“I choked on my lunch last week and it frightened the life out of us — my nurse is off, so I came to you”

In established MND the GP’s role is to recognise progression early and mobilise the multidisciplinary team quickly — especially when the specialist nurse is unavailable. Bulbar weakness causes dysphagia, coughing with thin fluids, sialorrhoea and weight loss; respiratory muscle weakness causes orthopnoea, morning headaches, daytime sleepiness and poor sleep, and should prompt urgent respiratory assessment for non-invasive ventilation, which can improve survival and quality of life. NICE advises discussing gastrostomy early and placing it before significant respiratory decline and weight loss; weight loss of 5% or more is a trigger for action. Riluzole is available as an oral suspension for people who cannot swallow tablets. Advance care planning should be offered at diagnosis and at each significant change: preferences, advance decision to refuse treatment (for example about NIV or feeding), ReSPECT, lasting power of attorney for health and welfare, preferred place of care, and anticipatory medicines. Reassure honestly: death from choking in MND is uncommon.