Sudden unexplained death

Review of the legal obligations of the doctor to discuss Sudden Unexplained Death in Epilepsy (SUDEP)--a cohort controlled comparative cross-matched study in an outpatient epilepsy clinic

INTRODUCTION

Acknowledging informed consent and warning of material risk, the present study examined the current debate regarding early discussion of Sudden Unexplained Death in Epilepsy (SUDEP). It sought to confirm the profile of those prone to SUDEP and to determine the basis for disclosure to patients.

METHODS

Patients with SUDEP attending an Australian outpatient epilepsy clinic between 1985 and 2000 were compared to an age, gender and epilepsy type cross-matched control group to ascertain risk factors for SUDEP and similarities to published parameters. These were evaluated as the basis for actions in negligence for either disclosure or failure to disclose.

RESULTS

Twenty-one SUDEP patients were identified: aged 18-70 years; the majority had localisation-related epilepsy (13:8, 62%); male to female ratio was 3:1; and 15/21 used polypharmacy, compared with 8/21 controls (P = 0.02951). Handedness, alcohol use or deterioration of epilepsy were unrelated.

DISCUSSION

This population mirrored the literature and confirmed an absence of risk factors amenable to modification. As discussion of SUDEP with males with localisation-related epilepsy on polypharmacy could not alter outcome it is unlikely that failure to disclose could be causal and hence successful in an action for negligence. Conversely, disclosure, in the absence of the patient seeking the information, may causally adversely affect quality of life hence providing successful action in negligence. Duty of care dictates open and frank discussion with those seeking the information. Thus, each case must be managed individually and doctors are advised to document the decision-making process.

Cardiorespiratory findings in sudden unexplained/unexpected death in epilepsy (SUDEP)

Sudden unexplained/unexpected death in epilepsy (SUDEP), with an incidence of 0.35-9.3/1000 patient-years depending on the severity of epilepsy, remains a diagnostic and therapeutic challenge. Potential pathomechanisms comprise cardiac arrhythmia, due to myocardial ischemia, electrolyte disturbances, arrhythmogenic drugs, or transmission of the epileptic activity via the autonomic nervous system to the heart, and central or obstructive apnea. In most studies on SUDEP, data are lacking about the family and patient's own clinical history, cardiovascular symptoms, concomitant diseases and prior findings. Whether arterial hypertension, diabetes, hypercholesterolemia, other neurologic disorders, lung diseases, smoking or electrolyte disturbances are risk factors for SUDEP is unknown. Whereas cardiac dysfunction during seizures has been documented by electrocardiography, and cardiac abnormalities are found in up to 33% of SUDEP cases autoptically, investigations between seizures found only little cardiac abnormalities. More knowledge about the cardiovascular and pulmonary status of epileptic patients during, immediately after and between seizures is needed, which may contribute to better understand and possibly prevent SUDEP by measures like "cardioprotective" drugs, respiratory therapy or implantation of a cardioverter/defibrillator.

Sudden unexpected death in epilepsy (SUDEP): risk factors and case control studies

Sudden unexpected death is an important category of mortality in the population with epilepsy. Possible risk factors have been identified from an epidemiological study of this phenomenon, but the exact mechanisms remain unclear. Some of these factors include: male sex; age 20-40 years; generalized seizures; poor seizure control; poor compliance with medication. Case-control studies now being undertaken are the next step in the elucidation of these factors. The results of one study to date reinforce the view that, in the majority of cases, sudden unexpected death in epilepsy (SUDEP) is a seizure-related event. This suggests that improvement in seizure control and the avoidance of polytherapy may be important in risk reduction. An ongoing exploratory case-control study in the UK has identified 154 cases of SUDEP, each of which will have four controls, matched for age and geographical location, in order to examine the influence of various parameters on the risk of sudden death.