Breathlessness Causing Distress in the Last Days

Last updated 1 Jun 2026 · Palliative care

📋 Key Information Summary

📋

Distressing breathlessness in the last days of life is a common and feared symptom; effective management is a core palliative medicine competency.
Nonpharmacological strategies — upright positioning, calm environment, cool airflow, hand-held fan, and reassurance — are first-line and should be initiated before or alongside medications.
Low-dose opioids (e.g. morphine 2.5–5 mg SC/PO q4h or equivalent) are the evidence-based pharmacological first-line for refractory breathlessness; they reduce the central perception of dyspnoea without causing clinically significant respiratory depression at palliative doses.
If already on regular opioids, increase the current dose by 25–50% to manage breathlessness; avoid starting high doses in opioid-naïve patients in the last days.
Benzodiazepines (midazolam SC 2.5–5 mg PRN or regular q4h; clonazepam 0.5–1 mg SL/PO) are second-line and reserved for breathlessness with significant anxiety or when opioids alone are insufficient.
Routine supplemental oxygen is NOT recommended for breathlessness in non-hypoxaemic patients; a fan directed at the face is equally effective and preferred.
In hypoxaemic patients (SpO₂ < 90%), a cautious trial of low-flow oxygen (1–2 L/min via nasal prongs) may be trialled and continued only if symptomatic benefit is demonstrated.
High-flow oxygen, CPAP, and BiPAP are generally inappropriate in the last days; they may prolong dying and cause distress.
Anticipate and plan for escalating breathlessness — write up PRN subcutaneous orders for morphine and midazolam in advance (anticipatory prescribing).
Continuous subcutaneous infusion (CSCI) via syringe driver (e.g. McKinley T34) is preferred when the oral/sublingual route is no longer feasible.
Reassure family/carers that opioid and benzodiazepine use for breathlessness at end of life does not hasten death when used appropriately; address fears of "over-sedation" proactively.
Regularly reassess breathlessness using a patient-reported tool (e.g. numerical rating scale 0–10) or observational scale (e.g. Respiratory Distress Observation Scale) if the patient is no longer communicative.
Aboriginal and Torres Strait Islander patients may experience additional barriers including remote location, cultural concepts of dying on Country, and distrust of hospital-based care; culturally safe communication is essential.

Introduction & Australian Epidemiology

Breathlessness (dyspnoea) is one of the most prevalent and distressing symptoms experienced by patients in the last days of life, affecting up to 70% of patients with advanced cancer and an even greater proportion of those with end-stage heart failure, chronic obstructive pulmonary disease (COPD), and motor neurone disease. It is the subjective experience of difficult, laboured, or uncomfortable breathing and is often described as "air hunger" or a sensation of suffocation.

In the terminal phase — typically defined as the final 2–7 days before death — breathlessness frequently worsens as cardiopulmonary function declines, secretions accumulate, and conscious state fluctuates. The distress it causes extends beyond the patient to family and carers who witness the struggle to breathe, making effective management a priority for the entire care team.

Australian data indicate that approximately 160,000 Australians die each year, with the majority dying in acute hospitals (54%), residential aged care (32%), or at home (14%). Among palliative care admissions to Australian hospitals, breathlessness ranks among the top three reasons for referral alongside pain and delirium. The Australian Institute of Health and Welfare (AIHW) reports that chronic respiratory diseases are the third leading cause of death in Australia, and heart failure is a leading cause of death in those aged over 65, ensuring that terminal breathlessness remains a pervasive clinical challenge.

This guideline addresses the assessment and management of breathlessness causing distress in the last days of life, with an emphasis on practical, evidence-based pharmacological and nonpharmacological interventions applicable across Australian care settings — including hospital, residential aged care, and the community.

⚠️

Goal of care clarification: Always confirm and document the goals of care before initiating end-of-life symptom management. If the goal is comfort-focused, escalate symptom relief aggressively. If goals are unclear, convene a family meeting or contact the treating specialist before proceeding.

Nonpharmacological Care

Nonpharmacological interventions are the foundation of managing breathlessness in the terminal phase and should be implemented before or concurrently with pharmacological therapy. These strategies are safe, have no adverse effects, and may reduce the dose of opioids and sedatives required.

Positioning

Sit the patient upright (45–90°) or in a high-Fowler's position using a hospital bed or wedge pillows. Leaning forward with arms supported on a table ("tripod position") may also relieve breathlessness. For patients who cannot sit upright, a lateral recumbent position with the head of bed elevated is preferred over supine.

Calming Environment

Reduce environmental triggers — dim lights, minimise noise, limit the number of visitors, and ensure the room temperature is cool (20–22°C). A calm, quiet environment reduces sympathetic activation and the sense of panic that accompanies breathlessness.

Fan and Cool Airflow

Direct a hand-held fan or clip-on fan towards the patient's face. The airflow stimulates trigeminal nerve receptors on the cheeks and nasal mucosa, reducing the perception of breathlessness. This is a simple, effective, and evidence-based intervention that can be used by family members at the bedside.

Reassurance and Relaxation

Calm, confident verbal reassurance from clinicians and trained volunteers can reduce panic. Teach simple breathing techniques if the patient is able (slow, pursed-lip breathing). Gentle music, guided imagery, or mindfulness recordings may help in earlier stages. Ensure family members are coached on maintaining a calm presence.

Secretion Management

Reposition the patient to allow secretions to drain (lateral position). Hyoscine butylbromide 20 mg SC q4h or glycopyrrolate 200 mcg SC q6h can reduce excessive secretions ("death rattle"). Avoid routine suctioning — it is invasive, distressing, and rarely helpful in the terminal phase.

💡

Evidence tip: A 2019 Cochrane review found that a hand-held fan directed at the face significantly reduced dyspnoea visual analogue scores within 5 minutes, comparable to low-flow oxygen in non-hypoxaemic patients. This supports its routine use at the bedside.

Morphine

Opioids are the evidence-based pharmacological mainstay for refractory breathlessness in palliative care. Morphine is the most extensively studied and most commonly used agent in Australia. It reduces the central perception of breathlessness by modulating the chemoreceptor response to hypoxaemia and hypercapnia, without causing clinically significant respiratory depression at appropriately titrated palliative doses.

🚨

Safety: In the opioid-naïve patient in the last days of life, start with LOW doses (morphine 2.5 mg SC q4h or equivalent). Titrate slowly. Rapid dose escalation risks excessive sedation, myoclonus, and respiratory depression. If the patient is already on regular opioids for pain, increase the existing dose by 25–50% for breathlessness rather than starting a new opioid.

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Morphine — Subcutaneous (First-Line)

Ordine® · DBL Morphine · Opioid analgesic

Opioid-naïve dose 2.5–5 mg SC q4h with 2.5 mg SC q1h PRN breakthrough

Opioid-tolerant dose Increase current 4-hourly dose by 25–50%; recalculate breakthrough as 1/6th of total daily dose

Route Subcutaneous (preferred in last days); oral/SL if still swallowing

Renal adjustment eGFR 10–30: reduce dose by 50%, extend interval; eGFR <10 or dialysis: avoid morphine (use fentanyl or alfentanil)

Hepatic adjustment Reduce dose by 50% in severe hepatic impairment

PBS status ✔ PBS Authority Required — Palliative Care

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Morphine — Oral / Sublingual (If Able to Swallow)

Sevredol® (IR) · MS Contin® (SR) · Kapanol® (SR)

Opioid-naïve dose (IR) 2.5–5 mg PO/SL q4h

Duration Continue while oral route viable; convert to SC when swallowing is unreliable

Note In the last days, SC is preferred as GI absorption becomes unpredictable

PBS status ✔ PBS Authority Required — Palliative Care

Morphine Dose Conversion and Titration

Scenario	Action
Opioid-naïve patient, breathlessness score ≥ 5/10	Start morphine 2.5 mg SC q4h + 2.5 mg SC q1h PRN
Already on morphine for pain, breathlessness poorly controlled	Increase regular dose by 25–50%; add or increase PRN breakthrough
Breakthrough dose used ≥ 3 times in 24 hours	Increase the regular (q4h) dose by the amount of total breakthrough used
Excessive sedation or respiratory rate < 8/min	Hold next dose; reassess; consider naloxone 200 mcg IV/SC diluted 1:10, titrate
CSCI via syringe driver required	Calculate total 24-hour SC dose and infuse continuously over 24 hours (e.g. McKinley T34)

⚠️

Clinical pearl — morphine does not hasten death: Multiple systematic reviews (including Maltoni et al. 2012, Currow et al. 2014) have demonstrated that appropriately titrated opioids for breathlessness do not shorten life in the terminal phase. Communicate this clearly to families and junior medical staff.

Midazolam / Clonazepam

Benzodiazepines are second-line agents for terminal breathlessness. They are indicated when breathlessness is accompanied by significant anxiety or panic, when opioid-induced dyspnoea relief is incomplete despite adequate titration, or when the breathlessness is predominantly driven by anxiety and air hunger. They act via GABA-A receptor agonism, producing anxiolysis, sedation, and muscle relaxation.

⚠️

Important: Benzodiazepines should NOT replace opioids as first-line treatment for breathlessness. They are adjunctive agents. Starting a benzodiazepine without an opioid is only appropriate if there is a documented opioid allergy or the patient/family has made an informed refusal of opioids.

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Midazolam — Subcutaneous

Hypnovel® · Midazolam Injection · Benzodiazepine

Adult dose — PRN 2.5 mg SC q1h PRN for acute breathlessness with anxiety

Adult dose — Regular 2.5–5 mg SC q4h (or 10–20 mg SC over 24 hours via CSCI/syringe driver) if breathlessness with anxiety is persistent

Maximum Up to 60 mg/24 h via CSCI in refractory cases (specialist palliative care guidance recommended above 30 mg/24 h)

Onset SC: 2–5 minutes; ideal for acute distress episodes

Renal adjustment No significant adjustment required; use lower doses in frail elderly

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

PBS status ✔ PBS Authority Required — Palliative Care

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Clonazepam — Oral / Sublingual

Rivotril® · Paxam® · Benzodiazepine

Adult dose 0.5–1 mg SL/PO BD (morning and night); titrate to effect, maximum 4 mg/day

Onset SL: 10–15 minutes; PO: 30–60 minutes; longer duration of action than midazolam

When to use Preferred when oral/sublingual route available and a longer-acting agent is desired; useful for daytime anxiolysis when midazolam CSCI is not required

Renal adjustment No specific dose adjustment; use with caution in frail elderly

PBS status ✔ PBS Restricted Benefit

When to Add a Benzodiazepine — Decision Aid

Clinical Scenario	Recommended Action
Breathlessness improving with morphine alone	Continue opioid; do NOT add benzodiazepine
Breathlessness persists despite adequate morphine, significant anxiety component	Add midazolam 2.5 mg SC PRN or regular q4h
Acute panic / air hunger unresponsive to morphine PRN	Midazolam 2.5–5 mg STAT SC; repeat in 30 min if needed; start CSCI
Persistent anxiety between acute episodes (patient still swallowing)	Clonazepam 0.5 mg SL BD; titrate to 1 mg BD
Opioid allergy documented	Benzodiazepine as primary agent; specialist palliative care review recommended

ℹ️

Syringe driver compatibility: Midazolam and morphine are commonly co-infused in a single syringe driver (McKinley T34) in 0.9% sodium chloride. They are chemically compatible for up to 24 hours. Check local palliative care guidelines for mixing and stability information.

Oxygen Considerations

The role of supplemental oxygen in managing terminal breathlessness is frequently misunderstood. Oxygen is NOT a first-line treatment for breathlessness in the last days of life unless the patient is hypoxaemic (SpO₂ < 90%). In non-hypoxaemic patients, oxygen provides no additional benefit over room air and may cause harm through nasal dryness, equipment-related discomfort, and a false sense that breathlessness is being "treated."

No Hypoxia

SpO₂ ≥ 90%

Breathlessness is due to increased respiratory drive, anxiety, or reduced ventilatory capacity — not low oxygen.

Action: No oxygen. Use fan, positioning, opioids, and benzodiazepines if needed.

Mild Hypoxia

SpO₂ 85–89%

Patient may or may not benefit from low-flow oxygen.

Action: Trial of O₂ 1–2 L/min via nasal prongs. Continue ONLY if patient reports subjective improvement. Remove if no benefit after 15–30 min.

Significant Hypoxia

SpO₂ < 85%

Often reflects severe underlying pathology (pulmonary embolism, extensive lung disease, large effusion).

Action: O₂ 2–4 L/min nasal prongs. Add morphine + midazolam. Discuss ceiling of care with family. Avoid escalation to HFNP or CPAP unless goals of care clearly indicate this.

🚨

Do NOT escalate oxygen in the dying patient. High-flow nasal prongs (HFNP), CPAP, BiPAP, and intubation are generally inappropriate in the last days of life if the goal of care is comfort. These interventions may prolong the dying process, increase distress, and prevent peaceful death. Ensure a ceiling-of-care plan is documented.

Oxygen vs Fan — Head-to-Head

Feature	Supplemental Oxygen	Hand-Held Fan
Effectiveness in non-hypoxaemic patients	No better than placebo / medical air	Reduces dyspnoea VAS scores significantly
Equipment required	Oxygen concentrator or cylinder, tubing, prongs	Hand-held or clip-on fan (minimal cost)
Adverse effects	Nasal dryness, skin pressure injury, equipment dependence	None
Portability	Limited (cylinders/portable concentrators)	Highly portable; can be used anywhere
Patient preference	Often preferred due to cultural expectation that "oxygen helps"	Increasingly recognised; patient education needed
Cost	Ongoing supply and equipment costs	One-off minimal cost

ℹ️

Managing expectations: Many patients and families equate oxygen with "doing something." If oxygen is requested but not clinically indicated, explain that a fan can be equally effective and that medications (morphine) will better relieve the feeling of breathlessness. Frame the removal of oxygen as a positive step towards comfort, not as "giving up."

Anticipatory Prescribing & Syringe Driver Management

In the last days of life, the oral and sublingual routes often become unreliable due to decreased consciousness, nausea, or dysphagia. Anticipatory prescribing of subcutaneous medications ensures rapid access to symptom relief without delays in pharmacy processing or medical review.

Standard Anticipatory Prescribing Kit (Subcutaneous)

Symptom

Drug

Dose & Route

Frequency

Breathlessness

Morphine

2.5–5 mg SC

q1h PRN (breakthrough) or q4h regular

Breathlessness + Anxiety

Midazolam

2.5–5 mg SC

q1h PRN or q4h regular; or CSCI

Secretions ("death rattle")

Hyoscine butylbromide

20 mg SC

q4h PRN or regular

Agitation / Delirium

Haloperidol

1–2.5 mg SC

q4h PRN or BD regular

Nausea / Vomiting

Metoclopramide

10 mg SC

q8h PRN or regular

Syringe Driver (CSCI) — When and How

A continuous subcutaneous infusion (CSCI) via a syringe driver such as the McKinley T34 is indicated when:

The patient is unable to swallow reliably
Symptoms are persistent despite regular PRN doses
Multiple subcutaneous injections are causing discomfort
The patient or family prefers continuous comfort without repeated needle-sticks

⚠️

Converting PRN doses to CSCI: Calculate the total SC dose used over the previous 24 hours (regular + breakthrough), then infuse this amount over 24 hours. If uncertain, start at 50–75% of the total 24-hour dose to allow a safety margin. Review within 4–6 hours.

Monitoring

Monitoring in the last days of life should be proportionate to the goals of care. The aim is to ensure adequate symptom relief without causing unnecessary intrusion. Invasive monitoring (arterial blood gases, continuous telemetry) is generally inappropriate if the goal is comfort.

Essential

Breathlessness severity assessment

Patient-reported: numerical rating scale 0–10 or visual analogue scale. Observational: Respiratory Distress Observation Scale (RDOS) for non-communicative patients. Assess before and 30–60 min after each intervention.

Essential

Respiratory rate and pattern

Monitor for Cheyne-Stokes respiration (common and non-distressing in the dying), excessive sedation (RR < 8/min), and airway obstruction (stridor, gurgling).

Available

Pulse oximetry (SpO₂)

Useful to guide oxygen therapy decision (is the patient hypoxaemic?). May be discontinued if it causes distress or if oxygen use has been ceased per care plan.

Available

Level of consciousness / Sedation Scale

Use the Richmond Agitation-Sedation Scale (RASS) or Pasero Opioid Sedation Scale (POSS). A RASS of –3 to –4 (deep sedation) in the last days is acceptable if the patient is comfortable and goals of care are comfort-focused.

Specialist

Arterial blood gas

Rarely indicated in the terminal phase. Consider only if diagnostic uncertainty exists and the result would change management (e.g. suspected tension pneumothorax, massive PE amenable to intervention).

Assessment Frequency

After each dose change

Reassess breathlessness severity 30–60 min after each dose increase or new agent. Document response.

Every 2–4 hours

Assess respiratory rate, sedation level, and overall comfort while on regular medications or CSCI.

At each nursing handover

Review 24-hour total drug usage, breakthrough frequency, and whether the current regimen is adequate or requires escalation.

At each family update

Explain current symptom control measures to family, address concerns about medications, and reinforce that comfort is the priority.

Special Populations

👶

Paediatric Patients

Morphine 100–200 mcg/kg SC q4h (opioid-naïve); titrate carefully. Use paediatric palliative care specialist guidance.

Midazolam 50–100 mcg/kg SC q4h for refractory breathlessness with anxiety. CSCI via syringe driver is well-established in paediatric palliative care.

Nonpharmacological Age-appropriate positioning, parental presence, calming music, and gentle touch. Parental coaching on fan use and positioning is essential.

Referral Refer to a specialist paediatric palliative care team (e.g. Bear Cottage, Very Special Kids) for all children with terminal breathlessness.

🤰

Pregnancy

Context Terminal breathlessness in pregnancy is rare. Goals of care should be discussed urgently with the patient, partner, and multidisciplinary team.

Morphine Crosses the placenta. May cause neonatal respiratory depression if delivery is imminent. Use lowest effective dose; involve obstetric and neonatal teams.

Midazolam Category D in pregnancy. Avoid if possible. Use only if benefits clearly outweigh risks and the patient is not expected to deliver.

👴

Elderly / Frail

Morphine Start at the lower end of dosing (2.5 mg SC q4h). Elderly patients have reduced hepatic and renal clearance; prolonged half-life increases risk of accumulation and over-sedation.

Midazolam Use lower doses (1.25–2.5 mg SC). Increased sensitivity to benzodiazepines in elderly; monitor for excessive sedation and paradoxical agitation.

Considerations Assess renal function (eGFR) before initiating morphine. If eGFR < 30, consider fentanyl as the opioid of choice. Review concurrent medications for interactions (CNS depressants, anticholinergics).

🫘

Renal Impairment

Morphine AVOID in eGFR < 10 or dialysis. Active metabolites (M6G, M3G) accumulate, causing prolonged sedation, myoclonus, and seizures. Use fentanyl 12.5–25 mcg SC q1h PRN or alfentanil instead.

Midazolam No significant renal accumulation; preferred benzodiazepine in renal impairment. Use lower doses if concurrent hepatic impairment.

Opioid alternatives Fentanyl and alfentanil are preferred opioids in severe renal impairment due to absence of active renally-cleared metabolites.

🫁

Hepatic Impairment

Morphine Reduce dose by 50% in severe hepatic impairment (Child-Pugh C). Reduced first-pass metabolism increases oral bioavailability.

Midazolam Prolonged half-life in hepatic impairment. Reduce dose by 50% and extend intervals. Avoid in severe hepatic encephalopathy if possible.

Considerations Monitor closely for accumulation. Consider fentanyl as an alternative opioid (hepatic metabolism but shorter acting and more predictable).

🛡️

Immunocompromised

Considerations Terminal breathlessness in immunocompromised patients may have treatable causes (e.g. PJP pneumonia, pulmonary haemorrhage, large effusion). If the goal of care remains comfort, manage symptomatically as per this guideline. If reversible causes are identified and treatment aligns with goals, consider specific therapy (e.g. corticosteroids for lymphangitis).

Opioids / Benzodiazepines Standard dosing applies. No specific dose adjustments for immunosuppression per se — adjust for hepatic/renal function as indicated.

Aboriginal and Torres Strait Islander Health Considerations

Cultural concepts of dying

Many Aboriginal and Torres Strait Islander people have strong cultural beliefs about the importance of dying on Country — in their community or homeland. Facilitate repatriation where possible and align symptom management plans with these preferences. Avoid unnecessary hospital transfers that separate patients from their community.

Sorry Business and family involvement

Extended family and community may gather in large numbers during Sorry Business. This can be both a source of comfort and a logistical challenge in hospital settings. Accommodate large family groups where possible and involve family in decision-making about symptom management.

Remote and rural access

Aboriginal and Torres Strait Islander Australians living in remote communities may have limited access to palliative care specialists, syringe drivers, and 24-hour medical cover. Rural generalist doctors and Remote Area Nurses should be trained in anticipatory prescribing and oral/sublingual alternatives to CSCI. The Royal Flying Doctor Service may be required for medication supply and specialist consultation via telehealth.

Fear of opioids

Some patients and families may associate morphine with hastening death or with "giving up." Take time to explain in plain language — preferably with the help of an Aboriginal Health Worker or Aboriginal Liaison Officer — that morphine for breathlessness is about comfort, not sedation, and that it will not hasten death when used correctly.

Communication and health literacy

Use culturally appropriate, plain-language communication. Involve Aboriginal Health Workers or Aboriginal Liaison Officers in all discussions about end-of-life care. Written information should be available in plain English and, where possible, in local First Nations languages. Check understanding without being patronising.

Spiritual and traditional practices

Some communities may wish to incorporate traditional healing practices, smoking ceremonies, or spiritual rituals alongside Western medicine. Respect and accommodate these practices. They can provide significant comfort to the patient and do not typically conflict with pharmacological symptom management.

Higher disease burden

Aboriginal and Torres Strait Islander Australians experience chronic respiratory disease (COPD, bronchiectasis) and heart failure at 2–3 times the rate of non-Indigenous Australians. Terminal breathlessness is therefore disproportionately common. Ensure timely access to palliative care from diagnosis, not just in the last days.

📚 References

1. Bausewein C, Booth S, Gysels M, Higginson I. Non-pharmacological interventions for breathlessness in advanced stages of malignant and non-malignant diseases. Cochrane Database Syst Rev. 2008;(2):CD005623.
2. Currow DC, McDonald C, Oaten S, et al. Once-daily opioids for chronic dyspnea: a dose increment and pharmacovigilance study. J Pain Symptom Manage. 2011;42(3):388-399.
3. Ekström M, Bajwah S, Bland JM, Currow DC, Hussain J, Johnson MJ. One evidence base; three stories: do opioids relieve chronic breathlessness? Thorax. 2018;73(1):88-90.
4. Hui D, Bohlke K, Bao T, et al. Management of dyspnea in advanced cancer: ASCO guideline. J Clin Oncol. 2021;39(12):1389-1411.
5. Johnson MJ, Bland JM, Oxberry SG, Abernethy AP, Currow DC. Opioids for chronic refractory breathlessness: patient predictors of beneficial response. Eur Respir J. 2013;42(3):758-766.
6. Maltoni M, Scarpi E, Rosati M, et al. Palliative sedation in end-of-life care and survival: a systematic review. J Clin Oncol. 2012;30(12):1378-1383.
7. National Health and Medical Research Council (NHMRC). Guidelines for the Palliative Care Approach. Canberra: NHMRC; 2023.
8. Palliative Care Australia. National Palliative Care Standards. 5th ed. Canberra: Palliative Care Australia; 2018.
9. Swan F, Newey A, Bland M, et al. Airflow for the relief of dyspnoea in advanced chronic obstructive pulmonary disease and heart failure: a systematic review and meta-analysis. BMJ Open. 2019;9(11):e031717.
10. Australian Institute of Health and Welfare (AIHW). Palliative Care Services in Australia. Cat. no. HWI 318. Canberra: AIHW; 2023.
11. Abernethy AP, Currow DC, Frith P, Fazekas B, McHugh A, Bui C. Randomised, double blind, placebo controlled crossover trial of sustained release morphine for the management of refractory dyspnoea. BMJ. 2003;327(7414):523-528.
12. Currow DC, Abernethy AP, Frith P. Morphine for management of refractory dyspnoea. BMJ. 2003;327:1288-1289.
13. Palliative Care Expert Group. Therapeutic Guidelines: Palliative Care. Version 4. Melbourne: Therapeutic Guidelines Limited; 2024. [Note: used as clinical source; primary literature cited above.]
14. 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.
15. Farquhar MC, Prevost AT, McCrone P, et al. The clinical and cost effectiveness of a breathlessness intervention service for patients with advanced non-malignant disease and their informal carers: mixed findings of a mixed method randomised controlled trial. Thorax. 2016;71(8):688-695.

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).