Study indicates when to discuss early mortality risk in patients with epilepsy

Early online publication: Wednesday May 3, 2006. EMBARGO: 00:01H (London time) Wednesday May 3, 2006. In North America the embargo lifts at 18:30H ET Tuesday May 2, 2006.

Doctors should discuss the risk of premature death with epilepsy patients when treatment fails or is refused despite recurrent seizures, according to a study published online today (Wednesday May 3, 2006) by The Lancet Neurology.

Substantial debate surrounds the issue of whether and when to discuss the increased risk of premature death in patients with epilepsy. While physicians have a responsibility to fully discuss any risks associated with a disorder and its treatment, some have argued that the patient has a right not to know. Most people diagnosed with epilepsy can be expected to gain complete control of seizures and, therefore, would not be at increased risk of premature death from their epilepsy. Furthermore, imparting information about risk to life from seizures has the potential to cause harm--eg, unnecessary anxiety.

Rajiv Mohanraj and colleagues retrospectively assessed mortality data in patients with epilepsy to quantify the mortality risk associated with epilepsy. "Our study assessed mortality in patients with newly diagnosed and chronic epilepsy from the same population source and attending the same clinical service for up to 20 years, making these data especially useful to clinicians who wish to broach this issue with their patients."

Patients with newly diagnosed epilepsy who did not respond to treatment had increased mortality compared with the general population, but there was no rise in mortality rates in those who became seizure free at follow-up. "In light of our results, routine discussion of mortality at the time of diagnosis might not be necessary, especially if this does not affect the management of the disorder. However, mortality risks should be discussed with all patients diagnosed with epilepsy who choose not to take antiepileptic drugs", the authors say.

In patients with chronic epilepsy there was more than double the expected number of deaths and incidence of sudden unexpected death in epilepsy was more than double that in patients with newly diagnosed epilepsy. The greatest excess in mortality was reported in patients younger than 30 years. Evidence suggests that nocturnal supervision could be protective in patients who continue to have frequent seizures, and treatment with antiepileptic drugs reduce the possibility of sudden unexpected death. "Mortality risks and preventive strategies should be discussed with patients diagnosed with epilepsy for whom treatment has not achieved seizure freedom and with those who refuse treatment despite recurrent seizures", the authors suggest.

In an accompanying Reflection and Reaction article Roy Beran comments that there are "specific circumstances in which the discussion of possible premature death associated with epilepsy might not only be acceptable but may also be absolutely mandatory to ensure that the patient has been fully appraised of relevant material risks to be able to make an informed decision about treatment".

Martin J Brodie, Epilepsy Unit, Western Infirmary, Glasgow G11 6NT, UK. T) 0141 211 2572

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