Table 3

Management of Parkinson’s disease and seizures during end of life

Parkinson’s disease
  • Prognosis thought to be weeks consider:

    • To minimise rigidity and /or prevent symptoms of dopamine withdrawal, consider a dopamine agonist patch (eg, rotigotine) or subcutaneous apomorphine if oral route is lost and no enteral route available.

    • If they have a percutaneous endoscopic gastrostomy or nasogastric tube, dispersible Madopar can be given.

  • Prognosis likely days: the recommendation would be to focus on standard anticipatory medications, using midazolam as a muscle relaxant/opioid for pain. Even in last days of life, rotigotine is effective in preventing distress due to withdrawal symptoms. Common symptoms for relief during end of life include secretions, pain, agitation and fever.27

  • Choice of anti-emetic may need to be considered with caution due to risk of increasing rigidity. Generally avoid metoclopramide/haloperidol and use levomepromazine/cyclizine with caution. Ondansetron and domperidone are safe.

  • Cover risk of seizures if oral route is lost and no enteral route with recommendation for medication via a syringe pump. Midazolam remains the most common choice of anti-seizure medication in the dying phase with starting doses of 20–30 mg over 24 hours usually recommended. Other anti-seizure medications such as levetiracetam, phenobarbital and sodium valproate can be given via subcutaneous infusion but issues such as availability in community settings may focus the advice.

  • An intravenous infusion may be appropriate during the dying phase for someone dying acutely but is less likely to be used in an expected/anticipated death.28