Seizure Management in Palliative Care: An Exploratory Cross-sectional Survey of Physician Practices in Germany

Seizures pose significant challenges in patients with serious illness, particularly when altered consciousness or dysphagia impair the ability to take antiseizure medication (ASM). However, evidence to inform seizure management in palliative care is limited. Although guidelines exist for epilepsy populations, recommendations for people with serious illness or the end of life are scarce.

To characterize seizure management practices and use of ASM in specialized inpatient (SIPC) and outpatient palliative care (SOPC) in Germany.

We conducted an exploratory cross-sectional online survey among palliative care physicians in Germany between 08/2023 and 10/2023. The questionnaire covered key domains, including ASM selection, routes of administration, timing and regimens of acute seizure treatment, transition to benzodiazepines (BZD-ASM), ASM discontinuation, and challenges encountered in clinical practice.

Among the 111 participating palliative care physicians, 98% reported initiating maintenance ASM, most commonly Levetiracetam (98%) and Midazolam (75%). Most physicians (99%) reported routinely using rescue medication for acute seizures. Midazolam was the most frequently reported first-line rescue medication, preferred in SIPC by 53% and in SOPC by 65%. For second-line treatment of status epilepticus, Levetiracetam was the most frequent choice in SIPC (50%), while Midazolam was preferred in SOPC (52%).

Seizure management in palliative care in Germany reflects the specific requirements of patients with serious illness and partly deviates from established epilepsy guidelines. Findings point to a shift towards individualized approaches, including prioritization of BZD-ASM, flexible routes of administration, and increased off-label use. This highlights the need for tailored guidelines and prospective research in palliative care.