What is the appropriate management for a patient who experiences a seizure before death?

Management of Seizures in End-of-Life Care

For patients experiencing seizures in the terminal phase of life, the primary goal is comfort-focused management with benzodiazepines to control seizure activity and prevent suffering, rather than aggressive workup or long-term seizure prevention. 1, 2

Immediate Seizure Control

Acute Seizure Management

• Administer lorazepam 4 mg IV slowly (2 mg/min) as first-line treatment for active seizures 2
• If seizures continue after 10-15 minutes, give an additional 4 mg IV dose slowly 2
• Alternative: diazepam 5-10 mg IV (injected slowly over at least 1 minute per 5 mg), which can be repeated in 3-4 hours if necessary 1
• Ensure airway patency and have respiratory support equipment immediately available, as benzodiazepines carry significant risk of respiratory depression 2

Status Epilepticus in Terminal Patients

• For continuous or recurrent seizures, lorazepam up to a maximum of 30 mg may be administered at 10-15 minute intervals, though experience beyond initial doses is limited 1
• Diazepam may be repeated every 3-4 hours for ongoing seizure control in the dying patient 1
• Respiratory depression is the most important risk and must be monitored, though in end-of-life care, comfort takes priority over aggressive ventilatory support 2

Comfort-Focused Approach vs. Aggressive Management

When to Avoid Extensive Workup

• Neuroimaging, EEG, and extensive laboratory testing are not indicated when seizures occur in the context of imminent death 3
• The American College of Emergency Physicians guidelines for first seizure workup do not apply to actively dying patients, where the focus shifts entirely to symptom management 4, 3
• Provoked seizures from metabolic derangements (hypoglycemia, hyponatremia, hypoxia, organ failure) are common in dying patients and do not require correction if death is imminent 5

Antiepileptic Drug Initiation

• Do not initiate long-term antiepileptic medications (levetiracetam, phenytoin, valproate) in patients who are actively dying 4
• Emergency physicians need not start antiepileptic therapy for provoked seizures when the precipitating condition is part of the dying process 4
• Short-acting benzodiazepines for immediate seizure control are sufficient for comfort care 1, 2

Special Considerations in Terminal Care

Aspiration Risk and NPO Status

• Keep patients NPO after seizures until swallowing can be assessed, as aspiration risk is significantly elevated 6
• In end-of-life care, this may mean maintaining NPO status indefinitely and using IV or rectal routes for all medications 6
• Multiple seizures substantially increase aspiration risk (recurrence risk increases from one-third to three-quarters) 6

Sudden Unexpected Death in Epilepsy (SUDEP)

• Some seizures may trigger an irreversible cascade of cardiopulmonary and cerebral changes leading to death even with immediate intervention 7
• Post-ictal intervention, including prompt resuscitation by medical personnel, has been shown ineffective in preventing some SUDEP cases 7
• In terminal patients, aggressive resuscitation after seizures may not be appropriate or desired based on goals of care 7

Medication Administration Routes

When IV Access is Unavailable

• Diazepam can be given intramuscularly (5-10 mg), though IV is strongly preferred for seizure control 1
• Lorazepam IM is not preferred for active seizures as therapeutic levels are not reached as quickly as IV administration 2
• Rectal diazepam is an alternative route when neither IV nor IM access is feasible 1

Common Pitfalls to Avoid

• Do not delay benzodiazepine administration while attempting extensive workup in dying patients 1, 2
• Do not use phenytoin for seizures secondary to alcohol withdrawal, theophylline toxicity, or isoniazid toxicity, as it is ineffective 5
• Do not allow oral intake before swallowing assessment, even if the patient appears alert, as post-ictal swallowing dysfunction can persist 6
• Do not assume all seizures require long-term antiepileptic therapy—most medically ill patients with secondary seizures do not have epilepsy and this should be explained to families 5
• Avoid small veins (dorsum of hand or wrist) for IV benzodiazepine administration and take extreme care to avoid intra-arterial injection 1

Monitoring and Ongoing Care

• Monitor vital signs, particularly respiratory rate and oxygen saturation, after benzodiazepine administration 2
• Elderly patients may have more profound and prolonged sedation with IV lorazepam, which may be acceptable in comfort care 2
• Equipment to maintain patent airway should be immediately available, though the decision to use it depends on goals of care 2
• Sedative effects may add to post-ictal impairment of consciousness, which is expected in terminal patients 2