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Objectives To investigate the efficacy and safety of oral (PO) and subcutaneous (SC) lacosamide for refractory symptoms in the palliative setting.Methods We conducted a retrospective chart review of the use of lacosamide since it was introduced in our palliative care service 1½ years ago. All clinical notes, medication administration records and infusion monitoring documentation were examined to ascertain therapeutic aim, efficacy, and tolerability.Results Lacosamide was administered to 91 patients; 90% had cancer. The most common indication was neuropathic pain (97%); there appeared to be a significant improvement in 35%; this was sometimes apparent within a few hours of an SC loading ‘test’ dose. Many recipients (44%) were in their last month of life. 59% received one or more SC doses; switching from PO to SC lacosamide was straightforward and it appeared compatible with a range of other palliative medications. Lacosamide appeared well tolerated; adverse effects were identified in 11% (10/91), half of whom (5%, 5/91) discontinued treatment. Of 59 admixtures infused SC, one mild SC site reaction occurred that resolved with the addition of dexamethasone.Conclusions Lacosamide appears to be a promising option for refractory symptoms warranting further study; SC administration is an advantage when the PO route is lost.