End of Life / Palliative Care

Last updated 1 Jun 2026 · Palliative Care

📋 Key Information Summary

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Palliative care aims to improve quality of life for patients with life-limiting illness; it is appropriate at any stage and can be delivered concurrently with disease-modifying treatment.
The WHO Analgesic Ladder guides pain management: Step 1 (non-opioids ± adjuvants) → Step 2 (weak opioids ± non-opioids ± adjuvants) → Step 3 (strong opioids ± non-opioids ± adjuvants). Bypass steps as clinically indicated.
Oral morphine is the first-line strong opioid; starting dose 2.5–5 mg every 4 hours for opioid-naïve patients, with regular reassessment.
Subcutaneous morphine infusion (via syringe driver) is preferred when the oral route is lost; convert using equianalgesic ratios and reduce total daily dose by 25–50% for cross-tolerance uncertainty.
Breakthrough (rescue) doses should be 10–20% of the total 24-hour opioid dose, given every 1–2 hours as needed.
Spinal (intrathecal/epidural) morphine is reserved for refractory pain unresponsive to systemic opioids or intolerable side effects; requires specialist referral.
Nausea in palliative care is managed by addressing the cause: haloperidol for drug-induced nausea, metoclopramide for gastroparesis, cyclizine or hyoscine for vestibular/mucosal causes.
Death rattle (pooled secretions) is managed with hyoscine butylbromide 20 mg SC or glycopyrrolate 200 mcg SC; repositioning and reassurance of family are equally important.
Terminal restlessness/agitation is treated with midazolam 2.5–5 mg SC stat, then continuous infusion 10–30 mg/24 h via syringe driver; rule out reversible causes first.
Anticipatory prescribing of subcutaneous medications for pain, nausea, secretions, and agitation should be arranged before the terminal phase to avoid delays and crisis management.
Communication skills — use SPIKES or NURSE frameworks when discussing prognosis; acknowledge grief and offer bereavement support including referral to specialist services.
Aboriginal and Torres Strait Islander communities may have distinct cultural and spiritual end-of-life practices; involve Aboriginal Health Workers/Practitioners early and support family and community decision-making.

Introduction & Australian Epidemiology

Palliative care is an approach that improves the quality of life of patients and their families facing the problems associated with life-threatening illness, through the prevention and relief of suffering by means of early identification, impeccable assessment, and treatment of pain and other physical, psychosocial, and spiritual problems (WHO, 2020). In Australia, general practitioners (GPs) play a central role in palliative care delivery, particularly in rural and remote settings where specialist palliative medicine services may be limited or absent.

Approximately 170,000 Australians die each year, with the majority of deaths occurring in those aged 65 years and older. Cancer remains a leading cause of death (~50,000 per year), but an increasing proportion of palliative care need arises from non-malignant conditions including end-stage heart failure, chronic obstructive pulmonary disease (COPD), motor neurone disease (MND), dementia, and end-stage renal disease. The Australian Institute of Health and Welfare (AIHW) reports that nearly 70% of Australians express a preference to die at home, yet only approximately 14% achieve this. In-hospital deaths remain the most common, followed by residential aged care facilities.

The National Palliative Care Strategy (2018) and the National Consensus Statement: Essential Elements for Safe and High-Quality End-of-Life Care (ACSQHC, 2015) outline the framework for delivery of end-of-life care across Australian health settings. The Palliative Care Outcomes Collaboration (PCOC) provides national benchmarking data on symptom burden and outcomes, demonstrating that consistent assessment using validated tools improves patient-reported outcomes.

Australian palliative care is funded through a combination of Medicare Benefits Schedule (MBS) items, the Pharmaceutical Benefits Scheme (PBS), state and territory health budgets, and the National Palliative Care Program. Telehealth MBS items (introduced during COVID-19 and now permanent) have expanded access to specialist palliative care for rural and remote populations.

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Australia has one of the highest rates of specialist palliative medicine physicians per capita in the OECD, yet access remains inequitable: metropolitan residents are 2–3 times more likely to access specialist services than those in outer regional or remote areas.

WHO Analgesic Ladder — Pain Management

The World Health Organization's Analgesic Ladder, first published in 1986, remains the cornerstone of cancer pain management and is widely applied in palliative care for both malignant and non-malignant conditions. The ladder provides a systematic, stepwise approach to analgesic selection, with the ability to move up or down based on response and changing clinical circumstances.

The Three-Step Ladder

Non-Opioids ± Adjuvants

For mild pain (NRS 1–3/10). Paracetamol 1 g PO QID (max 4 g/day; reduce to 2 g/day in low body weight <50 kg or hepatic impairment). NSAIDs such as ibuprofen 200–400 mg PO TDS or naproxen 250–500 mg PO BD for bony/metastatic pain. Consider celecoxib 200 mg PO OD if GI risk. Adjuvants (e.g., corticosteroids, gabapentinoids, antidepressants) may be added at any step.

Weak Opioids ± Non-Opioids ± Adjuvants

For moderate pain (NRS 4–6/10). Tramadol 50–100 mg PO every 4–6 hours (max 400 mg/day) or codeine 30–60 mg PO every 4–6 hours. Note: codeine is now Schedule 4 (prescription only) in Australia. Many palliative care experts recommend bypassing Step 2 and moving directly to low-dose strong opioids for simplicity and efficacy.

Strong Opioids ± Non-Opioids ± Adjuvants

For moderate-to-severe pain (NRS 7–10/10). Morphine is the strong opioid of first choice. Alternatives include oxycodone, hydromorphone, fentanyl (transdermal or IV/SC), methadone, and buprenorphine. Always prescribe regular laxatives with opioids (e.g., docusate with senna, or macrogol).

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Important: The ladder is a guide, not a rigid protocol. In palliative care, it is entirely appropriate — and often preferable — to bypass Steps 1 and 2, starting directly with a low-dose strong opioid (e.g., morphine 2.5–5 mg PO 4-hourly) when moderate-to-severe pain is anticipated or already present.

Adjuvant Analgesics

Adjuvant analgesics enhance pain relief, target specific pain mechanisms, or manage side effects. They can be used at any step of the ladder.

Pain Type	Adjuvant	Example Dose	Notes
Bone pain / raised ICP	Dexamethasone	4–8 mg PO/IV OD (morning)	Taper when stable; watch for hyperglycaemia, myopathy
Neuropathic pain	Gabapentin	100–300 mg PO OD, titrate to 300 mg TDS	Renal dose adjustment required; start low in elderly
Neuropathic pain	Pregabalin	25–75 mg PO BD, titrate to 150–300 mg BD	PBS Authority Required for neuropathic pain
Neuropathic pain / depression	Duloxetine	30 mg PO OD → 60 mg PO OD	Useful if concurrent depression; avoid with hepatic impairment
Muscle spasm / colic	Hyoscine butylbromide	20 mg SC/PO every 4–6 hours	Also for secretions; SC via syringe driver if needed
Visceral pain / bowel obstruction	Octreotide	100–300 mcg SC BD or continuous infusion	Reduces secretions in malignant bowel obstruction

Principles of Opioid Prescribing in Palliative Care

Choose the oral route wherever possible; switch to subcutaneous only when oral intake is no longer feasible.
Start low and titrate: begin with a low dose, review within 24–48 hours, and increase by 30–50% if pain persists.
Prescribe a regular opioid for continuous pain plus a breakthrough (PRN) dose for incident pain.
Breakthrough dose = 10–20% of the total 24-hour opioid dose, given every 1–2 hours as required.
Always co-prescribe regular laxatives (e.g., docusate sodium 50 mg + senna 8–16 mg nocte, or macrogol 3350 sachet OD).
Antiemetics (e.g., metoclopramide 10 mg PO/SC TDS) should be prescribed prophylactically for the first 5–7 days or until tolerance develops.
Monitor for opioid toxicity: drowsiness, myoclonus, hallucinations, respiratory depression. If suspected, reduce dose by 30–50% and consider naloxone if life-threatening respiratory depression occurs.

Morphine Use — Subcutaneous Infusion & Spinal Morphine

Morphine remains the strong opioid of first choice in Australian palliative care practice. When the oral route is no longer viable (e.g., severe nausea/vomiting, dysphagia, reduced consciousness, intestinal obstruction), subcutaneous administration via a continuous infusion — most commonly using a syringe driver — provides reliable and consistent analgesia.

Oral Morphine Preparations (PBS-listed)

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Morphine Sulfate IR (Immediate Release)

Ordine® · Sevredol® · Generic · Opioid analgesic

Adult dose 2.5–5 mg PO every 4 hours (opioid-naïve); titrate by 30–50% every 24–48 h

Paediatric dose 100–200 mcg/kg PO every 4 hours (opioid-naïve); specialist guidance recommended

Route Oral liquid (Ordine®) or tablets

Renal adjustment eGFR 10–50: extend interval to 6–8 h; eGFR <10: avoid or use with extreme caution — active metabolites accumulate

Hepatic adjustment Reduce dose 50% in severe hepatic impairment

PBS status ✔ PBS General Benefit

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Morphine Sulfate MR (Modified Release)

Kapanol® · MS Contin® · Generic · Opioid analgesic

Adult dose 10–20 mg PO every 12 hours (once stable on IR morphine); total daily IR dose ÷ 2 = BD dose

Paediatric dose Generally not recommended; specialist guidance only

Route Oral — swallow whole, do not crush (except Kapanol® beads may be sprinkled on soft food)

Renal adjustment Avoid in eGFR <30 (accumulation of active metabolites); use immediate-release with caution

PBS status ✔ PBS General Benefit

Subcutaneous Morphine Infusion (Syringe Driver)

The syringe driver (e.g., CADD-MS 3, Graseby MS series, McKinley T34) delivers a continuous subcutaneous infusion over 24 hours and is the standard method of parenteral opioid delivery in palliative care in Australia. Common sites include the anterior thigh, anterior abdominal wall, upper arm, or subclavicular area.

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Critical conversion rule: When converting from oral morphine to subcutaneous infusion, use the ratio oral : SC = 2 : 1 to 3 : 1. That is, divide the total 24-hour oral dose by 2–3. If converting due to toxicity or uncertainty, reduce by a further 25–50%. Always re-evaluate within 12–24 hours.

Scenario	Oral Morphine 24-hr Total	SC Morphine 24-hr Equivalent	Notes
Step-up conversion (stable pain)	60 mg oral/24 h	20–30 mg SC/24 h	Use ratio 2:1 if well tolerated; 3:1 if cautious
Toxicity present	Any dose	Reduce by 50% from calculated equivalent	Signs: myoclonus, drowsiness, hallucinations
Opioid-naïve	N/A	5–10 mg SC/24 h (starting dose)	Titrate after 24 h; breakthrough doses as stat SC injections

Syringe Driver Compatibility

Not all medications are compatible when mixed in a syringe driver. The following are commonly co-infused with morphine in palliative care syringe drivers (using water for injection or normal saline as diluent):

Metoclopramide — compatible with morphine (antiemetic/prokinetic)
Hyoscine butylbromide — compatible with morphine (anti-secretory)
Dexamethasone — compatible with morphine
Haloperidol — compatible with morphine (antiemetic/antipsychotic)
Midazolam — compatible with morphine (sedative/anticonvulsant)
Cyclizine — NOT compatible with morphine; must be given separately or via alternative route

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Syringe driver volumes: The CADD-MS 3 holds a maximum 30 mL syringe. Ensure 24-hour volume does not exceed syringe capacity. Common practice is to make up the driver to run for exactly 24 hours and change at the same time each day.

Spinal (Intrathecal & Epidural) Morphine

Intrathecal or epidural opioids are reserved for patients with refractory pain that cannot be controlled with systemic opioids, or in whom systemic opioid side effects are intolerable. This requires specialist pain medicine or palliative medicine referral.

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Intrathecal Morphine

Preservative-free morphine · Opioid analgesic

Adult dose 0.1–1 mg intrathecal OD-BD (via implanted pump or external catheter); titrate under specialist supervision

Conversion No reliable fixed ratio; intrathecal dose is typically 1/100th to 1/300th of the oral dose; specialist titration essential

Key consideration Must use preservative-free preparation ONLY; risk of arachnoiditis with preservatives

PBS status ⚠ Authority Required

Indications for spinal opioid referral include:

Severe pain (especially bilateral or midline — e.g., perineal, pelvic) not controlled by maximal tolerated systemic opioids with adjuvants
Unacceptable systemic opioid side effects (delirium, severe nausea, respiratory depression) at doses required for analgesia
Complex regional pain syndromes secondary to malignancy
Patients with an expected survival of >3 months who may benefit from an intrathecal pump (e.g., Medtronic SynchroMed II)

Equianalgesic Opioid Conversion Table

Opioid	Approximate Equianalgesic Dose (oral)	Approximate SC Equivalent	Key Notes
Morphine PO	30 mg/24 h	10–15 mg/24 h	Reference standard
Oxycodone PO	20 mg/24 h	10 mg/24 h SC	1.5× potency of oral morphine
Hydromorphone PO	5–7.5 mg/24 h	1.5–2 mg/24 h SC	Useful in renal impairment (fewer active metabolites)
Fentanyl transdermal	Patch 12 mcg/h ≈ 30–45 mg morphine PO/24 h	N/A (transdermal)	48–72 h onset after application; not for acute titration
Methadone	Variable — non-linear conversion	Variable	Specialist initiation ONLY; long half-life (15–60 h); risk of accumulation

Common Symptom Control

Symptom management in the terminal phase requires an anticipatory, proactive approach. The Australian Commission on Safety and Quality in Health Care (ACSQHC) recommends that all patients identified as entering the last days of life have an anticipatory prescribing plan documented, with subcutaneous medications available for rapid administration.

Nausea and Vomiting

Nausea affects 40–70% of patients with advanced cancer and is common in other palliative conditions. Management should be directed at the underlying cause where possible.

Cause	Mechanism	First-Line Agent	Dose	PBS
Drug-induced (opioids)	Chemoreceptor trigger zone (CTZ)	Haloperidol	0.5–1.5 mg PO/SC OD-BD	✔ PBS General Benefit
Gastroparesis / gastric stasis	Vagal / motility	Metoclopramide	10 mg PO/SC TDS (before meals)	✔ PBS General Benefit
Vestibular / motion-related	Vestibular / histaminic	Cyclizine	50 mg PO/SC TDS	✔ PBS General Benefit
Mucosal irritation / raised ICP	Vagal / central	Dexamethasone	4–8 mg PO/IV/SC OD (morning)	✔ PBS General Benefit
Malignant bowel obstruction	Mixed	Octreotide ± Cyclizine	Octreotide 100–300 mcg SC BD	⚠ Authority Required
Chemotherapy-induced	CTZ / cortical	Ondansetron	4–8 mg PO/IV BD-TDS	✔ PBS General Benefit

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Cyclizine and syringe driver note: Cyclizine is NOT compatible with morphine in a syringe driver. If both are required, administer cyclizine via a separate syringe driver, give as intermittent SC injections, or use hyoscine butylbromide or haloperidol as compatible alternatives in the morphine driver.

Excessive Secretions (Death Rattle)

Pooled oropharyngeal secretions occur in 25–92% of dying patients and, while not distressing to the patient (who is typically unconscious), can be profoundly distressing for families and carers. Management involves both pharmacological and non-pharmacological strategies.

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Hyoscine Butylbromide

Buscopan® · Antispasmodic / Anti-secretory

Adult dose 20 mg SC stat, then 60–80 mg/24 h via syringe driver (or 20 mg SC every 4–6 h PRN)

Onset SC: within 15–30 minutes

Key notes Compatible with morphine in syringe driver; does NOT cross blood-brain barrier (minimal CNS effects)

PBS status ✔ PBS General Benefit

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Glycopyrrolate (Glycopyrronium)

Robinul® · Anticholinergic / Anti-secretory

Adult dose 200 mcg SC stat, then 600–1200 mcg/24 h via syringe driver (or 200 mcg SC every 4–6 h PRN)

Key notes Does NOT cross blood-brain barrier; less sedation than hyoscine hydrobromide; compatible with morphine

PBS status ✔ PBS General Benefit

Non-pharmacological measures:

Reposition the patient onto their side to allow secretions to drain by gravity
Gently suction only if easily accessible and not causing distress (suctioning can increase secretion production)
Reassure family members that the sound, while distressing, is not associated with patient suffering
Avoid excessive IV/SC fluid administration, which can worsen secretions

Terminal Restlessness and Agitation

Terminal restlessness (terminal agitation, terminal delirium) occurs in 25–85% of dying patients and manifests as agitation, confusion, myoclonus, picking at bedclothes, and purposeless movements. Before treating, consider and address reversible causes.

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Reversible causes to consider: urinary retention (perform bladder scan), faecal impaction (digital examination), opioid toxicity (reduce dose), medication side effects (anticholinergics, benzodiazepines, steroids), uncontrolled pain, hypoxia, metabolic derangement (hypercalcaemia, hyponatraemia, hepatic encephalopathy), and anxiety/distress (psychosocial needs).

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Midazolam

Hypnovel® · Generic · Benzodiazepine / Sedative

Adult dose (first-line) 2.5–5 mg SC stat, then 10–30 mg/24 h via syringe driver; titrate to effect

Route Subcutaneous (preferred), IV, intranasal, buccal

Key notes Compatible with morphine in syringe driver; dose range in terminal care is wide (up to 60 mg/24 h); aim for comfort, not necessarily full consciousness

PBS status ✔ PBS General Benefit

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Haloperidol

Serenace® · Generic · Antipsychotic

Adult dose 0.5–2.5 mg SC/PO stat, then 2.5–10 mg/24 h via syringe driver or divided doses PO

Key notes Useful when agitation has a psychotic component; antiemetic properties are an advantage; compatible with morphine in driver

Cautions QT prolongation risk; avoid in Lewy body dementia (severe sensitivity reactions)

PBS status ✔ PBS General Benefit

Other Common Symptoms in the Terminal Phase

Symptom	Management
Dyspnoea	Low-dose morphine (2.5–5 mg PO/SC); fan directed at face; midazolam if anxiety-driven; supplemental O₂ only if hypoxaemic (SpO₂ <90%)
Constipation	Prevent with regular laxatives from opioid initiation. If impacted: rectal bisacodyl or arachis oil (Microlax®); if no bowel obstruction: oral macrogol + senna
Hiccups	Chlorpromazine 25 mg PO/IM OD-BD, or haloperidol 1–2 mg PO/SC OD, or baclofen 5 mg PO TDS
Anorexia/cachexia	Avoid forced feeding; dexamethasone 2–4 mg OD short-term or megestrol acetate 160–480 mg OD (limited evidence); family education re natural dying process
Mouth care	Regular gentle mouth care with soft toothbrush; saline or sodium bicarbonate rinse; artificial saliva (Biotène®); lip balm for dry lips
Skin integrity	Regular repositioning (minimum 2-hourly); pressure-relieving mattresses; barrier cream for moisture areas; avoid aggressive wound debridement in terminal phase

Anticipatory Prescribing — The "Just in Case" Kit

All patients in the terminal phase (or those at risk of rapid deterioration) should have subcutaneous medications prescribed and available in the home or facility. The standard anticipatory medications in Australian palliative care practice are:

Morphine (for pain/dyspnoea)

Morphine sulfate 10 mg/mL, 1 mL ampoule. Dose: 2.5–5 mg SC PRN every 1–2 hours.

Midazolam (for agitation/restlessness)

Midazolam 5 mg/mL, 1 mL ampoule. Dose: 2.5–5 mg SC PRN every 1–2 hours.

Hyoscine butylbromide (for secretions)

Hyoscine butylbromide 20 mg/mL, 1 mL ampoule. Dose: 20 mg SC every 4–6 hours PRN.

Metoclopramide (for nausea)

Metoclopramide 10 mg/2 mL ampoule. Dose: 10 mg SC every 6–8 hours PRN.

Haloperidol (for nausea/agitation)

Haloperidol 5 mg/mL, 1 mL ampoule. Dose: 0.5–2.5 mg SC every 6–8 hours PRN.

Communicating with the Dying Patient & Grief

Effective communication is one of the most important skills in palliative care. Difficult conversations about prognosis, goals of care, and end-of-life decisions are a core responsibility of the general practitioner. Australian guidelines (including the National Consensus Statement and RACGP standards) emphasise that these conversations should be approached with preparation, honesty, empathy, and cultural sensitivity.

Frameworks for Breaking Bad News

Setting

Ensure a private, quiet environment. Sit at the patient's level. Ensure adequate time. Invite significant others if the patient wishes. Turn off mobile phones.

Perception

Ask what the patient already knows: "Can you tell me what you understand about your illness?" Assess their understanding and correct misconceptions gently.

Invitation

Ask how much information they want: "Would you like me to explain all the details, or would you prefer I share the main points?" Respect information preferences.

Knowledge

Share information using simple language. Warn before giving bad news: "I'm sorry, I have some difficult news." Use small chunks. Pause frequently. Avoid jargon.

Emotions

Acknowledge and respond to emotions with empathy. Use the NURSE mnemonic (see below). Allow silence. Do not rush to "fix" distress.

Summary & Strategy

Summarise the discussion. Develop a plan collaboratively. Ensure follow-up is arranged. Document the conversation in the medical record.

The NURSE Mnemonic — Responding to Emotions

Letter	Skill	Example
N	Naming	"It sounds like you're feeling frightened."
U	Understanding	"I can understand why you would feel that way."
R	Respecting	"You've shown incredible courage throughout all of this."
S	Supporting	"I want you to know that I will be here with you throughout this."
E	Exploring	"Can you tell me more about what worries you most?"

Discussing Prognosis and End-of-Life Planning

Advance care planning (ACP): Encourage all patients with life-limiting illness to discuss and document their values, preferences, and treatment wishes. In Australia, ACP documents (Advance Care Directive / Resuscitation Plan / Substitute Decision-Maker appointment) vary by state and territory. The Advance Care Planning Australia website provides jurisdiction-specific templates.
Goals of care discussions: Frame these around what matters to the patient: "What is most important to you in the time you have left?" Shift from curative to comfort-focused care when appropriate.
Resuscitation status: Discuss Do-Not-Resuscitate (DNR) / Not-For-Resuscitation (NFR) orders sensitively. In most Australian jurisdictions, CPR is a medical treatment that can be withheld if clinically futile. Document clearly in the patient record and ensure the patient/family understands.
Withholding and withdrawing treatment: It is ethically and legally appropriate to withhold or withdraw treatments (including artificial nutrition, hydration, antibiotics, and dialysis) when they are no longer providing benefit and may prolong suffering. This should be done with clear communication and documentation.

Grief and Bereavement

Grief is a normal, natural response to loss. However, a proportion of bereaved individuals (estimated 7–10%) will develop complicated (prolonged) grief disorder, now recognised in the DSM-5-TR and ICD-11. GPs are well placed to provide bereavement support and identify those at risk.

Risk factors for complicated grief:

Sudden or traumatic death
Loss of a child
Dependent or insecure attachment relationship with the deceased
Limited social support network
Previous history of mental health disorders (especially depression, anxiety, PTSD)
Concurrent life stressors
Aboriginal and Torres Strait Islander communities — grief may be compounded by intergenerational trauma and the cultural obligation of "sorry business"

GP bereavement support strategies:

Offer a follow-up appointment or phone call within 1–2 weeks of the death
Consider a condolence letter or card — a simple gesture with strong evidence of patient/carer appreciation
Review bereaved carers for depression, anxiety, substance misuse, and somatic symptoms at 1, 3, 6, and 12 months
Refer to specialist bereavement services when complicated grief is suspected (e.g., Grief Australia, Open Palliative Care services, state-based bereavement programs)
Children grieve differently — offer age-appropriate support and resources for families
Maintain awareness of cultural grief practices and support culturally safe bereavement care

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Spiritual care: Spiritual distress is common at end of life. GPs should ask open-ended questions about meaning, hope, and spiritual needs. Referral to hospital or community chaplaincy, pastoral care, or the patient's own spiritual community is appropriate. For Aboriginal and Torres Strait Islander patients, connection to Country, community, and cultural practices may be essential to a "good death."

Special Populations

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Pregnancy

Opioids Morphine can be used in pregnancy but monitor neonate for respiratory depression and neonatal abstinence syndrome if used near term. Short-acting opioids preferred. Avoid codeine in breastfeeding (CYP2D6 ultra-rapid metaboliser risk).

Midazolam Avoid in first trimester if possible; use lowest effective dose for shortest duration; neonatal respiratory depression risk near term.

Haloperidol Use with caution; avoid in third trimester (neonatal extrapyramidal symptoms). Risk–benefit discussion essential in terminal care.

Metoclopramide Considered safe in pregnancy for nausea; avoid prolonged use (>12 weeks) due to tardive dyskinesia risk.

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Paediatrics

Paediatric palliative care Children's palliative care is a distinct specialty. Always involve a paediatric palliative care team (e.g., Paediatric Palliative Care Australia and New Zealand network). Doses are weight-based; use mg/kg calculations.

Morphine Oral: 100–200 mcg/kg every 4 hours (opioid-naïve). SC infusion: 10–40 mcg/kg/hour. Use paediatric formulations (Ordine® 2 mg/mL, 10 mg/mL).

Midazolam SC: 50–100 mcg/kg stat; infusion 20–40 mcg/kg/hour. Shorter acting than in adults — may need more frequent administration or continuous infusion.

Communication Use age-appropriate language; involve child life therapists; honour the child's wishes where possible. Bereavement support for siblings is critical.

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Elderly

Opioids Start at 50% of standard adult dose; titrate slowly. Morphine active metabolites (M6G) accumulate in renal impairment — common in elderly. Consider hydromorphone or fentanyl if eGFR <30.

Anticholinergic burden Minimise anticholinergic medications (hyoscine, cyclizine). Use glycopyrrolate (does not cross BBB) when possible. High anticholinergic load increases delirium risk.

Delirium Common at end of life in elderly. Assess using the Confusion Assessment Method (CAM). Distinguish hypoactive from hyperactive subtypes. Haloperidol 0.5–1 mg for hyperactive; avoid in Lewy body dementia.

Polypharmacy Review and deprescribe non-essential medications. Statins, antihypertensives, and most preventive medications can often be safely ceased in the terminal phase.

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Renal Impairment

Morphine AVOID in eGFR <30. Active metabolites (morphine-6-glucuronide, morphine-3-glucuronide) accumulate, causing prolonged sedation, myoclonus, and respiratory depression.

Preferred opioids Fentanyl (transdermal or SC) or hydromorphone — both have no active renally-cleared metabolites. Start at 50% dose reduction and titrate carefully.

Dialysis patients Opioids (except fentanyl) may be partially removed by haemodialysis — dose after dialysis sessions. Fentanyl is not dialysed. Discuss stopping dialysis as a goals-of-care decision when appropriate.

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Hepatic Impairment

General principle All opioids require dose reduction in significant hepatic impairment (Child-Pugh B/C). Morphine: reduce by 50%. Fentanyl: use with caution (hepatic clearance but less affected than morphine).

Benzodiazepines Avoid long-acting benzodiazepines (diazepam, clonazepam). Midazolam has short half-life but sensitivity is increased — start at lowest dose. Lorazepam may be preferred (intermediate acting, no active metabolites).

Paracetamol Maximum 2 g/day in chronic liver disease. Safe in mild hepatic impairment at standard dose.

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Immunocompromised

Infection at end of life Febrile episodes are common in immunocompromised patients with advanced malignancy. Consider whether to treat infection actively (e.g., pneumonia) or allow natural dying. Goals-of-care discussions should occur before crises arise.

Opioid metabolism Hepatic dysfunction secondary to graft-versus-host disease or chemotherapy hepatotoxicity may affect opioid metabolism — titrate carefully.

Infection control Standard precautions in palliative care settings. Staff education on hand hygiene and PPE for patients with known multi-resistant organisms.

Aboriginal and Torres Strait Islander Health Considerations

Aboriginal and Torres Strait Islander Australians experience a burden of disease 2.3 times higher than non-Indigenous Australians and have significantly lower life expectancy (8.6 years for males, 7.8 years for females). Palliative care needs are consequently greater, yet access to culturally safe end-of-life care remains significantly lower. The AIHW reports that Indigenous Australians are less likely to die in palliative care settings and more likely to die in hospital, often far from Country and community.

Cultural concepts of death and dying

Death and dying are understood within complex cultural and spiritual frameworks. Many Aboriginal and Torres Strait Islander communities have strict protocols around naming, images, and belongings of the deceased. "Sorry business" (mourning) involves the entire community and may last for extended periods. GPs must seek guidance from Aboriginal Health Workers/Practitioners (AHW/Ps) and the patient's family about culturally appropriate practices.

Country and place of death

Dying on Country (traditional homeland) is profoundly important for many Aboriginal people. Facilitating transport home for end-of-life care, even to remote communities, should be a priority where feasible. State and territory patient-assisted travel schemes and the Royal Flying Doctor Service may assist.

Family and community decision-making

End-of-life decisions may involve extended family and community Elders, not just the individual patient. Western models of individual autonomy may not align with collective decision-making processes. Allow time and space for family discussions; do not rush advance care planning.

Language barriers

Many Aboriginal and Torres Strait Islander people speak English as a second, third, or fourth language. Use accredited interpreters (available through Aboriginal Interpreter Service in the NT and equivalent services in other states). Avoid medical jargon. Use visual aids and teach-back methods.

Distrust of health services

Historical and ongoing experiences of racism, forced removal of children, and institutional neglect contribute to significant distrust of mainstream health services. Building trust requires long-term relationships, cultural humility, and the involvement of AHW/Ps as cultural brokers.

Inter-generational grief and trauma

The cumulative effect of colonisation, dispossession, Stolen Generations, and ongoing disadvantage contributes to complex grief responses. Bereavement support must acknowledge this context. Deaths from chronic disease in younger age groups (compared to non-Indigenous populations) compound community grief.

Remote and rural access

Specialist palliative care services are largely concentrated in urban centres. AHW/Ps, remote area nurses, and Aboriginal Community Controlled Health Organisations (ACCHOs) are the primary providers of palliative care in many remote communities. Telehealth (MBS items 91790, 91800 etc.) can support specialist consultation. The Program of Experience in the Palliative Approach (PEPA) provides training for AHW/Ps and generalist clinicians.

Connection to culture and spirituality

Spiritual and cultural practices — including smoking ceremonies, connection to Elders, traditional healing, and art/storytelling — are integral to holistic palliative care. Health services should facilitate, not obstruct, these practices. The Palliative Care Australia "National Palliative Care Standards" explicitly recognise the importance of culturally safe care for First Nations peoples.

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Key resource: The RHDAustralia (Remote and Indigenous Health) and Palliative Care Australia provide culturally specific palliative care resources. The "Dying to Talk" discussion starter from Palliative Care Australia is available in multiple Aboriginal and Torres Strait Islander languages. Always involve an Aboriginal Health Worker/Practitioner in palliative care planning for Indigenous patients.

📚 References

1. World Health Organization. WHO guidelines for the pharmacological and radiotherapeutic management of cancer pain in adults and adolescents. Geneva: WHO; 2018.
2. Australian Commission on Safety and Quality in Health Care (ACSQHC). National Consensus Statement: Essential Elements for Safe and High-Quality End-of-Life Care. Sydney: ACSQHC; 2015.
3. Palliative Care Australia. National Palliative Care Standards. 5th ed. Canberra: Palliative Care Australia; 2018.
4. Australian Institute of Health and Welfare (AIHW). Palliative care services in Australia. Cat. no. HWI 323. Canberra: AIHW; 2023.
5. Royal Australian College of General Practitioners (RACGP). Providing end-of-life care: A guide for general practitioners. Melbourne: RACGP; 2020.
6. Australian and New Zealand Society of Palliative Medicine (ANZSPM). Opioid conversion guide. ANZSPM; 2021. Available at: anzspm.org.au.
7. Currow DC, Agar M, Sanderson C, et al. Populations who die without specialist palliative care: does lower uptake equate with unmet need? Palliative Medicine. 2008;22(1):43–50.
8. Department of Health (Australian Government). National Palliative Care Strategy 2018. Canberra: Commonwealth of Australia; 2019.
9. Shaw T, et al. Palliative care for Aboriginal and Torres Strait Islander peoples: a framework for practice. Australian Journal of Primary Health. 2020;26(3):203–208.
10. CareSearch. Clinical evidence for palliative care. Adelaide: Flinders University; 2024. Available at: caresearch.com.au.
11. Boland JW, et al. Use of strong opioids in advanced chronic kidney and liver disease: a systematic review. Journal of Pain and Symptom Management. 2020;59(3):683–697.
12. Prigerson HG, et al. Prolonged grief disorder: psychometric validation of criteria proposed for DSM-5-TR and ICD-11. PLoS Medicine. 2021;6(8):e1000121.
13. Advance Care Planning Australia. National framework for advance care planning. Austin Health; 2023. Available at: advancecareplanning.org.au.
14. Royal Australian and New Zealand College of Psychiatrists (RANZCP). Clinical practice guidelines for the management of delirium in older people. Melbourne: RANZCP; 2021.

for PBS scripts. Utilise ACCHS pharmacies and Remote Area Aboriginal Health Worker programs for medication supply in remote areas. Avoid initiating benzodiazepines; support holistic pain management including community-based exercise programs.

Preventive health

Promote bone health: encourage vitamin D supplementation (1000 IU daily in deficient individuals), smoking cessation support, reduction of alcohol intake, and weight-bearing exercise. MBS Item 715 health checks provide a structured opportunity to assess bone health, screen for osteoporosis risk factors, and discuss musculoskeletal health in a culturally safe context.

Quick Reference: Differential Diagnosis at a Glance

Costovertebral dysfunction

Paracetamol ± NSAID; manual therapy

2–6 weeks

Provocable on palpation; no red flags

Thoracic compression fracture

Paracetamol; ± calcitonin; DXA + osteoporosis Rx

6–12 weeks healing

Elderly; osteoporosis; acute onset

ACS (posterior MI)

Aspirin 300 mg, GTN, heparin; urgent PCI

Time-critical

ECG, troponin; CV risk factors

Aortic dissection

IV labetalol; urgent CT aortogram; surgery (Type A)

Time-critical

Tearing pain; BP differential >20 mmHg

Vertebral osteomyelitis

IV antibiotics (vancomycin + ceftriaxone initially); ID consult

6 weeks IV antibiotics

Fever, elevated CRP, IV drug use

Biliary colic / cholecystitis

Paracetamol ± morphine; lap cholecystectomy

Surgical within 72 h (cholecystitis)

RUQ/infrascapular; post-prandial; RUQ US

📚 References

1. Briggs AM, Smith AJ, Straker LM, Bragge P. Thoracic spine pain in the general population: prevalence, incidence and associated factors in children, adolescents and adults. A systematic review. BMC Musculoskelet Disord. 2009;10:77.
2. National Health and Medical Research Council (NHMRC). Evidence-based management of acute musculoskeletal pain. Canberra: NHMRC; 2003 (updated 2020).
3. Australian Institute of Health and Welfare (AIHW). Aboriginal and Torres Strait Islander Health Performance Framework: Summary report 2023. Canberra: AIHW; 2023.
4. Deyo RA, Rainville J, Kent DL. What can the history and physical examination tell us about low back pain? JAMA. 1992;268(6):760–765.
5. Stochkendahl MJ, Kjaer P, Hartvigsen J, et al. National Clinical Guidelines for non-surgical treatment of patients with recent onset low back pain or lumbar radiculopathy. Europ Spine J. 2018;27(1):60–75.
6. Erwin WM, Jackson PC, Homonko DA. Innervation of the human costovertebral joint: implications for clinical back pain syndromes. J Manipulative Physiol Ther. 2000;23(6):395–403.
7. Royal Australian College of General Practitioners (RACGP). Guidelines for preventive activities in general practice. 9th edn. Melbourne: RACGP; 2018 (updated 2023).
8. Hirsch JA, Singh V, Falco FJE, et al. Thoracic facet joint interventions. Pain Physician. 2016;19(4):E581–E593.
9. Erwin WM, Jackson PC. The costovertebral joint: anatomy, biomechanics, and clinical significance in thoracic back pain syndromes. J Can Chiropr Assoc. 2003;47(2):112–120.
10. Strayer RJ, Gunnerson JM, Brown LH, et al. Aortic dissection: clinical features, diagnosis, and management. Aust Crit Care. 2019;32(2):144–153.
11. Ombregt L. A system of orthopaedic medicine. 3rd edn. Edinburgh: Churchill Livingstone Elsevier; 2013. Chapter 18: Thoracic spine.
12. Lin CC, Chen KH, Li DM, et al. Characteristics and outcomes of patients presenting with thoracic back pain to the emergency department. Emerg Med Australas. 2020;32(5):805–811.

for PBS-listed medicines at participating pharmacies.

Cultural safety

Engagement with Aboriginal Community Controlled Health Organisations (ACCHOs) is essential. Cultural safety training for non-Indigenous clinicians, use of Aboriginal Health Workers and Liaison Officers, and incorporation of traditional healing practices alongside Western medicine improve treatment adherence and outcomes. Avoidance of eye contact, respect for gender-sensitive examination practices, and understanding of sorry business protocols are critical elements of culturally safe care.

Medication adherence

Complex DMARD regimens with frequent monitoring requirements present adherence challenges. Long-acting depot injections (e.g., methotrexate SC) may improve adherence compared to oral regimens. Community pharmacy partnerships through the Indigenous Pharmacy Programmes improve medication management.

Specific conditions

Rheumatic heart disease (RHD) requires secondary prophylaxis with benzathine penicillin G (BPG) 1.2 MU IM every 3–4 weeks for a minimum of 10 years or until age 21 (whichever is longer). RHD registers (e.g., NT RHD Register) facilitate recall and follow-up. The Australian RHD Endgame Strategy targets elimination by 2031.

Referral pathways

Referral through ACCHOs and Aboriginal Hospital Liaison Officers (AHLOs) improves engagement. The Specialist Outreach Assistance Programme provides funded specialist visits to remote communities. NT, WA, and QLD have specific rheumatology outreach programmes targeting Indigenous communities.

📚 References

1. Australian Institute of Health and Welfare (AIHW). Autoimmune disease in Australia. Cat. no. PHE 312. Canberra: AIHW; 2023.
2. Fraenkel L, Bathon JM, England BR, et al. 2021 American College of Rheumatology guideline for the treatment of rheumatoid arthritis. Arthritis Care Res. 2021;73(7):924–939.
3. Fanouriakis A, Kostopoulou M, Alber K, et al. 2019 update of the EULAR recommendations for the management of systemic lupus erythematosus. Ann Rheum Dis. 2019;78(6):736–745.
4. Chung SA, Langford CA, Maz M, et al. 2021 American College of Rheumatology/Vasculitis Foundation guideline for the management of antineutrophil cytoplasmic antibody-associated vasculitis. Arthritis Care Res. 2021;73(11):1583–1599.
5. Smolen JS, Landewé RBM, Bijlsma JWJ, et al. EULAR recommendations for the management of rheumatoid arthritis with synthetic and biological disease-modifying antirheumatic drugs: 2022 update. Ann Rheum Dis. 2023;82(1):3–18.
6. Australian Technical Advisory Group on Immunisation (ATAGI). Australian Immunisation Handbook. Australian Government Department of Health; 2024. Available from: immunisationhandbook.health.gov.au.
7. Rheumatic Heart Disease Australia (RHDAustralia). The 2020 Australian guideline for prevention, diagnosis, and management of acute rheumatic fever and rheumatic heart disease. 3rd ed. Darwin: Menzies School of Health Research; 2020.
8. Pharmaceutical Benefits Scheme (PBS). PBS Schedule. Australian Government Department of Health. Available from: pbs.gov.au. Accessed 2024.
9. Agarwal S, Cunnington J, Nossent J. Autoimmune disease in Indigenous Australians: a systematic review. Int J Rheum Dis. 2021;24(12):1487–1498.
10. Pisetsky DS. Antinuclear antibody testing — misunderstood or misused? Clin Immunol. 2023;255:109717.
11. Bertsias GK, Tektonidou M, Amoura Z, et al. Joint European League Against Rheumatism and European Renal Association–European Dialysis and Transplant Association (EULAR/ERA-EDTA) recommendations for the management of adult and paediatric lupus nephritis. Ann Rheum Dis. 2012;71(11):1771–1782.
12. Ledingham J, Deighton C; British Society for Rheumatology Standards, Audit and Guidelines Working Group. Update on the British Society for Rheumatology guidelines for prescribing TNFα blockers in adults with rheumatoid arthritis. Rheumatology. 2005;44(2):155–158.
13. National Health and Medical Research Council (NHMRC). National statement on ethical conduct in human research. Canberra: NHMRC; 2023 (updated).

for PBS-listed medicines at participating pharmacies.

Cultural safety

Medication adherence

Specific conditions

Referral pathways

📚 References

1. Australian Institute of Health and Welfare (AIHW). Autoimmune disease in Australia. Cat. no. PHE 312. Canberra: AIHW; 2023.
2. Fraenkel L, Bathon JM, England BR, et al. 2021 American College of Rheumatology guideline for the treatment of rheumatoid arthritis. Arthritis Care Res. 2021;73(7):924–939.
3. Fanouriakis A, Kostopoulou M, Alber K, et al. 2019 update of the EULAR recommendations for the management of systemic lupus erythematosus. Ann Rheum Dis. 2019;78(6):736–745.
4. Chung SA, Langford CA, Maz M, et al. 2021 American College of Rheumatology/Vasculitis Foundation guideline for the management of antineutrophil cytoplasmic antibody-associated vasculitis. Arthritis Care Res. 2021;73(11):1583–1599.
5. Smolen JS, Landewé RBM, Bijlsma JWJ, et al. EULAR recommendations for the management of rheumatoid arthritis with synthetic and biological disease-modifying antirheumatic drugs: 2022 update. Ann Rheum Dis. 2023;82(1):3–18.
6. Australian Technical Advisory Group on Immunisation (ATAGI). Australian Immunisation Handbook. Australian Government Department of Health; 2024. Available from: immunisationhandbook.health.gov.au.
7. Rheumatic Heart Disease Australia (RHDAustralia). The 2020 Australian guideline for prevention, diagnosis, and management of acute rheumatic fever and rheumatic heart disease. 3rd ed. Darwin: Menzies School of Health Research; 2020.
8. Pharmaceutical Benefits Scheme (PBS). PBS Schedule. Australian Government Department of Health. Available from: pbs.gov.au. Accessed 2024.
9. Agarwal S, Cunnington J, Nossent J. Autoimmune disease in Indigenous Australians: a systematic review. Int J Rheum Dis. 2021;24(12):1487–1498.
10. Pisetsky DS. Antinuclear antibody testing — misunderstood or misused? Clin Immunol. 2023;255:109717.
11. Bertsias GK, Tektonidou M, Amoura Z, et al. Joint European League Against Rheumatism and European Renal Association–European Dialysis and Transplant Association (EULAR/ERA-EDTA) recommendations for the management of adult and paediatric lupus nephritis. Ann Rheum Dis. 2012;71(11):1771–1782.
12. Ledingham J, Deighton C; British Society for Rheumatology Standards, Audit and Guidelines Working Group. Update on the British Society for Rheumatology guidelines for prescribing TNFα blockers in adults with rheumatoid arthritis. Rheumatology. 2005;44(2):155–158.
13. National Health and Medical Research Council (NHMRC). National statement on ethical conduct in human research. Canberra: NHMRC; 2023 (updated).