzodiazepines/anticonvulsants, or a new drug lowering seizure threshold
Pre-existing epilepsy - decompensated by intercurrent illness, drug interactions, or missed doses due to swallowing difficulty

Known cancer diagnosis and sites of disease (particularly CNS involvement)
Current medications (opioid dose/recent changes, anticonvulsants, recent dose reductions or missed doses)
Recent metabolic derangement (bloods if available), renal function, calcium
Baseline cognitive/functional status, to contextualise post-ictal recovery expectations

In the actively dying patient, investigation is usually limited to what would change management - a full seizure workup (imaging, extensive bloods) is often not appropriate or beneficial if the goal is symptom control rather than diagnosis/reversal of an underlying cause
Where reversible causes are suspected and treatment is still consistent with goals of care, targeted bloods (calcium, glucose, sodium, renal function) can guide correction of a specific precipitant

Benzodiazepines are first-line for acute seizure termination (e.g. midazolam - buccal, intranasal, or subcutaneous routes are practical in the community/home setting where IV access may not be available)
For recurrent seizures or a high ongoing risk, a subcutaneous infusion (e.g. midazolam via syringe driver) can provide ongoing seizure prophylaxis alongside other symptom control medications
Correct reversible metabolic precipitants where this remains consistent with the patient's goals of care (e.g. treating symptomatic hypercalcaemia)
Continue established anticonvulsants via an alternative route (e.g. subcutaneous/rectal) if the oral route is no longer reliable, rather than allowing an unintended gap in seizure control

Attributing a new seizure automatically to "disease progression" without considering readily reversible causes (opioid toxicity, metabolic derangement, missed anticonvulsant doses) that may be easily correctable even in a palliative context
Withholding benzodiazepines in a frail/elderly patient out of respiratory depression concern, when an ongoing or recurrent seizure itself poses a greater immediate risk
Forgetting that oral anticonvulsants need a route change (not simply stopping) once swallowing becomes unreliable, risking a preventable seizure from abrupt anticonvulsant discontinuation

1. Buccal/subcutaneous midazolam works in the community

"I don't need IV access to terminate a seizure at home - buccal or subcutaneous midazolam is effective and practical."

2. Don't assume it's 'just the tumour'

"A new seizure still deserves a quick check for a reversible trigger - hypercalcaemia, opioid toxicity, a missed anticonvulsant dose - even in a patient who is clearly dying."

3. Never let anticonvulsants lapse silently

"If swallowing fails, I switch the anticonvulsant route, I don't just let it stop."

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