• Exclude other causes for loss of consciousness and/or uncontrolled movements
• e.g. vasovagal episodes, postural hypotension, arrhythmias, hypoglycaemia, extrapyramidal side effects
• Assess history of seizures and risk factors e.g. cerebral disease
• Assess compliance and ability to take current anti-epileptic medications

• Dying patients may be unable to take oral anti-epileptic drugs
• anti-epileptic drugs have long half-life therefore not all patients will need additional anticonvulsant treatment
• in patients with history or risk of seizures, prescribe midazolam 5-10 mg IM PRN in addition to normal end of life PRN medication
• If recent seizures or significant concern about seizures, contact palliative care team (UHNM palliative care advice available 24 hr/day - see Rotawatch for details)
• consider midazolam 20-30 mg/24hrs by CSCI for prevention and control - see Continuous subcutaneous infusions (CSCI) in palliative care guideline
• in some situations, consider a continuous subcutaneous infusion of leviteracetam under the supervision of the palliative care team
• If non convulsive seizures identified on EEG, seek specialist advice from either neurology (UHNM neurology advice available from the neurology registrar on-call. See Rotawatch for details) or palliative care team

• It is distressing to witness a seizure
• if seizures occur, treat
• Investigations to find the underlying cause are unlikely to help
• Seek neurology or palliative care team help at the earliest opportunity 

Immediate care

• Put in a comfortable position, prevent injury
• Consider oxygen, assess patient, treat cause if possible and appropriate 

Resolves quickly

• Assess regularly, reassure, and proceed to seizure prevention guidance

Does not resolve in 5 min

• Cannula in situ: lorazepam 4 mg slow IV
• No cannula: do not cannulate, give midazolam 5-10 mg IM
• If seizure persists. repeat dose once after 10-20 min
• If seizure still persists, contact palliative care team
• consider Midazolam 20-30 mg SC over 24 hr via CSCI - see Continuous subcutaneous infusions (CSCI) in palliative care guideline

Caution

• Phenytoin and other anti-epileptic medications by IV infusion are unlikely to be appropriate in the last days of life
• require IV access and may require filter and cardiac monitoring