Epilepsy-related deaths: An Australian survey of the experiences and needs of people bereaved by epilepsy

Open ArchivePublished:May 15, 2015DOI:https://doi.org/10.1016/j.seizure.2015.05.007

      Highlights

      • Over half of respondents were unaware that epilepsy could be fatal.
      • For many, the epilepsy-related death had not been adequately explained to them.
      • Improved education and participation in risk-discussion is required.
      • Epilepsy-specific information and bereavement support is needed over time.

      Abstract

      Purpose

      This study explores the experiences and needs of bereaved family and friends following an epilepsy-related death in Australia.

      Method

      An online survey was used to collect demographic details of the person with epilepsy, epilepsy status, time since the death, satisfaction with service providers at the time of death, follow-up support, perceptions on how well the death was explained, and gaps in support or services.

      Results

      The survey was completed by 101 respondents describing 90 deceased individuals. Mean age at death was 32.1 years, with causes of death including SUDEP, epilepsy, drowning, cardiac arrest, asphyxiation, and motor vehicle accidents. Over half of the respondents indicated that they did not know, prior to the death, people could die of epilepsy. In addition, 38% indicated the death had not been adequately explained to them. Comments revealed services and supports which should be available following a death, and recommendations for existing epilepsy support services which might help to prevent future deaths.

      Conclusion

      Findings highlight the need to improve community understanding and support for those affected by epilepsy and to promote informed risk assessment and communication amongst patients, families and health professionals. People bereaved by epilepsy require both immediate and long-term epilepsy-specific information and support from professionals, informal communities and peer supporters.

      Keywords

      1. Introduction

      Epilepsy can be fatal but improved management has engendered a community perception that epilepsy is a benign condition [
      • Shankar R.
      • Cox D.
      • Jalihal V.
      • Brown S.
      • Hanna J.
      • McLean B.
      Sudden unexpected death in epilepsy (SUDEP): development of a safety checklist.
      ]. Data indicate that people with epilepsy have a risk of premature death that is 2–3 times higher than the general population [
      • Gaitatzis A.
      • Sander J.W.
      The mortality of epilepsy revisited.
      ]. In addition, the risk of dying suddenly and unexpectedly is approximately 24 times higher [
      • Ficker D.M.
      • So E.L.
      • Shen W.K.
      • Annegers J.F.
      • O’Brien P.C.
      • Cascino G.D.
      • et al.
      Population-based study of the incidence of sudden unexplained death in epilepsy.
      ]. Causes of death include status epilepticus, seizure related incidents such as drowning, falls and asphyxia, and negative treatment outcomes [
      • Gaitatzis A.
      • Sander J.W.
      The mortality of epilepsy revisited.
      ]. For many deaths, there is no adequate medical explanation. Historically, such deaths may have been classified as epilepsy, but they are now usually described as Sudden Unexpected Death in Epilepsy (SUDEP) [
      • Nashef L.
      • So E.L.
      • Ryvlin P.
      • Tomson T.
      Unifying the definitions of sudden unexpected death in epilepsy.
      ,
      • Shorvon S.
      • Tomson T.
      Sudden unexpected death in epilepsy.
      ], the most common cause of epilepsy-related death [
      • Friedman D.
      • Hirsch L.J.
      Sudden unexpected death in epilepsy – an overview of current understanding and future perspectives.
      ]. Those who die from epilepsy are often young and are frequently found deceased in bed by family or friends [
      • Friedman D.
      • Hirsch L.J.
      Sudden unexpected death in epilepsy – an overview of current understanding and future perspectives.
      ,
      • Kennelly C.
      • Riesel J.
      Sudden death and epilepsy: the views and experiences of bereaved relatives and carers.
      ]. The bereaved feel enormous regret if they did not realise death was a possibility [
      • Kennelly C.
      • Riesel J.
      Sudden death and epilepsy: the views and experiences of bereaved relatives and carers.
      ].
      In 2012, the total Australian population was 22,683,600 [
      • Australian Bureau of Statistics (ABS)
      3220.0 Population projections 2012 to 2101.
      ]. Recent estimates from a Tasmanian study suggest the overall prevalence of people treated with epilepsy is 4.4 per 1000, equating to approximately 99,800 people across Australia [
      • D'Souza W.
      • Quinn S.
      • Fryer J.
      • Taylor B.
      • Ficker D.
      • O’Brien T.
      • et al.
      The prevalence and demographic distribution of treated epilepsy: a community-based study in Tasmania, Australia.
      ]. Between 2008 and 2012, the average number of deaths in Australia attributed to epilepsy was 290 per year [
      • Australian Bureau of Statistics (ABS)
      3303.0 Causes of death, Australia, 2012.
      ]. This figure may seem modest, however, when assessed using Years of Potential Life Lost (YPLL75), a measure sensitive to premature death, the public health burden for epilepsy is seen to be greater than the highly publicised and well funded chronic health issue of asthma. Although the number of deaths in 2012 from asthma (386) was higher than epilepsy (265) [
      • Australian Bureau of Statistics (ABS)
      3303.0 Causes of death, Australia, 2012.
      ], the number of years of potential life lost (YPLL75) to epilepsy was 6621 (2012) compared to 3948 in asthma [
      • Australian Bureau of Statistics (ABS)
      General Record of Incidence of Mortality (GRIM) Books – Epilepsy.
      ]. Further comparisons reveal YPLL for SUDEP is higher than other neurological conditions including amyotrophic lateral sclerosis, multiple sclerosis, Alzheimer disease and Parkinson disease [
      • Thurman D.J.
      The epidemiology of SUDEP: a public health perspective.
      ].
      The experience of those bereaved by epilepsy is neglected in research. The only identified study was published in 2002 in the UK [
      • Kennelly C.
      • Riesel J.
      Sudden death and epilepsy: the views and experiences of bereaved relatives and carers.
      ]. This report identified family and carer dissatisfaction with health services prior to the deaths and factors which exacerbated the distress of the bereaved, including a lack of information and support. In Australia, anecdotal information suggests similar experiences. It is important to explore this issue systematically to illuminate the needs of those affected by epilepsy deaths, any gaps in service delivery, and possible areas of reform. The current study therefore aims to explore the experiences and needs of Australians bereaved by epilepsy.

      2. Methodology

      2.1 Participants

      Participants were self-selected individuals aged 18 years or over who had lost a family member or friend, with the underlying cause of death understood to be attributed to epilepsy.

      2.2 Procedure

      Ethics approval was granted from Flinders Social and Behavioural Research Ethics Committee (Project No. 5658). An invitation to participate in the survey was publicised by Epilepsy Australia, state epilepsy organisations, the Australian Epilepsy Research Register (AERR) and associated newsletters and websites. Participants were invited to complete a 28 question mixed methods electronic survey via SurveyMonkey between July 2012 and October 2013. The 20 min survey was created by health professionals and people bereaved by epilepsy with significant expertise in this field. A pilot study was conducted with five people and no changes were made. Therefore the data have been included in final analyses. Survey questions sought information on: the demographic details of the person with epilepsy; epilepsy status, time since death; satisfaction with service providers, at the time of death; follow-up support; prior awareness of epilepsy-related deaths; perceptions on how well the death was explained; and gaps in support or services. Participants indicated consent by submitting the survey. Participants were anonymous and were not required to answer all questions; hence there is some missing data. The only compulsory questions included the first name, gender and age of the person who died, and the respondent's date of birth and postcode. This data enabled researchers to determine if any respondents referred to the same individual.

      2.3 Analysis

      Survey data were downloaded from SurveyMonkey to SPSS 20, with qualitative comments imported into NVivo 10. Comments to open-ended questions were analysed using inductive data-driven thematic analysis [
      • Patton M.Q.
      Qualitative evaluation and research methods.
      ]. Two researchers with doctorate level qualifications read, discussed and collaboratively coded all qualitative data. Emerging themes were identified, reviewed, defined and named [
      • Braun V.
      • Clarke V.
      Using thematic analysis in psychology.
      ]. Selected quotes are presented in this paper to illustrate a range of perspectives with ID number and relationship indicated in parentheses. Simple descriptive statistics were used to demonstrate the valid percentage of responses for quantitative questions, in addition to means, ranges and rank ordering.

      3. Results

      3.1 Respondents

      A total of 101 valid Australian responses were received from bereaved family and friends from rural and metropolitan areas in all states except the Northern Territory (Vic 44; NSW 13; ACT 9; SA 7; Qld 4; WA 4; Tas 1; postcode not indicated 19). Respondents described 90 deceased individuals with epilepsy.
      Table 1 provides the demographic details of the deceased and their relationship with survey respondents. Some participants chose not to respond to particular questions, or did not have access to the requested information; therefore, valid percentages are reported in the results tables and missing data is noted.
      Table 1Demographic details of respondent and deceased.
      N (valid percent)
      Relationship to deceased (n = 101)
       Parent49 (48.5%)
       Sibling13 (12.9%)
       Partner12 (11.9%)
       Friend11 (10.9%)
       Daughter/son6 (5.9%)
       Other family member10 (9.9%)
      Sex of deceased (n = 90)
       Male42 (56%)
       Female33 (44%)
      Missing15
      Age of deceased (n = 90)
       Range7–84 years
       Mean32.1 years (SD 16.54)
      Living arrangement of deceased
       With partner/family/friends69 (79.3%)
       Alone12 (13.8%)
       Supported accommodation6 (6.9%)
      Missing3
      Time between epilepsy diagnosis and death
       Undiagnosed5 (5.7%)
       <1 year4 (4.5%)
       1–5 years20 (22.7%)
       6–10 years15 (17%)
       >10 years44 (50%)
      Missing2
      Was the person under the care of a specialist for epilepsy treatment?
       Yes66 (74.2%)
       No15 (16.9%)
       Unsure8 (9%)
      Missing1
      Almost half of the respondents were parents of the person with epilepsy (48%), with siblings, partners, daughters/sons and friends also represented in the sample. Ages of deceased ranged from 7 to 84 years with an average age of 32 years. Gender of deceased was disclosed in 75 of 90 cases (56% male). Living arrangements were recorded for 87 of the deceased. Of these the majority (79.3%) had been living with partners, family or friends. Others were living alone (13.8%) and in supported accommodation (6.9%).
      Information regarding the time which elapsed between the diagnosis of epilepsy and death was provided for 88 people. Death had occurred more than 10 years following diagnosis in 50%, within 5 years of diagnosis in 27%, and between 6 and 10 years post-diagnosis in 17%. It is noted that 5% died before an epilepsy diagnosis was made. These cases were included in analysis as the individual was either under the care of an epilepsy specialist, or the post mortem investigation indicated SUDEP as the cause of death. Approximately three quarters of the deceased were known to have been under the care of a specialist physician.

      3.2 Details associated with the death

      Details associated with the death are presented in Table 2. Of 88 deaths more than half (67%) had occurred in the five years prior to the survey, with 26% in the year immediately preceding survey. The remainder occurred more than 6 years prior. Approximately 80% of the deaths occurred in the person's home with others occurring in hospital or elsewhere. More than half of those who died were alone. Of the 90 cases respondents could confirm that a post mortem was performed in 63 and not performed in 10. Respondents provided cause of death for only half of the cases (n = 45), with most attributed to SUDEP (n = 18), followed by epilepsy (n = 13) and drowning (n = 8). Cardiac arrest, asphyxiation, motor vehicle accident, or unknown/still waiting were also noted. The majority of SUDEP deaths occurred within the past 5 years (n = 15), with three occurring 6–10 years ago.
      Table 2Details associated with the death (n = 90).
      N (valid percent)
      When did the death occur?
       <1 year23 (26.1%)
       1–5 years36 (40.9%)
       6–10 years16 (18.1%)
       >1013 (14.8%)
      Missing2
      Where did the death occur?
       Home71 (79.8%)
       Hospital7 (7.9%)
       Other11 (12.4%)
      Missing1
      Was the person alone at the time of death?
       Yes52 (58.4%)
       No32 (36%)
       Unsure5 (5.6%)
      Missing1
      Was a post mortem carried out following the death?
       Yes63 (82.9%)
       No10 (13.2%)
       Unsure3 (3.9%)
      Missing14
      Cause of death recorded (n = 45)
       SUDEP18 (40%)
       Epilepsy13 (28.9%)
       Drowning8 (17.8%)
       Cardiac arrest2 (4.4%)
       Asphyxiation1 (2.2%)
       Motor vehicle accident1 (2.2%)
       Unknown/still waiting2 (4.4%)

      3.3 Prior knowledge of epilepsy-related death

      Approximately half of the respondents indicated that they had not known a person could die because of epilepsy (n = 52, 53%). Thirty respondents provided further comments, with 13 indicating they used to believe epilepsy-related deaths could only occur as a result of an accident/trauma during a seizure (e.g. head injury or drowning). In one case, a parent asked their son's doctor directly if he could die from epilepsy, “Who answered no, unless drowning or falling of a ladder(#31; Parent).
      Five comments specifically related to poor knowledge of SUDEP until after the death (and subsequent internet searches), and others understood only people with severe, uncontrolled epilepsy were at risk of death. “It was never explained to me that [Name] could die of a seizure and how it could happen.” (#112; Parent).

      3.4 Explanation of the death

      Of 85 respondents, almost half (n = 38, 45%) felt the death was not adequately explained (Table 3). Many referred to the absence of a clear explanation of SUDEP, or where reliant on their own research. Those who did feel the explanation was adequate described supportive contact with specialists, responsive to family requests. Others did not desire further explanation.
      Table 3Was the death adequately explained to you? Please comment.
      ThemesExample of responses
      Yes (55%)
       Supportive experienceThe social worker at the coroner's office was excellent in explaining things to me…The actual autopsy report had to be delivered by a doctor so I selected my son's Paediatrician… He took over 2hours to go through every single line… and explain not only the medical terminology but the actual reality of what that meant in relation to [Name's] conditions, disorders and even the influences of my 19 years of nurturing and care for him. This was extremely helpful and led my eldest son and I to see that we had done the very best for him as we could…this way was really the best thing that could have happened under the circumstances for us.” (#6; Parent)
       Initiated by familyFollowing [child's] death and consequent autopsy report, we (family) all wanted answers to why [they] had died. We contacted [their] specialist, made an appointment to see him and from there began to understand SUDEP.” (#150; Parent)
       Further details not desiredWe were told we could get a copy of the coroner's report, but for me…I know she died from Epilepsy, it's not going to bring her back, and I don’t want to know any grisly details of exactly how.” (#45; Parent)
      No (45%)
       No clear explanation of SUDEPWe now understand there are a range of possible contributing factors to the death and more research is needed to clarify the mechanisms involved. The neurologist offered his condolences but no other information or support.” (#68; Parent)
      …because of the mystery surrounding SUDEP I don’t think anyone could adequately explain it to me.” (#49; Partner)
       Reliant on own researchI only know what I have searched and found.” (#108; Parent)
      Comments were received from 73 respondents regarding who provided the most helpful explanation of the death. Medical professionals, the coroner's office and epilepsy organisations were helpful for almost half, with the remainder relying on their own research, their family and friends, or had no-one to assist.

      3.5 Support and services: what was helpful following the death?

      Respondents were asked to indicate which supports (from a presented list) they accessed and to rate how helpful they were in the early weeks following the death and again as time has passed (1 = extremely helpful; 5 = not helpful). Table 4 presents the rank order of mean ratings, however it should be noted that experiences of all supports ranged from extremely helpful to a little helpful across all supports. Family and friends were rated as an extremely helpful source of support at both time periods. Professional supports and services (e.g. coroner, epilepsy support services, psychologist, and GP) were rated lower, but nevertheless very helpful. Specialist doctors for epilepsy care and general bereavement support groups rated only as ‘moderately helpful’ and hospital staff as the lowest mean support, rated as slightly helpful.
      Table 4Most helpful supports following the death.
      Early supports (during weeks following the death)Mean rating*Rating descriptionLater supportsMean rating
      1, extremely helpful and 5, not helpful.
      Rating description
      Family/friends (n = 82)1.5Extremely helpfulFamily/friends (n = 79)1.6Extremely helpful
      Faith/spirituality/church (n = 36)2.3Very helpfulLearning more about epilepsy-related death (n = 40)2.0Very helpful
      Psychologist/counsellor (n = 26)2.6Faith/spirituality/church (n = 30)2.1
      General practitioner (n = 47)2.8Taking action to help others with epilepsy (n = 28)2.3
      General epilepsy support services (n = 28)2.8Psychologist/counsellor (n = 31)2.3
      Support of others bereaved by epilepsy (n = 18)2.9Supporting others bereaved by epilepsy (n = 15)2.5
      Coroner's staff (n = 33)2.9General epilepsy support services (n = 20)2.8
      General Practitioner (n = 27)2.9
      School or work chaplain (n = 15)3.1Moderately helpfulSupport of others bereaved by epilepsy (n = 15)3.1Moderately helpful
      Police (n = 21)3.3General bereavement support group (n = 13)3.5
      General bereavement support group (n = 14)3.4School/work chaplain (n = 12)3.7
      Telephone help lines (n = 14)3.8Specialist doctor for epilepsy care (n = 17)3.8
      Specialist doctor for epilepsy care (n = 36)3.8
      Residential care staff (n = 10)3.9
      Hospital staff (n = 14)4.0Slightly helpful
      a 1, extremely helpful and 5, not helpful.

      3.6 Support and services: gaps and recommendations

      Respondents described both negative and positive experiences in support and services following the death, together with recommendations for future development. One hundred and thirty seven comments were coded under two main themes, identifying services and supports which should be available (a) prior to and (b) following the epilepsy related death.

      3.6.1 Support and services prior to death

      Respondents identified a range of services and supports which may have helped to reduce the risk of death (Table 5). The most prominent was further information and open discussion on epilepsy-related death by medical professionals. Awareness and discussion regarding SUDEP was limited, and believed by families to be influential in reducing risk.
      Table 5Experiences of and recommendations for support and services: prior to death.
      Sub-themesExample of responses
      Information and open discussion on epilepsy-related death“Please tell doctors/specialists to discuss it with their newly diagnosed patients.” (#45; Parent)



      In retrospect it was quite staggering that so many professionals including [husband's] GP, staff at the coroner's office and the pathologist had, by their own admission, such little knowledge of SUDEP.” (#149; Partner)
      Epilepsy awareness & education“More education… for the community, then young people may not be so embarrassed about their epilepsy.” (#58; Mother)
      Family-centred support“Provide and publicise support services for family of people with epilepsy. Most seems geared towards epilepsy sufferers themselves which is understandable but sometimes their family also needs information and support.” (#74; Daughter)
      Monitoring & regulation of care“The general public have no idea. There needs to be more education – about safety and the minimum level of care needed when looking after people with Epilepsy… Leaving someone alone in water who has uncontrolled Epilepsy inevitably has only one outcome. It should be seen as criminal negligence by the Police and Courts…these deaths are just so avoidable” (#124; Parent)
      Other“…I know a sudden death is extremely painful and hard to believe but please don’t forget the experience of watching someone deteriorate before your eyes as that can be just as hard. The end is still a shock as you always try to hope for a cure that never came.”(#53; Parent)



      “There is not much publicity about epilepsy in rural areas, so therefore support is even harder to find. No epilepsy specialist in rural areas where you can get help.” (#26: Parent)
      A range of comments identified the need for improved epilepsy awareness and education within schools, the general public, for extended family members, medical professionals and others such as police, coroners and support staff. It was felt that this may work to reduce stigma, and improve positive epilepsy management in the community.
      Another theme which emerged was the need for family centred support services which should include and engage with family members of people with epilepsy, including siblings and children.
      Monitoring and regulation of care was highlighted, drawing attention to the special needs of vulnerable people with epilepsy in residential services. One respondent reported a death by drowning in a disability service, highlighting the avoidable nature of some epilepsy-related deaths.
      Other comments described the devastating experience of watching the decline of their family member, highlighting the need for palliative support, and improvements to rural access to epilepsy specialists and support.

      3.6.2 Support and services following a death

      A range of supports and services required after the death were identified (Table 6).
      Table 6Experiences of and recommendations for support and services: following an epilepsy related death.
      Sub-themesExample of comments
      Grief & loss support
       Counselling“I found out through the Epilepsy Australia website about SUDEP and that there were bereavement counsellors to help. But our GP didn’t know about this service which may have been helpful.” (#62; Sibling)
       Emotional & peer support“A support group comprised of others bereaved by epilepsy would be very helpful and I know of no such group in Sydney.” (#37; Parent)
       Memorial services“I attended the memorial service and found it very comforting. I could relate to those people's loss and the trauma and pressure epilepsy puts on a lot of people in our community.” (#25; Partner)
       Timing of support“The family was offered grief counselling and support (by the State Coroner) after the sudden death, but we did not follow it up. In hindsight I believe it would have helped if there was a follow up from the service, say 6/12 months later. I believe it may have helped the family.” (#132; Sibling)
       Isolation & avoidance“We need more support than we’ve had. We feel very alone now.” (#64; Parent)
      “I was avoided by folks because I had lost a child. No one can bear the thought of that.” (#2; Parent)
       For extended family & friends“There was a complete vacuum of information from medicos, coroner, etc. as to what happened with my sister. That may have been available to her husband but not to siblings or our parents. I would have thought we would/should have a right to know to provide some understanding of the sudden death and help out with our grieving.” (#54; Sibling)
      Access to information
       Medical records, autopsy & police investigation reports“Autopsy report, medical records and genetic testing gathered by authorities is unavailable to the family. Such information may be useful in the management of health issues for other members.” (#109; Daughter)
       On epilepsy and SUDEP“Literature or social stories to properly explain epilepsy to small children to then assist with understanding how this could cause death.” (#36; Parent)
      “A clear programme of support for grieving family with a pack that be given to them at the hospital and with follow up calls. Support services are abysmal.” (#131; Parent)
      “At the time of our son's death the doctors were the only people we thought who could help us understand what had happened. They did not help at all and so we went on an information gathering trip of our own, which is ongoing. We are concerned for people who may not be able to do this due to their grief, resources, etc.” (#68; Parent)
       On epilepsy support services“To make it more known about the epilepsy support services… Perhaps when a death is ruled as Epilepsy… that a brochure or information about Epilepsy support is given to the family…. Or that information [is] sent out by the Coroner's office…. Also that more counsellors, psychologists and social workers, etc. have it as [a] referral/networking resource …” (#6; Parent)
      Follow-up from health professionals and other services“No support was offered to me from any organisation or professional.”(#108; Parent)
      Professional sensitivity & knowledge of SUDEP“A sympathetic and useful coroner's office would be a start. Plus a consistent and competent police force so our trauma would not have to be relived repeatedly.” (#131; Parent)
      The most common was the need for a range of grief and loss support services including: counselling; emotional and peer support; memorial services; the timing of support; availability for extended family and friends. A range of experiences of isolation, disconnection and avoidance were shared, with the absence of emotional support and counselling identified as a clear concern.
      Many respondents indicated they were unaware of any epilepsy peer support groups in Australia which addressed bereavement. The importance of shared experience was emphasised, highlighting the value of finding others who ‘have travelled the road.’: “Professionals have their place but cannot even come close to providing the comfort you can get from those with shared experience.” (#74; Daughter).
      Limited supports for extended family and friends were cited, with reports of a ‘vacuum of information’ from health professionals and the coroner. This may be due to issues of confidentiality required of health professionals, however emphasises the disconnection and need for referral to supports following the death.
      Establishing a website with FAQs on epilepsy related death and online forums were suggested, with others deeply appreciating ‘comforting’ and ‘supportive’ memorial services held in selected states. The timing of support was also identified as a critical issue, with epilepsy support services to be made available more immediately to grieving family members, as well as offered again at a later time to those who are not yet ready.
      Many respondents referred to the need for access to information following the death. Respondents wanted timely access to medical records and autopsy and investigation reports. Information on epilepsy in general, epilepsy-related deaths, and SUDEP where appropriate, was also identified as critical following a death. In addition, information on epilepsy organisations and other support services is needed, with comments indicating limited awareness of possible supports available.
      The need for follow-up from health professionals and other services was identified, with many respondents indicating disappointment that health professionals (including GPs, neurologist, hospital support groups and epilepsy organisations) made no contact following their family member's death.
      The final sub-theme relates to the need for increased professional sensitivity and knowledge of SUDEP. Examples of insensitive treatment by authorities and the coroner's office were provided, suggesting a need for epilepsy to be included in the training of police and those who investigate such deaths. For two respondents, the unexpected death was approached with some suspicion by some authorities, significantly impacting family stress at this time.

      4. Discussion

      Mortality in epilepsy receives little public attention, despite the fact that many of the deaths occur suddenly and unexpectedly in young people [
      • Shankar R.
      • Cox D.
      • Jalihal V.
      • Brown S.
      • Hanna J.
      • McLean B.
      Sudden unexpected death in epilepsy (SUDEP): development of a safety checklist.
      ]. Internationally, bereaved families and friends recount a lack of prior knowledge of risk and they question whether improved community awareness might reduce deaths [
      • Kennelly C.
      • Riesel J.
      Sudden death and epilepsy: the views and experiences of bereaved relatives and carers.
      ,
      ,
      ]. For those bereaved by epilepsy, support after the death is reported to be inadequate. This study explored the experience of Australians bereaved by epilepsy to identify gaps in support and services which need attention.
      Notably, half of the respondents were not aware that epilepsy could be fatal. This is not surprising as research into epilepsy risk communication indicates wide variation in practice [
      • Morton B.
      • Richardson A.
      • Duncan S.
      Sudden unexpected death in epilepsy (SUDEP): don’t ask, don’t tell?.
      ,
      • Vegni E.
      • Leone D.
      • Canevini M.
      • Tinuper P.
      • Moja E.
      Sudden unexpected death in epilepsy (SUDEP): a pilot study on truth telling among Italian epileptologists.
      ,
      • Waddell B.
      • McColl K.
      • Turner C.
      • Norman A.
      • Coker A.
      • White K.
      • et al.
      Are we discussing SUDEP? A retrospective case note analysis.
      ,
      • Miller W.R.
      • Young N.
      • Friedman D.
      • Buelow J.M.
      • Devinsky O.
      Discussing sudden unexpected death in epilepsy (SUDEP) with patients: practices of health-care providers.
      ]. Similarities can be seen with the study by Jones et al. [
      • Jones L.
      • Naude J.T.
      Sudden unexpected death in epilepsy information provision to parents of children with epilepsy – a service evaluation.
      ], in which 52% of 50 families of children diagnosed with epilepsy were unaware of SUDEP. Only 16% were informed of SUDEP by a doctor or epilepsy nurse, with 70% made aware through alternative sources such as the internet and media. The role of the internet was also highlighted in the study by Kroner et al. [
      • Kroner B.L.
      • Wright C.
      • Friedman D.
      • Macher K.
      • Preiss L.
      • Misajon J.
      • et al.
      Characteristics of epilepsy patients and caregivers who either have or have not heard of SUDEP.
      ], with 46.9% (n = 64) of caregiver respondents surveyed from an epilepsy clinic unaware of SUDEP, in contrast to only 21% (n = 547) of caregiver respondents from an internet survey. In the absence of risk communication in a clinical setting, the internet is filling the information gap.
      Many respondents in the current study reported that they had not received an adequate explanation of the death. Comments indicated that information was critical to assist in coping with the event. Relatives were left wondering why the death had occurred and desperately seeking answers. For some families there are questions about whether this could happen to other family members. Many of the respondents relied on family and friends or their own research to gather information, echoing the findings of Jones et al. [
      • Jones L.
      • Naude J.T.
      Sudden unexpected death in epilepsy information provision to parents of children with epilepsy – a service evaluation.
      ]. When deaths occur, participants recommended the following strategies: enhanced grief and loss services including face-to-face and online peer support; timely access to a range of information including medical records, autopsy findings, SUDEP resources, and police reports; referral to appropriate epilepsy organisations; timely and informed services from health professionals and community officers, with follow up.
      It is interesting that many respondents in this study raised circumstances prior to death as an area needing improvement. Their comments are in line with those of some health professionals who suggest that some epilepsy deaths may be preventable with appropriate guidance and care [
      • Hanna N.J.
      • Black M.
      • Sander J.W.S.
      • Smithson W.H.
      • Appleton R.
      • Brown S.
      • et al.
      The national sentinel clinical audit of epilepsy related death: epilepsy – death in the shadows.
      ,
      • Institute of Medicine
      Epilepsy across the spectrum: promoting health and understanding.
      ,
      • So E.L.
      • Bainbridge J.
      • Buchhalter J.R.
      • Donalty J.
      • Donner E.J.
      • Finucane A.
      • et al.
      Report of the American Epilepsy Society and the Epilepsy Foundation Joint Task Force on Sudden Unexplained Death in Epilepsy.
      ,
      • Hughes J.R.
      A review of sudden unexpected death in epilepsy: prediction of patients at risk.
      ,
      • Surges R.
      • Thijs R.D.
      • Tan H.L.
      • Sander J.W.
      Sudden unexpected death in epilepsy: risk factors and potential pathomechanisms.
      ,
      • Faught E.
      • Duh M.S.
      • Weiner J.R.
      • Guerin A.
      • Cunnington M.C.
      Nonadherence to antiepileptic drugs and increased mortality: findings from the RANSOM study.
      ,
      • Shankar R.
      • Jalihal V.
      • Walker M.
      • Laugharne R.
      • McLean B.
      • Carlyon E.
      • et al.
      A community study in Cornwall UK of sudden unexpected death in epilepsy (SUDEP) in a 9-year population sample.
      ]. Such a goal involves quality informed medical support [
      • Institute of Medicine
      Epilepsy across the spectrum: promoting health and understanding.
      ,
      • So E.L.
      • Bainbridge J.
      • Buchhalter J.R.
      • Donalty J.
      • Donner E.J.
      • Finucane A.
      • et al.
      Report of the American Epilepsy Society and the Epilepsy Foundation Joint Task Force on Sudden Unexplained Death in Epilepsy.
      ], optimisation of seizure control and patient education for self-management. Guidelines and recommendations now exist in some countries encouraging routine discussion with patients to inform and educate about risk avoidance [
      • Institute of Medicine
      Epilepsy across the spectrum: promoting health and understanding.
      ,
      • So E.L.
      • Bainbridge J.
      • Buchhalter J.R.
      • Donalty J.
      • Donner E.J.
      • Finucane A.
      • et al.
      Report of the American Epilepsy Society and the Epilepsy Foundation Joint Task Force on Sudden Unexplained Death in Epilepsy.
      ,
      • Scottish Intercollegiate Guidelines Network
      Diagnosis and Management of Epilepsy in Adults Edinburgh.
      ,
      • National Institute for Health and Care Excellence
      The epilepsies: the diagnosis and management of the epilepsies in adults and children in primary and secondary care, CG137.
      ,
      • Duff A.J.M.
      Determination of Sheriff Alistair Duff, Sheriff of Tayside Central and Fife at Dundee. Inquiry held under fatal accidents and sudden deaths inquiry (Scotland) Act 1976 into the deaths of Erin Casey and Christina Fiorre Ilia.
      ].
      Despite this increasing emphasis on pro-active risk communication in epilepsy, some health professionals hold the opinion that where a patient does not ask about SUDEP the decision about whether or not to discuss the issue remains at the discression of the doctor [
      • Beran R.
      SUDEP revisited – a decade on: have circumstances changed.
      ]. However the perspectives shared by bereaved family and friends in this current study, and the findings of other recent studies and inquiries [
      • Kroner B.L.
      • Wright C.
      • Friedman D.
      • Macher K.
      • Preiss L.
      • Misajon J.
      • et al.
      Characteristics of epilepsy patients and caregivers who either have or have not heard of SUDEP.
      ,
      • Duff A.J.M.
      Determination of Sheriff Alistair Duff, Sheriff of Tayside Central and Fife at Dundee. Inquiry held under fatal accidents and sudden deaths inquiry (Scotland) Act 1976 into the deaths of Erin Casey and Christina Fiorre Ilia.
      ,
      • Gayatri N.A.
      • Morrall M.C.
      • Jain V.
      • Kashyape P.
      • Pysden K.
      • Ferrie C.
      Parental and physician beliefs regarding the provision and content of written sudden unexpected death in epilepsy (SUDEP) information.
      ,
      • RamachandranNair R.
      • Jack S.M.
      • Meaney B.F.
      • Ronen G.M.
      SUDEP: what do parents want to know?.
      ], suggest that people with epilepsy and their families generally prefer, expect, and require, open and balanced communication of their individual risk, so that they can participate in informed decision making. It would be useful to have Australian specific guidelines to provide an agreed framework for practice.
      Comments by respondents in this study mirrored many of the comments arising from the UK study by Kennelly and Riesel in 2002 [
      • Kennelly C.
      • Riesel J.
      Sudden death and epilepsy: the views and experiences of bereaved relatives and carers.
      ]. Although there is 10 years between the studies the issues confronting Australian families now are strikingly similar to those in the UK at that time. It is notable that community action by bereaved families in the UK over the last 10 years has resulted in significant changes to UK epilepsy health care policies. The increased public discussion of epilepsy-related death has focussed attention on epilepsy care after, what one Chief UK Medical Officer referred to as, years of ‘…ignorance and apathy towards the needs of people with this common disorder’ [
      • Department of Health (DOH)
      Annual report of the Chief Medical Officer of the Department of Health 2001: epilepsy death in the shadows.
      ].
      A number of limitations impacting on the ability to draw generalised conclusions from this study are acknowledged. Although 83% of Australians were internet users in 2012 [
      • Australian Bureau of Statistics (ABS)
      81460.0 Household use of information technology, Australia 2012–2013.
      ], low responses to the online survey by a self-selected sample limit the generalizability of findings. Most respondents (66%) described events which occurred within the last 5 years (providing a strong emphasis on recent experiences), however, another 15% of deaths occurred more than 10 years ago. This may have influenced their accuracy of recall. In that time there has been some action to improve understanding and management of epilepsy-related death, with experiences possibly differing depending on the date of the death. Some respondents may not have been familiar with the detail requested in some questions (e.g. the time between diagnosis and death) which may compromise the validity of some responses. Survey questions were not compulsory which, although increased the likelihood of survey completion (e.g. respondents only completed questions they felt comfortable answering), also resulted in missing data. The survey was promoted through epilepsy agencies, thus reaching many families who may have had some access to support, but there may be other people bereaved by epilepsy who remain less engaged with services and whose isolation and distress may not have been represented here.
      There was a large Victorian representation in the sample (44%), suggesting a strong bias in findings. It is acknowledged that the state of Victoria has a particularly well developed network of epilepsy medical professionals and support services. However it is worth noting that Victorian respondents still viewed their awareness of epilepsy-related death, explanation of the death, and supports following the death as less than ideal. Group differences between Victoria and other states were not apparent in rates of SUDEP reported. Although 55% of Victorian respondents knew that people could die because of epilepsy, similar proportions were also seen in the NSW (54%) and SA (57%) groups–unfortunately small respondent numbers restrict our ability to draw meaningful conclusions between states.
      Respondents were not prompted to indicate if they were the regular caregiver of the deceased. Differentiation of respondents into regular caregivers versus non-regular would be useful as confidentiality issues could have prevented health professionals from talking to ‘other family members and friends’. This should be considered in future studies.

      5. Conclusion

      This study provides an Australian perspective on the experiences and needs of bereaved family and friends following epilepsy related death. The voices of people bereaved by epilepsy must be heard wherever epilepsy care is provided. These people have seen their loved ones live and die with epilepsy and they are well placed to comment on the strengths and weaknesses of epilepsy services. Findings indicate family and friends were often unaware of the risk of epilepsy related death, underlining the need to improve patient, family and professional education and participation in risk-discussion; an approach endorsed by guidelines but lacking in clinical practice. Results also highlight the need for both immediate and long-term epilepsy-specific information and support for the bereaved, from professionals, informal communities, and peer supporters. Future research measuring prospective, long-term outcomes of information and support identified in this study is warranted.

      Conflict of interest statement

      The authors report no conflicts of interest.

      Acknowledgements

      The development of this research was funded by Epilepsy Australia . Sincere thanks to the family and friends bereaved by epilepsy who generously participated in this study, Denise Chapman (Epilepsy Australia), Pauline Brockett (Library Manager, Epilepsy Foundation, Victoria), and Prof. Henry Smithson and Jane Hanna for survey feedback and proof reading.

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