Avoiding Inappropriate Resuscitation

Last updated 1 Jun 2026 · Palliative care

📋 Key Information Summary

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Cardiopulmonary resuscitation (CPR) is a default treatment in Australia unless a valid Do-Not-Resuscitate (DNR) or Not-for-Resuscitation (NFR) order is documented — proactively address resuscitation status in all patients with life-limiting illness.
CPR in actively dying or end-stage organ failure patients is almost never successful and causes rib fractures, visceral injury, and distressing last memories for families.
A resuscitation decision is a medical determination, not a patient right to demand — clinicians are not obligated to offer or provide futile treatment.
Use structured advance care planning (ACP) frameworks: discuss goals of care, ceiling of treatment, and escalation preferences well before an acute deterioration.
Document resuscitation status using state/territory-recognised forms (e.g., Resuscitation Plan in NSW, Goals of Care in Queensland, DNR form in Victoria) and ensure they are accessible in clinical systems and at the bedside.
The Recommended Summary Plan for Emergency Care and Treatment (ReSPECT) process is being adopted across Australian jurisdictions as a person-centred emergency care plan.
Valid DNR/NFR orders must be clearly communicated to ambulance services — without a documented plan, paramedics are legally and professionally obliged to commence CPR.
Ambulance and emergency plans (e.g., Ambulance Victoria's Treat-Refer-Transfer framework, NSW Health's Acute Resuscitation Plan) should specify comfort care, symptom management, and whether transfer to hospital is desired.
Family communication should be empathetic, non-judgemental, and frame the decision as "what we can do" rather than "what we are not doing" — avoid the term "Do Not Resuscitate" with families when possible.
Revisit resuscitation decisions at key transitions: hospital admission, discharge, clinical deterioration, or change in care setting.
Aboriginal and Torres Strait Islander patients may have cultural obligations around death, sorry business, and family decision-making — engage Aboriginal Health Workers and allow family-led discussions.
Inadequate documentation is the single most common reason for inappropriate resuscitation — ensure plans are signed, dated, current, and accessible to all care providers including after-hours staff.

Introduction & Australian Epidemiology

Cardiopulmonary resuscitation (CPR) was developed in the 1960s for unexpected cardiac arrest in otherwise healthy individuals. Over subsequent decades it became a default intervention applied to virtually all hospitalised patients unless explicitly documented otherwise. In contemporary Australian practice, it is recognised that CPR confers no benefit — and often causes significant harm — in patients with end-stage organ failure, advanced malignancy, frailty, or those in the active phase of dying.

In Australia, approximately 160,000 people die each year, with the majority occurring in hospital or residential aged care facilities. Surveys consistently show that most Australians prefer to die at home or in a hospice setting, yet fewer than 20% achieve this. A significant proportion of hospital deaths involve unwanted escalation of treatment, including CPR, intensive care unit (ICU) admission, and mechanical ventilation, often because a resuscitation decision was never discussed or documented.

National data from the Australasian Resuscitation Outcomes Consortium (Aus-ROC) demonstrates that survival to hospital discharge following in-hospital cardiac arrest is approximately 20–25% overall, but falls below 5% in patients with metastatic cancer, end-stage renal failure, end-stage heart failure (NYHA Class IV), severe sepsis, or a Palliative Performance Scale (PPS) score below 30%. Out-of-hospital cardiac arrest survival in Australia remains around 10–12% where bystander CPR is initiated, but is negligible in patients found in aged care facilities with known terminal illness.

This topic addresses the clinical framework for appropriate resuscitation decision-making, documentation requirements across Australian jurisdictions, coordination with ambulance services, and compassionate communication with patients and families. The overarching principle is that avoiding inappropriate resuscitation is not "doing nothing" — it is a deliberate, documented decision to redirect care towards comfort, dignity, and symptom management.

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Key principle: In all Australian states and territories, CPR is considered a default treatment. Unless a valid, current, and accessible resuscitation plan explicitly states otherwise, emergency services and hospital staff will commence resuscitation. Proactive documentation is essential.

Resuscitation Status

Resuscitation status refers to the medical determination of whether CPR (including defibrillation, intubation, and advanced cardiac life support) should be attempted in the event of cardiac or respiratory arrest. It is a clinical decision made by a senior medical officer in consultation with the patient (where capable), their substitute decision-maker, and the multidisciplinary team.

When to Initiate Resuscitation Status Discussion

A resuscitation discussion should be triggered at defined clinical milestones, not left until the terminal event:

Diagnosis of a life-limiting illness with expected trajectory of decline (e.g., metastatic cancer, end-stage COPD, motor neurone disease)
Frailty Clinical Frailty Scale (CFS) score ≥ 7 (severely frail) or Palliative Performance Scale (PPS) ≤ 40%
Admission to hospital with acute deterioration of a chronic condition
Transfer to residential aged care (transition of care)
Referral to palliative care or hospice services
Patient or family-initiated request to discuss end-of-life wishes
ICU step-down when further escalation is not consistent with prognosis

Categories of Resuscitation Plan

For Full Active Treatment

All interventions including CPR, ICU admission, mechanical ventilation, and inotropes are appropriate. Appropriate where prognosis is reasonable and patient wishes are for full escalation.

Setting: Hospital ward, ICU

Not for CPR / Ceiling of Care Limitation

CPR will not be attempted in the event of cardiac arrest. Other active treatments (antibiotics, IV fluids, transfusion, non-invasive ventilation) may continue as appropriate. May include ceiling of ICU care or specific exclusions.

Setting: Hospital, community palliative care

Comfort Measures Only / End-of-Life Care

Active treatment directed at symptom relief only. No CPR, no ICU, no antibiotics for infection, no transfer to hospital unless for refractory symptoms. Focus on dignity, comfort, and family presence.

Setting: Home, hospice, RACF

Futility and the Clinician's Obligation

Australian medical law and ethics, guided by the Australian Medical Association (AMA) and the Australasian College for Emergency Medicine (ACEM), recognise that clinicians are not obliged to provide treatment that is futile, harmful, or not clinically indicated. CPR that will not restore meaningful circulation or survival is considered medically futile. This is not a withdrawal of care — it is a redirection towards appropriate care.

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Safety-critical point: If there is doubt about the validity of a resuscitation plan, or if the plan is not accessible (e.g., it is filed at the GP but the patient is at home), paramedics and emergency staff will commence full resuscitation. Always ensure the plan is available at point of care — on the fridge (Ambulance-recognised form), in the My Health Record, and in hospital electronic medical records.

Australian Legal Framework

Resuscitation decisions are governed by a combination of common law, state/territory legislation, and professional guidelines:

Common law: A competent adult has the right to refuse treatment, including life-sustaining treatment. This is well-established in Australian case law (e.g., Re T (Adult: Refusal of Treatment) principles adopted in Australian jurisdictions).
State/territory guardianship and medical treatment legislation: Each jurisdiction has specific legislation governing substitute decision-making for patients without capacity (e.g., NSW Guardianship Act 1987, Vic Medical Treatment Planning and Decisions Act 2016, Qld Powers of Attorney Act 1998).
Advance Care Directives (ACDs): Legally recognised in all Australian states and territories under varying legislation. A valid ACD refusing CPR must be respected by treating clinicians, provided it applies to the current clinical situation.
Professional standards: The Medical Board of Australia's Good Medical Practice code requires clinicians to consider the patient's wishes, provide honest information, and make decisions in the patient's best interest.

Documentation

Clear, accessible, and current documentation is the single most important factor in preventing inappropriate resuscitation. A verbal agreement with the patient or family, without formal documentation, offers no protection when emergency services arrive or an after-hours medical officer is called.

State and Territory Resuscitation Plan Forms

Each Australian jurisdiction has its own recognised documentation for resuscitation and treatment limitation decisions:

Jurisdiction	Form / Document	Key Features
New South Wales	Resuscitation Plan (R-Plan) / Goals of Patient Care (GOPC)	Recognised by NSW Ambulance; includes CPR status, ceiling of treatment, and preferred place of care
Victoria	Resuscitation Plan / Advance Care Directive (under Medical Treatment Planning and Decisions Act 2016)	Must be signed by medical practitioner; Ambulance Victoria recognises valid plans
Queensland	Resuscitation Plan (RP) / Advance Health Directive (AHD)	Queensland Ambulance Service recognises RPs; AHD is legally binding under Powers of Attorney Act 1998
South Australia	Resuscitation Plan / Advance Care Directive (under Advance Care Directives Act 2013)	ACDs have statutory recognition; SA Ambulance Service trains paramedics to identify and follow
Western Australia	Resuscitation Plan / Advance Health Directive (under Guardianship and Administration Act 1990)	WA Ambulance Service recognises plans; Community palliative care teams assist with documentation
Tasmania	Advance Care Directive / Resuscitation Plan	Under Guardianship and Administration Act 1995; Ambulance Tasmania training includes plan recognition
Northern Territory	Advance Personal Plan / Resuscitation Plan	Under Advance Personal Planning Act 2013; St John NT Ambulance recognises valid plans
ACT	Health Direction / Advance Care Directive	Under Medical Treatment (Health Directions) Act 2006; ACT Ambulance Service recognises plans

What Must Be Documented

Patient identification: Full name, date of birth, Medicare number, address
Clinical basis: Primary diagnosis, comorbidities, reason for resuscitation decision
Resuscitation status: For CPR / Not for CPR — stated explicitly and unambiguously
Ceiling of treatment: Specify what treatments are and are not appropriate (e.g., IV fluids: yes; ICU transfer: no; antibiotics for pneumonia: comfort measures only)
Patient/family involvement: Who was consulted, what was discussed, and whether the patient agreed
Medical officer signature: Signed and dated by the responsible medical officer (registrar or above in most jurisdictions)
Review date: Resuscitation plans should be reviewed at a minimum every 90 days or with any significant change in clinical status

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ReSPECT Process: The Recommended Summary Plan for Emergency Care and Treatment (ReSPECT) is being progressively adopted across Australian health services. ReSPECT provides a structured, person-centred approach that records both clinical recommendations and patient preferences for emergency care. It is designed to travel with the patient across care settings.

Common Documentation Failures

Verbal-only agreement not committed to the recognised form
Plan filed in the medical record but not accessible to ambulance or after-hours staff
Outdated plan not reviewed after clinical deterioration or hospital transfer
Incomplete documentation — e.g., "Not for CPR" without specifying ceiling of other treatments
Plan signed by a junior doctor without adequate senior review or clinical justification
Failure to notify the patient's GP, community palliative care team, and regular pharmacist

Ambulance Plans

Coordination with state and territory ambulance services is a critical and frequently overlooked step in avoiding inappropriate resuscitation. In the absence of a documented plan, Australian paramedics are professionally and legally required to initiate full resuscitation. Even if a patient has a documented NFR in the hospital, this has no standing with ambulance services unless the jurisdiction-specific ambulance-recognised plan is in place.

Key Principles for Ambulance Plans

Use the specific resuscitation/ACP form recognised by your state or territory ambulance service (see Documentation table above)
The form must be physically accessible — on the refrigerator (for home patients), at the bedside (for RACF patients), or electronically accessible in the ambulance dispatch system
The form must be current (signed within the review period — typically 90 days in most jurisdictions)
Contact the ambulance service to register the plan if required by your jurisdiction (e.g., Ambulance Victoria's PALMedicine service, NSW Ambulance's My Health Record integration)

Treat, Refer, or Transfer Decision

Ambulance plans should clearly articulate the desired response for different clinical scenarios:

Treat on Scene

Paramedics attend, provide symptom management (e.g., subcutaneous or buccal medications from the patient's end-of-life medication kit), and remain with the patient until comfortable. No transfer to hospital.

Refer to Community Palliative Care

Paramedics contact the community palliative care team (24-hour on-call service) for phone advice or home visit. Patient remains at home with community support.

Transfer to Hospital (for specific symptom control)

Transfer for management of refractory symptoms not controllable in the community (e.g., superior vena cava obstruction, pathological fracture). Comfort-focused treatment continues during transport.

Full Active Treatment

Standard ambulance response including CPR, defibrillation, intubation, and transport to nearest emergency department. For patients with reversible conditions and a realistic chance of meaningful recovery.

End-of-Life Medication Kits for Home

Patients dying at home should have an anticipatory medication kit available. These kits are prescribed by the GP or palliative care team and kept in the home. Paramedics may be instructed to administer these medications under the existing care plan:

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Morphine Sulfate (SC)

Ordine® · Generic · Opioid analgesic

Adult dose 2.5–10 mg SC every 4 hours PRN for pain/dyspnoea; start 2.5–5 mg if opioid-naïve

Paediatric dose 0.1–0.2 mg/kg SC every 4 hours PRN

Renal adjustment eGFR <30 mL/min: reduce dose by 50% or use hydromorphone; avoid morphine-6-glucuronide accumulation

PBS status ✔ PBS General Benefit

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Midazolam (SC)

Hypnovel® · Generic · Benzodiazepine

Adult dose 2.5–5 mg SC every 4 hours PRN for anxiety, restlessness, or terminal agitation; continuous infusion 10–30 mg/24 hours SC for refractory agitation

Paediatric dose 0.05–0.1 mg/kg SC every 4 hours PRN

Renal adjustment No significant adjustment required; use with caution in hepatic impairment

PBS status ✔ PBS General Benefit

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Hyoscine Butylbromide (SC)

Buscopan® · Generic · Antispasmodic/antisecretory

Adult dose 20 mg SC every 4–8 hours PRN for death rattle (secretions)

Paediatric dose 0.5–1 mg/kg SC every 6–8 hours PRN (max 20 mg)

Renal adjustment No adjustment required

PBS status ✔ PBS General Benefit

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Ambulance without a plan: If paramedics are called and no valid, current, accessible resuscitation plan exists, they will commence full resuscitation by default. This commonly results in distressed patients being intubated and transported to ED, where they may die in unfamiliar surroundings. Families may be traumatised by witnessing unwanted interventions. Ensure plans are in place and accessible before an emergency occurs.

Family Communication

Discussing resuscitation status with patients and families is one of the most challenging conversations in clinical practice. When done well, it provides reassurance, reduces anxiety, and ensures care aligns with the patient's values. When done poorly, it can cause lasting psychological harm, erode trust, and lead to conflict between families and the treating team.

Communication Frameworks

Evidence-based communication tools assist clinicians in structuring resuscitation conversations:

Setting Up

Ensure privacy, adequate time, appropriate attendees (patient, family, GP, social worker, interpreter if needed). Sit down. Turn off pagers. Introduce everyone present.

Perception

Ask the patient/family what they understand about the current situation. "Can you tell me what you understand about your mother's condition?" Listen without correcting immediately.

Invitation

Ask permission to share information and discuss next steps. "Would it be alright if I talked to you about what we can expect and how we can best care for your mother?"

Knowledge

Provide information in layers — start with a warning shot ("I'm afraid I have some difficult news"), state the situation clearly, and explain what treatments can and cannot achieve.

Empathy

Respond to emotion before continuing. "I can see this is very difficult to hear." Allow silence. Acknowledge the gravity of the conversation.

Strategy & Summary

Outline the plan: "What we will focus on is making sure your mother is comfortable, that she is not in pain, and that we support you and your family through this." Confirm understanding. Document the conversation.

Language to Use and Avoid

❌ Avoid	✅ Use Instead
"Do Not Resuscitate" / "DNR"	"We have a plan to focus on comfort and dignity" / "We will not be using machines to restart the heart"
"There's nothing more we can do"	"There is a lot we can do to make sure your father is comfortable and supported"
"We're withdrawing treatment"	"We are changing the focus of treatment to comfort"
"Would you like us to do everything?"	"Let me explain what treatments are available and which ones would be helpful for your mother's situation"
"He's a fighter; he wouldn't want to give up"	"We will continue to fight for his comfort and dignity. We will not abandon him."
"You need to decide now"	"Take the time you need. We can talk again tomorrow. There is no rush."

Addressing Common Family Concerns

"You're giving up on her": Emphasise that this is not abandonment — "We are changing what we are doing for her, not what we are doing about her. Our team will be just as involved."
"But she's a fighter / she wouldn't want this": Explore what the patient would have wanted. Use values-based language — "Your mother always said she wanted to be at home and not hooked up to machines. This plan honours those wishes."
"What if he wakes up?": Explain the clinical reality gently — "The brain has been very severely affected. Even if the heart could be restarted, there would not be meaningful recovery."
"Can we get a second opinion?": Always agree. Offer a palliative care consult, a second physician review, or a family meeting with the treating team. This is not adversarial — it is part of good care.
Guilt about "choosing" comfort care: Reframe — "This is not your decision alone. This is a recommendation based on what is medically appropriate. We are supporting you, not burdening you with the decision."

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Best practice: Document all family conversations in the medical record, including who attended, what was discussed, the family's understanding, and agreed next steps. Use a structured family meeting template. Send a summary letter to the GP and community palliative care team.

Special Populations

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Pregnancy

Resuscitation decisions in pregnant patients require consideration of both maternal and fetal welfare.

In a pregnant patient with a valid ACD refusing CPR, the treating team must consider gestational age and viability of the fetus — perimortem caesarean section may be indicated if fetal viability is likely (>23 weeks).

Consult obstetrics, neonatology, and ethics early. Document multidisciplinary decisions thoroughly.

Resuscitation planning in pregnant women with terminal illness (e.g., advanced cancer) should involve perinatal palliative care services.

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Paediatrics

Resuscitation decisions in children are profoundly sensitive. Parents are the substitute decision-makers for children under 18 (with mature minor exceptions in some jurisdictions).

CPR in children with life-limiting conditions (e.g., severe cerebral palsy, trisomy, progressive neuromuscular disease) should be discussed early with families by senior paediatricians and paediatric palliative care teams.

Use age-appropriate frameworks: discuss the child's quality of life, trajectory, and what CPR would realistically achieve.

Neonatal resuscitation decisions require perinatal palliative care pathways, ideally initiated antenatally when a life-limiting condition is diagnosed.

Document using jurisdiction-specific paediatric resuscitation plans and ensure the child's regular paediatrician is informed.

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Elderly / Frail

Frailty is an independent predictor of poor outcomes from CPR. Use the Clinical Frailty Scale (CFS) to guide discussions — a CFS ≥ 7 (severely frail) is associated with very low survival after cardiac arrest.

In residential aged care facilities (RACFs), ensure a current resuscitation plan is on file and a copy is provided to the local ambulance service.

Many elderly patients have not had a resuscitation discussion — proactive planning by GPs during chronic disease reviews reduces inappropriate escalation.

Multimorbidity and polypharmacy in the elderly require individualised assessment rather than age-based blanket decisions.

Ensure advance care planning discussions occur during My Health Ageing assessments (Medicare Items 701–707).

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Renal Impairment

Patients on dialysis have a 20–25% one-year mortality rate. Resuscitation planning should be integrated into dialysis care pathways.

Withdrawal from dialysis is one of the most common causes of death in dialysis patients — resuscitation planning should occur when dialysis withdrawal is considered.

Ensure end-of-life medications are renally adjusted (e.g., morphine dose reduction if eGFR <30, use hydromorphone as alternative).

Patients with CKD stages 4–5 should have a resuscitation plan documented at their renal outpatient clinic.

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Immunocompromised

Patients with haematological malignancy undergoing chemotherapy, bone marrow transplant recipients, and those on immunosuppressive therapy have high ICU mortality if they develop septic shock or multiorgan failure.

Proactive resuscitation planning should occur before initiating high-risk chemotherapy regimens (e.g., induction for AML, conditioning for stem cell transplant).

Discuss the "failure to thrive" trajectory — if neutropenic sepsis or graft-versus-host disease does not respond to treatment, early transition to comfort care should be planned.

HIV-positive patients with advanced immunosuppression (CD4 <50) and opportunistic infections should have resuscitation status reviewed at each admission.

Aboriginal and Torres Strait Islander Health Considerations

Aboriginal and Torres Strait Islander Health

Resuscitation and end-of-life discussions with Aboriginal and Torres Strait Islander patients and communities require deep cultural sensitivity, an understanding of Indigenous concepts of death and dying, and a commitment to self-determination in health care. Inappropriate resuscitation of Indigenous patients — particularly in remote communities — is a significant concern, often arising from inadequate documentation, poor communication between services, and a reluctance by non-Indigenous clinicians to initiate end-of-life conversations.

Cultural concepts of dying

Many Aboriginal and Torres Strait Islander people view death as a return to Country and as part of a spiritual journey. The Western medical imperative to "fight death" through CPR may conflict with cultural beliefs. Some communities use the term "sorry business" to describe the period of mourning and may have strong preferences about where death occurs (preferably on Country).

Family and community decision-making

Health decisions are often collective, involving extended family, Elders, and community members — not just the patient and next of kin. Expect and accommodate larger family meetings. Provide time and space for community consultation. Recognise that the patient may defer to family Elders.

Language and communication

English may be a second, third, or fourth language for many Aboriginal and Torres Strait Islander patients, particularly in remote communities. Use interpreter services (Aboriginal Interpreter Service in NT, Aboriginal Language and Translation Service in other jurisdictions). Avoid jargon. Use visual aids and culturally appropriate educational materials (e.g., resources from the Australian Indigenous Doctors' Association).

Sorry business and naming restrictions

In some communities, it is culturally inappropriate to speak the name of a deceased person or to show images of them. Be aware of these sensitivities when documenting and communicating about patients. Respect protocols around sorry business — clinical discussions may need to pause during mourning periods.

Aboriginal Health Workers and Liaison Officers

Engage Aboriginal Health Workers (AHWs) and Aboriginal Health Practitioners (AHPs) as cultural brokers in all resuscitation and end-of-life discussions. They can explain concepts in culturally appropriate ways, facilitate family meetings, and identify community-specific protocols. Funded through Indigenous-specific health programs (Closing the Gap PBS Co-payment measure).

Remote and very remote access

In remote communities, ambulance response times may exceed 1 hour. Without a documented plan, community members may attempt CPR for extended periods. Ensure that resuscitation plans are clearly communicated to remote health clinic staff, stored in Primary Care Information Systems (PCIS) or Communicare, and that community members are informed of the plan. Royal Flying Doctor Service (RFDS) retrieval teams should be notified of resuscitation status before activation.

Advance care planning resources

Use culturally adapted advance care planning resources: Palliative Care Australia's "Dying to Talk" campaign includes Indigenous-specific materials. The Aboriginal and Torres Strait Islander Dementia Advisory Service provides support for Indigenous people with dementia and their families. RHDAustralia provides end-of-life care guidance for rheumatic heart disease patients in remote communities.

Racism and systemic barriers

Aboriginal and Torres Strait Islander patients may have experienced racism in health care, leading to distrust. Approach end-of-life conversations with humility, acknowledge historical trauma, and demonstrate that decisions are guided by the patient's values, not by resource constraints. Explicitly state that comfort care is not "giving up" or rationing.

📚 References

1. Australian Resuscitation Council. ANZCOR Guideline 10.1 — Cardiopulmonary Resuscitation. Melbourne: Australian Resuscitation Council; 2024.
2. Australasian College for Emergency Medicine (ACEM). Statement on Resuscitation in the Emergency Department. Melbourne: ACEM; 2022.
3. Australian Medical Association (AMA). Position Statement on End of Life Care 2022. Canberra: AMA; 2022.
4. Palliative Care Australia. National Palliative Care Standards. 5th ed. Canberra: Palliative Care Australia; 2018.
5. Advance Care Planning Australia. National Framework for Advance Care Planning. Melbourne: Austin Health; 2023. Available from: advancecareplanning.org.au.
6. Australian Institute of Health and Welfare (AIHW). Deaths in Australia. Cat. no. PHE 229. Canberra: AIHW; 2023.
7. Resuscitation Council (UK). Recommended Summary Plan for Emergency Care and Treatment (ReSPECT). London: Resuscitation Council UK; 2020. Adapted for Australian use by state health departments.
8. NSW Health. Resuscitation Plan (R-Plan) — Policy Directive PD2019_036. Sydney: NSW Ministry of Health; 2019.
9. Department of Health Victoria. Medical Treatment Planning and Decisions Act 2016 — Clinical Guideline. Melbourne: Victorian Government; 2018.
10. Queensland Health. Resuscitation Plan Clinical Guideline. Brisbane: Queensland Government; 2021.
11. Australasian Resuscitation Outcomes Consortium (Aus-ROC). Annual Report on Out-of-Hospital Cardiac Arrest in Australia and New Zealand. Melbourne: Aus-ROC; 2023.
12. Detering KM, Hancock AD, Reade MC, Silvester W. The impact of advance care planning on end of life care in elderly patients: randomised controlled trial. BMJ. 2010;340:c1345.
13. Aboriginal and Torres Strait Islander Healing Foundation. Working with Aboriginal and Torres Strait Islander People in End-of-Life Care: A Resource for Health Professionals. Canberra: Healing Foundation; 2021.
14. Australian Indigenous Doctors' Association (AIDA). End-of-Life Care for Aboriginal and Torres Strait Islander Australians: A Framework for Practice. Canberra: AIDA; 2020.
15. Buck K, Detering KM, Sellars M, et al. Prevalence of advance care planning documentation in Australian health and residential aged care services. BMJ Supportive & Palliative Care. 2021;11(3):306–313.
16. Royal Australian College of General Practitioners (RACGP). Aged Care Clinical Guide (Silver Book). 5th ed. Melbourne: RACGP; 2023.

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).