Anticipatory Prescribing

Last updated 1 Jun 2026 · Palliative care

📋 Key Information Summary

📋

Anticipatory prescribing is the proactive preparation of injectable medications and equipment for predictable end-of-life symptoms, reducing crisis-driven interventions and unplanned hospital transfers.
Initiate anticipatory prescribing when a patient is identified as being in the last days to weeks of life, ideally before symptoms escalate.
Morphine (immediate-release oral solution or SC injection) is the first-line agent for both pain and respiratory distress/dyspnoea at end of life; typical SC bolus 2.5–5 mg 2-hourly PRN.
Midazolam (SC) is the first-line benzodiazepine for terminal restlessness, agitation, and seizures; typical dose 2.5–5 mg SC bolus, with subcutaneous infusion (syringe driver) 10–30 mg over 24 hours if symptoms are refractory.
Clonazepam (oral/sublingual) is useful for myoclonus and anticipatory anxiety; 0.5–1 mg BD/TDS.
Haloperidol (SC/PO) is first-line for nausea and vomiting of central origin and delirium with agitation; typical dose 0.5–2.5 mg SC/PO BD/TDS.
Metoclopramide (SC/PO) is preferred for nausea from gastric stasis and visceral distension; 10 mg SC/PO TDS-QDS; contraindicated in bowel obstruction.
Hyoscine butylbromide (Buscopan®) 20 mg SC and glycopyrrolate 0.2 mg SC are first-line anticholinergics for death rattle (excessive respiratory secretions).
Always prepare a syringe driver (e.g., McKinley T34™ or CADD-Solis®) when continuous symptom control is required; standard diluents and compatibility charts must guide mixing.
All anticipated medications should be kept in the patient's home or residential aged-care facility with clear written instructions and a 24-hour contact number for the palliative care team.
Renal and hepatic impairment significantly alter opioid and benzodiazepine clearance — reduce doses and extend intervals accordingly.
Aboriginal and Torres Strait Islander communities require culturally safe end-of-life conversations, community-controlled health service involvement, and awareness of geographical barriers to medication access.

Introduction & Australian Epidemiology

Anticipatory prescribing is a cornerstone of high-quality palliative care. It involves the proactive ordering, supply, and home storage of injectable medications before symptoms become acute, so that carers and clinicians can respond rapidly to predictable complications such as pain escalation, respiratory distress, nausea, agitation, and excessive secretions.

In Australia, approximately 160,000 people die each year, with the majority being older adults with chronic, life-limiting illnesses. The Australian Institute of Health and Welfare (AIHW) reports that over 70% of Australians express a preference to die at home or in a community setting, yet only around 15% of deaths currently occur at home. One of the key modifiable barriers to achieving a home death is the lack of timely access to injectable medications after hours — a gap that anticipatory prescribing directly addresses.

The National Consensus Statement: Essential Elements for Safe and High-Quality End-of-Life Care (ACSQHC) identifies anticipatory prescribing as an essential element of safe end-of-life care. Palliative Care Australia's National Palliative Care Standards (5th edition) similarly endorse proactive symptom planning as a core standard. State and territory ambulance services, residential aged-care facilities, and hospital-in-the-home programmes across Australia increasingly mandate anticipatory prescribing pathways.

This article covers the four principal drug classes used in anticipatory prescribing for adults in Australia: opioids (morphine), benzodiazepines (midazolam, clonazepam), antiemetics/antipsychotics (haloperidol, metoclopramide), and anticholinergics (hyoscine butylbromide, glycopyrrolate). Practical guidance on syringe drivers, equipment, monitoring, special populations, and Aboriginal and Torres Strait Islander considerations is included.

Anticipatory Prescribing Principles

Anticipatory prescribing should follow a structured approach to ensure safe, timely, and effective symptom management at end of life.

Identify the dying phase

Use validated tools such as the Supportive and Palliative Care Indicators Tool (SPICT™) or the Surprise Question ("Would I be surprised if this patient died in the next 12 months?") to identify patients approaching end of life. Clinical signs include progressive decline, increasing dependency, recurrent hospitalisations, and multi-organ failure.

Goals-of-care discussion

Undertake a goals-of-care conversation with the patient (where possible) and their family. Document the care plan, including the decision to focus on comfort measures and the anticipated symptom trajectory. Use the ACSQHC Goals-of-Care documentation form appropriate to your state or territory.

Prescribe the "just-in-case" kit

Prescribe a standard set of subcutaneous medications to be kept at the bedside or in the home. The typical Australian anticipatory prescribing kit includes four drug classes covering the five most common end-of-life symptoms: pain, dyspnoea, nausea/vomiting, agitation/restlessness, and excessive secretions. Prescribe at least 48–72 hours of medication.

Prepare equipment

Supply subcutaneous butterfly needles (23G or 25G), syringes, sharps containers, and consider a syringe driver if continuous infusion is anticipated. Ensure written dosing instructions are left at the bedside with a contact number for the palliative care team (available 24/7).

Education and handover

Educate family carers and/or residential aged-care facility staff on when and how to administer medications. Provide written action plans. If community nurses or after-hours services will administer medications, ensure they have been briefed and have access to the medications.

⚠️

Medication access after hours: In rural and remote Australia, after-hours pharmacy access may be severely limited. Always ensure anticipatory medications are prescribed and dispensed before they are needed. Engage local pharmacists and consider arrangements with Royal Flying Doctor Service (RFDS) in remote areas.

Standard Anticipatory Prescribing Kit — Quick Reference

Pain / Dyspnoea

Morphine 2.5–10 mg SC 2-hourly PRN

48–72 hours

Reduce dose if renal impairment or opioid-naïve elderly

Agitation / Restlessness

Midazolam 2.5–5 mg SC 2-hourly PRN

48–72 hours

Syringe driver 10–30 mg/24 h if refractory

Nausea / Vomiting

Haloperidol 1–2.5 mg SC BD-TDS

48–72 hours

Add metoclopramide if gastric stasis

Secretions (death rattle)

Hyoscine butylbromide 20 mg SC 4-hourly PRN

48–72 hours

Glycopyrrolate 0.2 mg SC alternative

Seizures

Midazolam 5–10 mg SC stat

As needed

Consider clonazepam 1 mg SC for prolonged seizure prophylaxis

Morphine

Morphine is the most widely used opioid in Australian palliative care and remains the gold-standard agent for both nociceptive pain and respiratory distress/dyspnoea at end of life. Its well-characterised pharmacology, multiple formulations, and familiar dose-conversion ratios make it the default first-line choice in anticipatory prescribing kits.

Pharmacology

Morphine is a μ-opioid receptor agonist. It undergoes hepatic glucuronidation to morphine-3-glucuronide (M3G — neuroexcitatory, potentially causing myoclonus and hyperalgesia) and morphine-6-glucuronide (M6G — analgesic, accumulates in renal impairment). Both active metabolites are renally excreted, mandating dose reduction in chronic kidney disease.

Indications at End of Life

Pain: Visceral, somatic, and neuropathic pain (as adjuvant). Starting dose depends on prior opioid exposure.
Dyspnoea: Low-dose morphine reduces the central respiratory drive and the sensation of breathlessness. Evidence from randomised trials and systematic reviews supports its use in end-stage COPD, heart failure, and cancer-related dyspnoea.

Available Formulations

Formulation	Product (Australia)	Use	PBS Status
Immediate-release oral solution	Ordine® 2 mg/mL, 5 mg/mL, 10 mg/mL; Sevre-Duo®	Breakthrough pain, dyspnoea; can be given sublingually if swallowing difficult	✔ PBS General Benefit
Subcutaneous injection	DBL Morphine Sulphate 10 mg/mL, 15 mg/mL, 20 mg/mL, 30 mg/mL ampoules	Parenteral breakthrough pain and dyspnoea; syringe driver infusion	Restricted Benefit — Palliative Care
Sustained-release oral	Kapanol®, MS Contin®, Morphgesic SR®	Background pain (not typically in acute anticipatory kit)	✔ PBS General Benefit

💊

Morphine — Subcutaneous Bolus

DBL Morphine Sulphate · Opioid analgesic

Opioid-naïve adult dose 2.5–5 mg SC 2-hourly PRN (for pain or dyspnoea)

Opioid-tolerant adult dose 10–20% of total 24-hour oral morphine equivalent as SC bolus 2-hourly PRN

Syringe driver dose Equivalent to total PRN boluses in 24 hours, plus current regular dose, divided over 24 hours

Paediatric dose 50–100 mcg/kg SC 2–4 hourly PRN; consult paediatric palliative care

Renal impairment eGFR 30–50: reduce dose by 50%, extend interval to 4-hourly. eGFR <30: avoid morphine; use fentanyl or hydromorphone

Hepatic impairment Reduce dose by 50% in severe hepatic impairment; monitor for sedation

PBS status Restricted Benefit — Palliative Care

🚨

Renal impairment — avoid morphine: In patients with eGFR <30 mL/min/1.73 m², morphine's active metabolites (M3G, M6G) accumulate significantly, causing prolonged sedation, respiratory depression, and myoclonic jerks. Switch to fentanyl or hydromorphone, which have no clinically significant renally-cleared active metabolites.

Oral-to-Parenteral Conversion

The standard oral-to-subcutaneous conversion ratio for morphine in Australian palliative care practice is approximately 2:1 to 3:1 (i.e., 2–3 mg oral morphine ≈ 1 mg SC morphine). When converting from sustained-release to subcutaneous, calculate the total 24-hour oral dose first, then divide by the conversion factor.

Side Effects and Management

Nausea: Common on initiation. Co-prescribe haloperidol or metoclopramide (see below).
Constipation: Continue regular laxatives (e.g., macrogol, senna, or lactulose) until the last days of life when oral intake ceases.
Sedation: Usually precedes respiratory depression. Assess using the Richmond Agitation–Sedation Scale (RASS). If RASS ≤ −3, hold next dose and review.
Myoclonus: May indicate metabolite accumulation (especially in renal impairment) or high-dose opioid use. Switch opioid or add midazolam/clonazepam.
Respiratory depression: Rare at appropriate palliative doses. If respiratory rate <8/min with excessive sedation, withhold opioid and consider naloxone 40–200 mcg IV/SC diluted — titrate cautiously to avoid precipitating acute withdrawal and pain crisis.

Midazolam & Clonazepam

Benzodiazepines are essential in the anticipatory prescribing kit for managing terminal restlessness and agitation, anxiety, myoclonus, and seizures at end of life. Midazolam is the preferred parenteral agent due to its rapid onset and short duration of action when given as intermittent boluses, while clonazepam offers a longer-acting oral option.

Midazolam

Midazolam is a short-acting benzodiazepine with an onset of 1–3 minutes (SC) and duration of 2–4 hours for bolus doses. It is the first-line agent for acute terminal agitation and is also effective for seizure management at end of life.

💊

Midazolam

Hypnovel® · DBL Midazolam · Benzodiazepine

Adult dose — agitation/anxiety 2.5–5 mg SC bolus, repeat 2-hourly PRN; max 20 mg/24 h as boluses before converting to infusion

Syringe driver (continuous infusion) 10–30 mg over 24 hours SC via syringe driver for refractory agitation

Adult dose — seizures 5–10 mg SC/IM/IV stat; repeat once after 10 min if needed; then syringe driver 20–60 mg/24 h

Paediatric dose 50–100 mcg/kg SC/IN 2–4 hourly PRN; consult paediatric palliative care

Renal impairment No significant dose adjustment; active metabolite (α-hydroxymidazolam) has minimal renal accumulation

Hepatic impairment Reduce dose by 50% in severe hepatic impairment; prolonged elimination half-life

PBS status Restricted Benefit — Palliative Care

⚠️

Terminal restlessness — differential diagnosis: Before escalating midazolam, consider reversible causes including urinary retention (catheterise), faecal impaction (digital examination), medication-induced agitation (e.g., opioids, corticosteroids), and uncontrolled pain. Benzodiazepines alone may not resolve agitation caused by unaddressed physical symptoms.

Clonazepam

Clonazepam has a longer duration of action (6–12 hours) and is particularly useful for myoclonus associated with high-dose opioid use and for persistent anxiety between midazolam doses. It can be given orally or sublingually.

💊

Clonazepam

Rivotril® · Paxam® · Benzodiazepine

Adult dose — myoclonus 0.5–1 mg PO/SL BD–TDS

Adult dose — anxiety 0.25–0.5 mg PO/SL BD, titrate to 1–2 mg BD

Renal impairment No specific dose adjustment required; use with caution

Hepatic impairment Reduce dose; prolonged half-life in hepatic dysfunction

PBS status ✔ PBS General Benefit

Syringe Driver — Midazolam Infusion

When intermittent SC boluses of midazolam fail to control agitation within 24 hours, convert to a continuous subcutaneous infusion via syringe driver. Calculate the total bolus dose required in the preceding 24 hours and use this as the starting infusion dose. Typical range is 10–30 mg/24 hours, but higher doses (up to 60–100 mg/24 h) may be needed in refractory terminal agitation — always consult specialist palliative care before exceeding 30 mg/24 h.

ℹ️

Syringe driver compatibility: Midazolam is compatible with morphine, haloperidol, hyoscine butylbromide, and metoclopramide in the same syringe driver at clinically relevant concentrations. Use 0.9% sodium chloride or water for injections as diluent. Always check the current compatibility chart (e.g., Palliative Care Therapeutic Guidelines or local hospital protocol) before mixing.

Haloperidol & Metoclopramide

Nausea and vomiting are among the most distressing symptoms at end of life, affecting up to 70% of patients with advanced cancer and a significant proportion of patients with end-stage organ failure. Delirium with agitation also affects 28–83% of patients in the last days of life. Haloperidol and metoclopramide are the principal antiemetic agents in the anticipatory prescribing kit, each targeting different mechanisms of nausea.

Haloperidol

Haloperidol is a butyrophenone antipsychotic that acts primarily as a dopamine D₂ antagonist in the chemoreceptor trigger zone (CTZ). It is the first-line antiemetic for nausea of central origin (metabolic, drug-induced, raised intracranial pressure) and is also effective for managing delirium with agitation at end of life. Low doses are effective and extrapyramidal side effects are uncommon in the palliative care context at typical doses.

💊

Haloperidol

Serenace® · Haldol® · Butyrophenone antipsychotic

Adult dose — nausea 0.5–2.5 mg PO/SC BD–TDS

Adult dose — delirium/agitation 1–2.5 mg SC/PO BD–TDS; titrate up to 5 mg TDS in refractory delirium under specialist guidance

Syringe driver dose 2.5–10 mg over 24 hours SC

Paediatric dose 10–25 mcg/kg PO/SC BD–TDS; consult paediatric palliative care

Renal impairment No specific dose adjustment; use lower end of dosing range

Hepatic impairment Reduce dose by 50%; haloperidol undergoes extensive hepatic metabolism

PBS status ✔ PBS General Benefit (oral); Restricted Benefit — Palliative Care (injection)

⚠️

QT prolongation risk: Haloperidol can prolong the QT interval, particularly at higher doses and when given intravenously. At end-of-life doses (0.5–2.5 mg SC/PO), the risk is low. However, avoid in patients with known QT prolongation, significant electrolyte disturbances (hypokalaemia, hypomagnesaemia), or concurrent use of other QT-prolonging drugs. ECG monitoring is recommended if IV haloperidol is used or doses exceed 5 mg/day.

Metoclopramide

Metoclopramide is a dopamine D₂ antagonist and 5-HT₄ agonist with prokinetic activity. It is preferred for nausea caused by gastric stasis, opioid-induced nausea (via enhanced gastric motility), and hepatic capsular distension. It is contraindicated in mechanical bowel obstruction as it increases gastrointestinal motility.

💊

Metoclopramide

Maxolon® · Pramin® · Dopamine antagonist / Prokinetic

Adult dose 10 mg PO/SC TDS–QDS, 30 min before meals and at bedtime

Syringe driver dose 30–60 mg over 24 hours SC

Paediatric dose 100–150 mcg/kg PO/SC TDS–QDS (max 500 mcg/kg/day); consult paediatric palliative care

Renal impairment eGFR 10–50: reduce dose by 50%; eGFR <10: reduce by 75%

Hepatic impairment No specific adjustment; use caution

PBS status ✔ PBS General Benefit

🚨

Bowel obstruction: Metoclopramide is contraindicated in mechanical bowel obstruction. In patients with nausea due to bowel obstruction, use haloperidol, cyclizine, or dexamethasone. If partial obstruction, octreotide (50–100 mcg SC BD) may reduce secretion volume and colicky pain.

Choosing Between Haloperidol and Metoclopramide

Nausea Mechanism	Preferred Agent	Clinical Scenario
Central (CTZ/metabolic)	Haloperidol	Drug-induced (e.g., opioids, antibiotics), uraemia, hypercalcaemia
Gastric stasis	Metoclopramide	Opioid-induced delayed gastric emptying, gastroparesis, hepatic capsular distension
Bowel obstruction	Haloperidol (± cyclizine)	Avoid metoclopramide; add octreotide for secretion control
Vestibular / positional	Cyclizine (alternative)	Cerebral metastases, raised ICP
Delirium with agitation	Haloperidol	End-of-life delirium — combined antiemetic and antipsychotic effect

Anticholinergics (Hyoscine Butylbromide & Glycopyrrolate)

Anticholinergic (antimuscarinic) medications are used in the anticipatory kit primarily for the management of death rattle — the noisy, rattling respiratory secretions caused by pooled oropharyngeal and bronchial secretions in the dying patient who can no longer cough or swallow effectively. This sound can be profoundly distressing to family members and carers, although evidence suggests the dying patient is unlikely to be aware of it.

Mechanism

Anticholinergic agents block muscarinic (M₃) receptors on submucosal glands in the airways and oropharynx, reducing the volume of secretions produced. They do not clear existing secretions but prevent further accumulation.

First-Line: Hyoscine Butylbromide (Buscopan®)

Hyoscine butylbromide is a quaternary ammonium antimuscarinic that does not cross the blood-brain barrier significantly, making it preferred over hyoscine hydrobromide as it causes less central sedation and confusion. It is widely available in Australia and is the standard first-line agent for death rattle.

💊

Hyoscine Butylbromide

Buscopan® · Antimuscarinic

Adult dose — SC bolus 20 mg SC 4–6 hourly PRN

Syringe driver dose 60–80 mg over 24 hours SC (can increase to 120 mg/24 h under specialist guidance)

Oral dose (less commonly used) 10–20 mg PO TDS (limited role at end of life due to reduced oral intake)

Renal impairment No specific dose adjustment

Hepatic impairment No specific dose adjustment

PBS status ✔ PBS General Benefit (oral); Restricted Benefit — Palliative Care (injection)

Second-Line: Glycopyrrolate (Glycopyrronium)

Glycopyrrolate is a quaternary ammonium antimuscarinic with similar peripheral selectivity to hyoscine butylbromide. It causes less sedation and may have a slightly longer duration of action. It is available in Australia but less commonly stocked in community pharmacies than hyoscine butylbromide.

💊

Glycopyrrolate

Glycopyrronium bromide · Robinul® · Antimuscarinic

Adult dose — SC bolus 0.2 mg SC 6–8 hourly PRN

Syringe driver dose 0.6–1.2 mg over 24 hours SC

Renal impairment Use with caution; no specific dose adjustment required

Hepatic impairment No specific dose adjustment

PBS status Restricted Benefit (injection); not widely PBS-listed for oral use

Alternative: Hyoscine Hydrobromide

Hyoscine hydrobromide (scopolamine) crosses the blood-brain barrier and can cause sedation, confusion, and hallucinations. It is generally reserved as a second- or third-line option for death rattle. However, the sedating effect may be desirable if concurrent terminal agitation is present. Dose: 0.4 mg (400 mcg) SC 4–6 hourly PRN or 1.2 mg over 24 hours via syringe driver.

ℹ️

Non-pharmacological measures for death rattle: Reposition the patient into a semi-prone or lateral position to allow secretions to drain by gravity. Gentle oropharyngeal suctioning may be attempted but is often poorly tolerated and can cause distress. Reassure family members that the sound is not causing the patient distress. Over-hydration (IV fluids) increases secretion volume and should be avoided in the dying phase.

Other Indications for Anticholinergics at End of Life

Colicky abdominal pain: Hyoscine butylbromide 20 mg SC 4–6 hourly for bowel colic or ureteric colic when active management is not appropriate.
Sweating: Hyoscine butylbromide or glycopyrrolate can reduce troublesome sweating in the dying phase.
Sialorrhoea: Glycopyrrolate is preferred for excessive salivation (e.g., in motor neurone disease or post-stroke), particularly as it causes less central sedation.

Syringe Drivers & Practical Equipment

A subcutaneous infusion pump (syringe driver) is indicated when a patient requires continuous symptom control that cannot be adequately managed with intermittent bolus injections, or when the patient can no longer take oral medications. Common indications include continuous opioid infusion for background pain, continuous midazolam for refractory agitation, and combination infusions for multiple concurrent symptoms.

Common Syringe Driver Devices in Australia

Device	Syringe Size	Key Features
McKinley T34™	20 mL or 50 mL	Most commonly used in Australian community palliative care; programmable rate; bolus dose capability; lightweight
CADD-Solis® VIP	Various	Multiple infusion modes; PCA capability; used in hospital and specialist palliative care units
BD Alaris™	Various	Hospital-based syringe pump; used in inpatient palliative care units

Syringe Driver Drug Compatibility

The following combinations are commonly used in a single syringe driver with 0.9% sodium chloride or water for injections as diluent. Always verify against the most current compatibility data.

Drug Combination	Compatible	Notes
Morphine + Midazolam	✔ Yes	Most common dual combination for pain + agitation
Morphine + Haloperidol	✔ Yes	Pain + nausea
Morphine + Haloperidol + Hyoscine butylbromide	✔ Yes	Triple combination — pain + nausea + secretions
Morphine + Midazolam + Haloperidol + Hyoscine butylbromide	✔ Yes	Quadruple combination — all four drug classes; total volume should not exceed syringe capacity
Morphine + Metoclopramide	✔ Yes	Pain + gastric stasis-related nausea
Haloperidol + Metoclopramide	✔ Yes	Dual antiemetic approach
Midazolam + Hyoscine butylbromide	✔ Yes	Agitation + secretions (no opioid required)

Essential Equipment Checklist

Subcutaneous butterfly/Scalp Vein needles — 23G or 25G
Syringes (1 mL, 3 mL, 5 mL, 10 mL)
0.9% sodium chloride ampoules (for dilution)
Water for injections ampoules
Sharps container
Alcohol swabs
Adhesive dressing (for SC site fixation)
Syringe driver + batteries (if home-based driver anticipated)
Written medication action plan with dose instructions
24-hour contact number for palliative care team

Monitoring & Safety

Monitoring at end of life is focused on symptom response and safety rather than routine biochemistry. The goal is to achieve adequate symptom relief while minimising adverse effects, maintaining the patient's comfort and dignity.

Key Monitoring Parameters

Essential Pain assessment Use validated tool (e.g., Abbey Pain Scale for non-verbal patients, Numerical Rating Scale for verbal patients). Reassess 30–60 min after each SC bolus.

Essential Sedation level (RASS) Richmond Agitation–Sedation Scale: target RASS 0 to −1 (alert and calm to light sedation). If RASS ≤ −3, withhold sedating medications and review.

Essential Respiratory rate Monitor before each opioid dose. RR <8/min with excessive sedation: withhold opioid, consider naloxone.

Available Oxygen saturation (SpO₂) Useful if available but should not drive decision-making in the actively dying patient. SpO₂ may be unreliable in poor peripheral perfusion.

Available Blood glucose If patient is on corticosteroids or has known diabetes; hypoglycaemia can cause confusion and agitation.

Essential Subcutaneous site Inspect every 24 hours for erythema, swelling, or extravasation. Rotate site every 3–7 days or sooner if problems arise.

ℹ️

Principle of double effect: Administering opioids and sedatives at appropriate doses for symptom relief near end of life — even if there is a theoretical risk of hastening death — is ethically and legally acceptable in Australian law. The intent is symptom relief, not euthanasia. Ensure clear documentation of symptom indications and clinical rationale.

Special Populations

🫘 Renal Impairment

Morphine — Avoid if eGFR <30 mL/min/1.73 m². Active metabolites (M3G, M6G) accumulate causing prolonged sedation, myoclonus, and respiratory depression. Use fentanyl or hydromorphone instead.

Midazolam — Minimal renal accumulation of active metabolites; generally safe. Use standard doses and titrate to effect.

Haloperidol — No significant dose adjustment required. Use lower end of dosing range.

Metoclopramide — Reduce dose by 50% (eGFR 10–50) or 75% (eGFR <10). Increased risk of extrapyramidal side effects with accumulation.

Hyoscine butylbromide — No specific dose adjustment.

Consider discussing with renal palliative care specialist or palliative medicine consultant for complex decisions regarding dialysis withdrawal and symptom management.

🫁 Hepatic Impairment

Morphine — Reduce dose by 50% in severe hepatic impairment. First-pass metabolism is reduced; oral bioavailability increases.

Midazolam — Prolonged half-life; reduce dose by 50%. Avoid continuous infusion without close monitoring.

Haloperidol — Extensively hepatically metabolised; reduce dose by 50% and extend interval.

Metoclopramide — No specific adjustment; use caution.

Patients with liver failure may have coagulopathy — ensure subcutaneous sites are monitored for haematoma formation.

👶 Paediatrics

Morphine — 50–100 mcg/kg SC 2–4 hourly PRN for opioid-naïve children. Titrate carefully.

Midazolam — 50–100 mcg/kg SC/IN 2–4 hourly PRN. Intranasal midazolam is effective for seizure management in children.

Haloperidol — 10–25 mcg/kg PO/SC BD–TDS. Lower risk of extrapyramidal side effects in children at these doses.

Paediatric palliative care is a highly specialised area. Always consult a paediatric palliative care team (e.g., Bear Cottage, each children's hospital palliative care service) for anticipatory prescribing in children. Weight-based dosing is mandatory.

👴 Elderly (≥75 years)

All medications — Start at lower doses and titrate slowly. Elderly patients have reduced hepatic and renal clearance, increased sensitivity to opioids and benzodiazepines, and higher risk of falls, sedation, and delirium.

Morphine — Start at 1.25–2.5 mg SC bolus in frail elderly opioid-naïve patients.

Midazolam — Start at 1.25–2.5 mg SC; elderly patients are more sensitive to benzodiazepine-induced sedation.

Residential aged-care facilities (RACFs) should have anticipatory prescribing protocols in place. After-hours access to medications can be a significant barrier — plan ahead. Ensure medication charts are legible, doses are explicit, and staff are trained.

🛡️ Immunocompromised

All medications — No specific dose adjustments related to immunosuppression. However, consider drug interactions with immunosuppressant regimens (e.g., tacrolimus and haloperidol both prolong QT; ciclosporin and opioid interactions).

In patients with neutropenic sepsis transitioning to palliative care, antibiotic withdrawal decisions should be made collaboratively with the haematology/oncology team, patient, and family.

🤰 Pregnancy

Pregnancy at end of life is rare — Most anticipatory prescribing medications carry category C (morphine, midazolam) or B3 (haloperidol) classifications in the Australian pregnancy category system.

If end-of-life care is required in a pregnant patient, specialist palliative care and obstetric teams must be involved in all prescribing decisions. Neonatal considerations for viable pregnancies must be addressed.

Aboriginal and Torres Strait Islander Health Considerations

Aboriginal and Torres Strait Islander Health

Cultural safety in end-of-life discussions

End-of-life conversations require cultural sensitivity and should be led or guided by Aboriginal and Torres Strait Islander health workers or liaison officers where available. The concept of "sorry business" (mourning and death-related cultural practices) is deeply important and varies between communities. Avoid imposing Western timelines or frameworks. Allow family and community members to be present and involved in care planning. Recognise that some communities have strong beliefs about discussing death openly — approach conversations with patience, respect, and appropriate introductions.

Geographic and access barriers

Many Aboriginal and Torres Strait Islander Australians live in remote and very remote areas where pharmacy access is extremely limited. The Royal Flying Doctor Service (RFDS) and Remote Area Aboriginal Health Services may be the primary providers of end-of-life care. Anticipatory medications must be prescribed and supplied well in advance. Cold-chain requirements for some injectable medications must be considered in hot climates. Aboriginal Community Controlled Health Organisations (ACCHOs) should be central partners in planning end-of-life medication access.

Country and connection to land

Many Aboriginal and Torres Strait Islander patients express a strong preference to return to their traditional lands (Country) to die. Facilitating this requires advance planning for medication supply, equipment transport, and community support. Palliative care services should actively support "return to Country" wishes wherever safely achievable, including arranging anticipatory medication kits that can be transported to remote communities.

Family and community involvement

Aboriginal and Torres Strait Islander approaches to dying often involve the broader community, extended family networks, and cultural practices that may include traditional healing alongside Western medicine. Anticipatory prescribing should be discussed in a way that respects and integrates these practices. Family members may wish to be trained in medication administration — this should be facilitated where appropriate, with clear documentation and support from visiting nurses or ACCHO staff.

After-hours medication access

After-hours pharmacy access is a critical barrier in remote communities. The Australian Government's Closing the Gap PBS Co-payment measure reduces PBS co-payments for Aboriginal and Torres Strait Islander Australians, but this does not address the physical availability of medications. Engagement with RFDS, local health centres, and pre-positioning of medication stocks at remote clinics are essential strategies. Palliative care emergency kits with pre-drawn syringes may be necessary in some settings.

Language and health literacy

Written medication instructions may not be accessible for patients and carers whose first language is not English or who have limited literacy. Verbal instructions in language, with the use of interpreters (Aboriginal Interpreter Service or Torres Strait Islander interpreter services), pictorial medication guides, and video resources should be used. Aboriginal health workers and liaison officers are essential in bridging communication gaps.

📚 References

1. Palliative Care Australia. National Palliative Care Standards. 5th ed. Canberra: Palliative Care Australia; 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. Australian Government Department of Health and Aged Care. National Palliative Care Strategy 2018. Canberra: Commonwealth of Australia; 2018.
4. Currow DC, McDonald C, Oaten S, et al. Once-daily opioids for chronic dyspnoea: a dose increment and pharmacovigilance study. J Pain Symptom Manage. 2011;42(3):388–399.
5. Bajwah S, Higginson IJ, Ross JR, et al. Specialist palliative care is more than drugs: a retrospective study of ILD patients. Lung. 2012;190(3):303–308.
6. Hui D, De La Cruz M, Thorney S, Bruera E. The role of anticipatory prescribing in end-of-life care. J Pain Symptom Manage. 2011;41(6):1014–1021.
7. Agar MR, Lawlor PG, Quinn S, et al. Efficacy of oral risperidone, haloperidol, or placebo for symptoms of delirium among patients in palliative care: a randomized clinical trial. JAMA Intern Med. 2017;177(1):34–42.
8. Wee B, Hillier R. Interventions for noisy breathing in patients near to death. Cochrane Database Syst Rev. 2008;(1):CD005177.
9. Australian Institute of Health and Welfare (AIHW). Palliative care services in Australia. Cat. no. HWV 78. Canberra: AIHW; 2023.
10. Royal Australian College of General Practitioners (RACGP). Specific Interests: Palliative Care. Melbourne: RACGP; 2023.
11. World Health Organization (WHO). WHO Guidelines for the Pharmacological and Radiotherapeutic Management of Cancer Pain in Adults and Adolescents. Geneva: WHO; 2018.
12. Aboriginal and Torres Strait Islander Health Performance Framework. Measure 3.09: Access to palliative care. Australian Government; 2023.
13. To THM, Agar M, Shelby-James T, et al. Prescribing for end-of-life care in the Australian aged care setting: a prospective audit. Intern Med J. 2013;43(10):1138–1143.
14. National Institute for Health and Care Excellence (NICE). End of life care for adults: service delivery. NICE guideline [NG142]. London: NICE; 2019.

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).