Continuation of sedative infusions during palliative extubation for refractory status epilepticus in hepatic encephalopathy: A case report

Refractory status epilepticus complicating hepatic encephalopathy poses unique palliative challenges as standard extubation protocols typically reduce or discontinue sedative infusions, risking immediate seizure recurrence and distress. We report a 53-year-old man with end-stage cirrhosis and hepatocellular carcinoma who developed hepatic encephalopathy and refractory status epilepticus precipitated by small bowel obstruction. Despite ammonia-lowering therapy and multiple antiseizure medications, seizures remained refractory. Electroencephalography confirmed status epilepticus despite escalating therapy. Given prohibitive surgical risk and poor prognosis, the multidisciplinary team and patient's family elected to withdraw life-sustaining treatments, requesting he not die with an endotracheal tube in place. He underwent palliative extubation while continuing propofol and midazolam infusions to suppress seizure activity and ensure comfort. He died peacefully without visible seizure activity. Although limited by a single patient, this case provides a practical example of a rarely described palliative strategy: continuing sedative infusions during palliative extubation to prevent agonal seizures in refractory status epilepticus.