Family and Carer Needs After Death

Last updated 1 Jun 2026 · Palliative care

📋 Key Information Summary

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The period immediately following a patient's death is critical for supporting families and carers — their needs extend well beyond the clinical event and require a structured, compassionate approach.
Emotional presence and active listening are the most valued interventions; clinicians should avoid platitudes and allow silence, tears, and open expression of grief.
Families should be offered a quiet, private space and adequate time with the deceased before any practical procedures (e.g., removal of lines, transfer) are initiated.
Cultural, spiritual, and religious practices around death vary widely — always ask about specific wishes rather than making assumptions based on ethnicity or background.
Aboriginal and Torres Strait Islander communities may have distinct cultural protocols around death, Sorry Business, and avoidance of names/images of the deceased — honouring these is essential.
Clinicians should provide clear, practical information about contacting a funeral director, required documentation (medical certificate of cause of death, Coroner referral criteria), and timelines.
A medical certificate of cause of death must be completed by the treating doctor; referral to the Coroner is required when death is unexpected, violent, or of unknown cause.
Carers who have provided prolonged care may experience anticipatory grief, relief, guilt, and role loss simultaneously — all of which are normal and should be validated.
Structured bereavement follow-up (phone call within 1–2 weeks, formal assessment at 6–8 weeks, onward referral if complicated grief persists beyond 12 months) is recommended best practice.
Complicated (prolonged) grief affects approximately 7–10% of bereaved individuals and is characterised by persistent yearning, inability to accept the death, and functional impairment beyond 12 months.
Bereavement risk stratification helps target intensive support to those at highest risk: sudden/unexpected death, limited social support, prior mental health conditions, dependent relationship with the deceased, and ATSI families.
Key Australian bereavement resources include GriefLine (1300 845 745), Lifeline (13 11 14), Palliative Care Australia, state-based palliative care bereavement services, and local community health centres.

Introduction & Australian Context

The death of a patient marks not an endpoint of care but a transition — from caring for the patient to supporting those left behind. Families, partners, children, and carers who have been intimately involved in the patient's illness and final days carry complex emotional, cultural, spiritual, and practical needs that require deliberate attention from the healthcare team.

In Australia, approximately 170,000 people die each year, and for every death, an estimated 5–10 close family members and carers are significantly affected by bereavement (Australian Institute of Health and Welfare, 2023). Carers Australia estimates that over 2.65 million Australians provide informal care, many of whom will experience grief that is compounded by exhaustion, role loss, financial stress, and social isolation after the death of the person they cared for.

The Palliative Care Australia National Palliative Care Standards (5th edition, 2018) explicitly include bereavement care as Standard 8: "Bereavement support is provided to the family, carers, and other people who are significant to the person receiving palliative care." This standard applies across all settings — hospital, hospice, residential aged care, and community.

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Clinician responsibility: Bereavement support is not an optional extra. It is a core component of palliative care and is increasingly included in clinical governance frameworks, NSQHS Standards, and accreditation requirements. Failure to provide structured follow-up may constitute a gap in care.

This guideline addresses four interconnected domains of family and carer need following a death: emotional support, cultural and spiritual practices, engagement with funeral directors and legal processes, and structured bereavement follow-up. It is intended for all clinicians who may be present at or involved in the care of a dying patient — including general practitioners, hospital medical officers, nurses, allied health professionals, and palliative care specialists.

Emotional Support

Emotional support in the immediate aftermath of death is the foundation upon which all other bereavement care is built. The quality of this initial interaction can significantly influence the family's grief trajectory and their later engagement with bereavement services.

Immediate After Death: What Families Need

Presence and empathy: Clinicians should remain present, make eye contact, and communicate compassion. Simple statements such as "I am so sorry for your loss" and "We were privileged to care for [name]" are appropriate and valued.
Avoidance of platitudes: Phrases such as "everything happens for a reason," "they're in a better place," or "at least they're not suffering" can feel dismissive. Allow the family to lead the emotional narrative.
Time with the deceased: Families should be offered unlimited time (within practical limits) with the body. Rushing removal of the body or intrusive early procedures (e.g., disconnecting infusion pumps loudly) should be avoided.
Private, quiet space: Wherever the death occurs (hospital ward, ICU, hospice, home), a calm environment should be facilitated. In hospital, consider relocating other patients or drawing screens.
Normalising grief responses: Inform families that crying, silence, anger, laughter, numbness, and even apparent indifference are all normal grief responses. There is no "right way" to grieve.

Supporting Carers Specifically

Carers who have provided hands-on care over weeks, months, or years face unique grief challenges:

Relief and guilt: Many carers experience profound relief at the end of suffering, followed immediately by guilt about feeling relieved. This is extremely common and should be normalised explicitly.
Role loss and identity crisis: When the role of "carer" has dominated daily life, the death may leave a void of purpose and structure. Practical suggestions (e.g., gradually reintroducing activities, connecting with carer support groups) are helpful.
Physical exhaustion: Carers may be physically depleted at the time of death. Encourage rest, nutrition, and accepting help from family and community.
Anticipatory grief: Many carers began grieving long before the death. Validate that their grief journey started earlier than others might recognise.

Supporting Children and Adolescents

Children should be told the truth in age-appropriate language. Avoid euphemisms such as "passed away" or "gone to sleep" for young children, as these can cause confusion and fear.
Adolescents may wish to see the body and should be given the choice, with appropriate preparation and support.
Schools should be notified (with the family's consent) so that teachers can provide appropriate support.
Refer to state-based childhood bereavement services (e.g., Feel the Magic, Kids Helpline 1800 55 1800, National Association for Loss and Grief).

When to Be Concerned

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Red flags for immediate crisis intervention: Expressed suicidal ideation, active self-harm, acute psychotic symptoms (e.g., persistent hallucinations of the deceased beyond brief hypnagogic experiences), severe dissociation, inability to care for dependent children, or substance intoxication. Refer immediately to crisis mental health services (e.g., local CATT/LMHU team, Lifeline 13 11 14, Emergency Department).

Cultural, Spiritual, and Religious Practices

Australia is one of the most culturally and religiously diverse nations on earth. Families' needs around death are profoundly shaped by cultural, spiritual, and religious beliefs, and clinicians must approach each situation with curiosity and respect rather than assumptions.

General Principles

Ask, don't assume: Never presume a family's practices based on surname, appearance, or perceived ethnicity. Always ask: "Are there any cultural, spiritual, or religious practices that are important to you and your family at this time?"
Document wishes early: Cultural and spiritual wishes should be documented in the patient's care plan during the palliative care phase, not only at the time of death.
Facilitate access to religious leaders: Have contact details readily available for hospital chaplaincy, local religious leaders, and multi-faith support services.
Accommodate rituals: Where safe and practical, accommodate washing of the body, positioning of the body, placement of religious items, readings, prayers, vigils, and specific timing requirements.

Common Cultural and Religious Practices in Australia

Tradition	Key Practices After Death	Clinician Considerations
Islam	Body should be washed (ghusl) and shrouded by same-sex family or community members as soon as possible. Burial preferred (not cremation). Facing Mecca. Funeral ideally within 24 hours.	Facilitate prompt release of body. Provide a clean, private room for washing. Avoid unnecessary autopsy unless legally required. Contact local Islamic funeral services.
Judaism	Body should not be left alone (shmirah — watching). Washing and shrouding by chevra kadisha (burial society). Burial within 24 hours preferred. Cremation traditionally prohibited in Orthodox practice.	Allow continuous presence at the bedside. Contact the local chevra kadisha or synagogue. Respect shabbat observance (no phone calls from Friday sunset to Saturday sunset unless emergency).
Hinduism	Cremation preferred. Body may be washed and dressed by family. A lamp or candle may be placed near the body. Specific mantras and prayers recited. 13-day mourning period (shraddha).	Allow time for rituals at the bedside. Facilitate access to crematorium. Be aware that organ donation may have complex cultural implications — discuss sensitively.
Buddhism	Body should ideally not be touched for several hours after death (to allow consciousness to depart peacefully). Chanting by monks or family. Cremation common. Avoid disturbing the body unnecessarily.	Minimise handling of the body in the first hours. Allow time for chanting. Provide a calm, quiet environment. Contact local Buddhist temple if requested.
Christianity (varied)	Wide variation. May include last rites (Catholic — anointing of the sick, viaticum), prayers, reading of scripture, vigil. Burial or cremation acceptable in most denominations.	Contact hospital chaplain or family's local minister/priest. Catholic families may request a crucifix or rosary with the body. Protestant families may prefer a simple service.
Sikhism	Cremation preferred. Body is bathed and dressed by family. Prayers (Japji Sahib) recited. Ashes immersed in flowing water. 10-day mourning period with continuous reading of Sri Guru Granth Sahib.	Facilitate prompt arrangements. Allow family time for prayer. Contact local Gurdwara for support.

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Important: This table is a guide only — individual and family practices may differ significantly from these general descriptions. Always confirm specific wishes with the family or their nominated religious/cultural liaison.

Non-Religious and Secular Families

An increasing proportion of Australians identify as having no religion (38.9% in the 2021 Census). Secular families may still have strong wishes about the death experience — including music, readings, personal rituals, or environmental preferences (e.g., opening a window, placing flowers). These wishes are equally valid and should be facilitated.

Funeral Director & Legal Processes

The practical steps following a death can feel overwhelming for grieving families. Clinicians play a key role in providing clear, timely guidance on the administrative and legal requirements, while being sensitive to the family's emotional state.

Medical Certificate of Cause of Death

In all Australian states and territories, a registered medical practitioner who has attended the deceased during their last illness must complete a Medical Certificate of Cause of Death (MCCD).
The certificate must be completed as soon as practicable — ideally within 24 hours of death (requirements vary by jurisdiction).
The certificate should accurately reflect the cause of death, including the underlying cause, immediate cause, and any contributing conditions. Avoid vague terms such as "cardiac arrest" or "old age" as sole causes.
The MCCD is required before the funeral director can proceed with transfer and burial/cremation arrangements.

When to Refer to the Coroner

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Coronial referral is mandatory when death: Was unexpected or occurred suddenly; resulted from violence, injury, or accident; occurred during or shortly after a medical procedure (including anaesthesia); is of unknown cause; occurred in custody or state care; or where the identity of the deceased is unknown. Do NOT issue an MCCD in these circumstances — contact the police or Coroner's office. Requirements vary by state/territory.

Families should be informed sensitively that a Coroner's referral may delay the release of the body and funeral arrangements. Explain the process clearly and offer to facilitate communication with the Coroner's office.

Engaging a Funeral Director

Families should be advised that they have the right to choose any licensed funeral director — they are not obligated to use one recommended by the hospital or facility.
Provide families with a list of local funeral directors (many hospitals keep a contact list that is non-preferential). Include culturally specific services where relevant (e.g., Islamic funeral services, Aboriginal funeral services).
Funeral costs vary enormously (from approximately ,000 for a basic cremation to ,000+ for a full burial service). Families experiencing financial hardship can be referred to state government funeral assistance programs, community organisations, or social work.
Ensure the family understands they do not need to make all decisions immediately — most funeral directors will arrange transfer of the body and allow time for planning.

Organ and Tissue Donation

If the patient was a registered organ donor or the family wishes to discuss donation, contact the DonateLife organ donation coordinator immediately. Do not delay for organ donation considerations that would significantly prevent families from proceeding with cultural practices.
Tissue donation (e.g., corneas, skin, bone, heart valves) has a longer time window (up to 24–48 hours after death in some cases) and may be appropriate even when organ donation is not possible.
Approach the conversation with sensitivity and ensure the family understands that the quality of end-of-life care is not affected by the donation decision.

Personal Effects and Practical Matters

Return the patient's personal belongings to the next of kin promptly and with care. Inventory items and obtain a signature.
Provide information about notifying relevant agencies (e.g., Medicare, Centrelink, banks, superannuation, insurance) — many funeral directors can assist with this.
Advise the family about the need to obtain multiple certified copies of the death certificate for legal and financial purposes (typically 5–10 recommended).

Bereavement Follow-Up

Structured bereavement follow-up is a core standard of palliative care (Palliative Care Australia, Standard 8) and should be provided to all bereaved families, with intensity calibrated to assessed risk.

Bereavement Risk Stratification

Not all bereaved individuals require the same level of support. Risk stratification enables targeted resource allocation to those most at risk of complicated grief.

Lower Risk

Standard Bereavement Care

Expected death after chronic illness. Adequate social support. No prior psychiatric history. Secure coping style. Death was anticipated and prepared for.

Setting: Written bereavement information, sympathy card/letter, phone call at 2 weeks, open referral if needed

Moderate Risk

Enhanced Bereavement Care

Mixed or ambivalent relationship with deceased. Limited social support. History of depression or anxiety (managed). Financial stress or role loss. Young children in the family.

Setting: Phone call at 1 and 4 weeks, formal assessment at 6–8 weeks, offer of bereavement counselling, ongoing follow-up for 6–12 months

High Risk

Intensive Bereavement Support

Sudden or traumatic death. History of complicated grief or major psychiatric illness. Suicide bereavement. Dependent/intensely enmeshed relationship. Social isolation. Aboriginal and Torres Strait Islander families. Culturally and linguistically diverse families with limited English. Multiple recent losses.

Setting: Contact within 48 hours, regular follow-up from week 1, formal assessment at 6 weeks, referral to specialist bereavement services or mental health, long-term follow-up for 12–24 months

Timeline for Bereavement Follow-Up

0–48 hours

Verbal condolence (in person or phone). Offer of practical information (funeral directors, legal requirements). Document family risk factors and cultural wishes. For high-risk families: direct referral to bereavement service.

1–2 weeks

Follow-up phone call by a member of the care team (GP, palliative care nurse, or social worker). Assess coping, sleep, appetite, substance use, and social support. Send written condolence letter or card. Provide bereavement information pack.

4–6 weeks

Second phone call or home visit (particularly for high-risk families). Assess for persistent acute grief symptoms. Review whether the family has accessed support services. Check practical needs (finances, housing, childcare).

6–8 weeks

Formal bereavement assessment. Use of validated screening tools where available (e.g., PG-13 — Prolonged Grief-13, ICG — Inventory of Complicated Grief). Decision regarding further intervention or discharge.

3–6 months

Follow-up for moderate- and high-risk families. Offer bereavement support groups. Monitor for emergence of complicated grief. Encourage engagement with community, social, and spiritual supports.

12 months

Anniversary contact (phone call or letter). Final formal assessment for complicated grief. If complicated grief is diagnosed (persistent symptoms >12 months with functional impairment), refer for specialist therapy (complicated grief treatment, CBT, or pharmacotherapy).

Recognising Complicated (Prolonged) Grief

Complicated grief — now formally recognised as Prolonged Grief Disorder in DSM-5-TR and ICD-11 — affects an estimated 7–10% of bereaved individuals and requires specific intervention beyond supportive counselling.

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Diagnostic features of Prolonged Grief Disorder (DSM-5-TR): Persistent yearning/longing for the deceased; preoccupation with the deceased or circumstances of the death; marked difficulty accepting the death; emotional numbness or feeling that life is meaningless; intense loneliness or detachment from others; significant functional impairment. Symptoms must persist for at least 12 months (6 months in ICD-11) and not be better explained by another mental disorder, substance use, or medical condition.

Pharmacotherapy in Bereavement

Routine prescription of anxiolytics or hypnotics for normal grief is not recommended. Short-term pharmacotherapy may be considered for acute distress (e.g., severe insomnia, anxiety) when non-pharmacological measures are insufficient.

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Temazepam

Temtabs® · Normison® · Benzodiazepine (hypnotic)

Adult dose 10–20 mg PO nocte, short-term only (≤2 weeks)

Paediatric dose Not recommended in bereavement-related insomnia in children; use non-pharmacological approaches

Renal adjustment No specific adjustment; use with caution if eGFR <30 mL/min

Hepatic adjustment Reduce dose in hepatic impairment; avoid in severe liver disease

PBS status ✔ PBS General Benefit

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Sertraline

Zoloft® · Generic · SSRI antidepressant

Adult dose 50 mg PO mane, titrate to 100–200 mg daily if needed; trial ≥8 weeks

Paediatric dose Not indicated for grief alone; if comorbid depression: 25–200 mg/day (paediatric psychiatrist supervision)

Renal adjustment No adjustment required

Hepatic adjustment Reduce dose or frequency in hepatic impairment

PBS status ✔ PBS General Benefit

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Note: Antidepressants are indicated for comorbid major depressive disorder in bereavement — not for normal grief itself. SSRIs (sertraline, citalopram) are first-line. Referral to a psychiatrist or psychologist with expertise in grief disorders is recommended for complicated/prolonged grief disorder.

Australian Bereavement Resources

GriefLine

1300 845 745

National telephone and online counselling (free)

Lifeline

13 11 14

24/7 crisis support and suicide prevention

Kids Helpline

1800 55 1800

Free counselling for young people aged 5–25

Palliative Care Australia

palliativecare.org.au

Directory of state/territory palliative care services

Carers Australia

1800 242 636

Support for carers including post-bereavement

beyondblue

1300 22 4636

Depression and anxiety support

SANDS

1300 072 637

Stillbirth and neonatal death support

Special Populations

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Paediatric Families

When a child dies, parents may experience the most intense grief possible. Provide extended time, ongoing support, and immediate referral to specialist paediatric bereavement services.

Sibling grief is often overlooked. Brothers and sisters need age-appropriate information, reassurance that they are not to blame, and inclusion in family rituals.

Consider referral to: Red Nose Grief and Loss (1300 308 307), Stillbirth and Neonatal Death Support (SANDS), and state-based paediatric palliative care bereavement programs.

Perinatal and neonatal deaths may involve additional legal requirements (registration of birth and death) depending on gestational age and state/territory legislation.

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Elderly Bereaved Spouses

Elderly spouses are at increased risk of complicated grief, depression, functional decline, and mortality in the year following bereavement (the "widowhood effect").

Screen for depression (PHQ-9), assess for falls risk, medication management capacity, nutrition, and social isolation at all follow-up contacts.

Coordinate with the GP for ongoing monitoring. Encourage connection with community services (Meals on Wheels, community transport, social groups).

Cognitive decline or delirium in the elderly may be precipitated by bereavement — investigate if new confusion occurs.

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CALD (Culturally and Linguistically Diverse) Families

Language barriers compound grief. Provide bereavement information in the family's preferred language. Use accredited interpreters (TIS National — 131 450) for all significant discussions.

Be aware that grief expression varies culturally — some cultures have elaborate, extended mourning periods that should be respected and supported.

Refugee and asylum-seeker families may have experienced prior traumatic losses — bereavement may trigger complex trauma responses.

Connect with Multicultural Australia, Settlement Services International (SSI), and local multicultural health services.

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Same-Sex Partners and Non-Traditional Families

Same-sex partners, de facto partners, chosen families, and carers who are not legally recognised next-of-kin may face additional challenges in accessing support and recognition.

Ensure that the bereavement follow-up extends to the person most significantly affected — regardless of their legal relationship to the deceased.

Be mindful of pronoun use, chosen names, and family structures. Ask the patient (during palliative care) and the family (after death) about their preferred terms and relationships.

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Families Affected by Suicide

Suicide bereavement is a major risk factor for complicated grief, PTSD, depression, and suicidal behaviour in surviving family members.

Refer to specialist suicide bereavement services (e.g., StandBy Support After Suicide — 1300 727 247, Roses in the Memory Garden).

Avoid stigmatising language. Refer to "death by suicide" or "died by suicide" rather than "committed suicide."

Children bereaved by suicide require specialist support — contact Kids Helpline or child mental health services.

Aboriginal and Torres Strait Islander Health Considerations

Aboriginal and Torres Strait Islander Health

Death and bereavement carry profound cultural, spiritual, and communal significance for Aboriginal and Torres Strait Islander peoples. The loss of a community member affects not only the immediate family but the broader kinship network and community as a whole. Healthcare services must approach end-of-life and post-death care with deep cultural respect and flexibility.

Sorry Business

Sorry Business is the collective term for the mourning practices of Aboriginal and Torres Strait Islander peoples. It encompasses a range of cultural obligations, rituals, and ceremonies that may continue for weeks or months.
Sorry Business may involve extended family and community travelling significant distances — including from remote communities — to be present. Workplaces, schools, and services should be understanding of these absences.
The bereaved family may require practical support with travel, accommodation, and food for large numbers of family members gathering for Sorry Business.

Cultural Protocols Around Death

Avoidance of the deceased's name: In many Aboriginal and Torres Strait Islander communities, it is culturally inappropriate to speak the name of a deceased person, display their image, or use recordings of their voice. This may last for a defined period or indefinitely depending on community custom. Clinicians must respect this and modify documentation and communication accordingly.
Body preparation: Family members may wish to wash, dress, and prepare the body according to cultural practice. This should be facilitated with a private space and adequate time.
Smoking ceremony: Some communities perform a smoking ceremony to cleanse the space where the person died. Hospitals and health services should have policies to accommodate this safely.
Skin name and kinship: Aboriginal kinship systems determine specific roles and obligations after a death. Some family members may have particular responsibilities, and some individuals may be prohibited from viewing the body. Ask the family about these protocols.

Barriers to Bereavement Support

Geographic isolation

Remote and very remote communities have limited access to bereavement services, mental health professionals, and counselling. Telehealth and Aboriginal Community Controlled Health Organisations (ACCHOs) are critical pathways.

Distrust of mainstream services

Historical and ongoing experiences of racism, forced removal of children (Stolen Generations), and institutional harm create legitimate distrust. Bereavement support should be delivered through or in partnership with ACCHOs wherever possible.

Cumulative grief

Aboriginal and Torres Strait Islander communities experience disproportionately high rates of premature death, leading to cumulative and intergenerational grief. Standard bereavement models may be insufficient — trauma-informed and culturally grounded approaches are essential.

Language and communication

English may be a second, third, or fourth language for some community members, particularly in remote areas. Use Aboriginal health workers and interpreters. Provide information in plain language and visual formats.

Social determinants

Housing insecurity, financial stress, food insecurity, and limited transport compound grief. Bereavement care must include practical social support and referrals to community services.

Recommended Practices

Engage Aboriginal and Torres Strait Islander health workers and liaison officers early in the palliative care process and at the time of death.
Allow flexible visiting hours, family accommodation, and communal gathering spaces in hospitals and hospices.
Partner with ACCHOs for bereavement follow-up — e.g., Winnunga Nimmityjah (ACT), Tharawal (NSW), CATSINaM member services.
Use the Australian Indigenous Psychologists Association (AIPA) and Gayaa Dhuwi (Proud Spirit) Australia resources for culturally appropriate grief and trauma support.
Recognise that grief in Aboriginal and Torres Strait Islander communities is a collective, not solely individual, experience — support should extend to the community where possible.

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Critical reminder: Never assume that a single Aboriginal or Torres Strait Islander community's practices represent all communities. There are hundreds of distinct nations and language groups across Australia, each with unique cultural protocols. Always ask the family and community about their specific wishes and practices.

📚 References

1. Palliative Care Australia. National Palliative Care Standards. 5th ed. Canberra: Palliative Care Australia; 2018.
2. Australian Institute of Health and Welfare. Palliative care services in Australia. AIHW; 2023. Available from: aihw.gov.au.
3. Prigerson HG, Boelen PA, Cozza SJ, et al. Prolonged grief disorder criteria: a preliminary consensus of the International Prolonged Grief Disorder Consortium. J Affect Disord. 2021;282:87–94.
4. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders. 5th ed., text rev. (DSM-5-TR). Washington, DC: APA; 2022.
5. World Health Organization. ICD-11 for Mortality and Morbidity Statistics. Prolonged Grief Disorder (6B42). WHO; 2024.
6. Carers Australia. Carer Statistics. Canberra: Carers Australia; 2023. Available from: carersaustralia.com.au.
7. Aboriginal and Torres Strait Islander Healing Foundation. Working Together: Aboriginal and Torres Strait Islander Mental Health and Wellbeing Principles and Practice. 2nd ed. Canberra: Commonwealth of Australia; 2014.
8. Australian Bureau of Statistics. Census of Population and Housing: Cultural diversity. ABS; 2021.
9. Kissane DW, Bloch S. Family grief. Br J Psychiatry. 2002;178(6):484–487.
10. Breen LJ, O'Connor M. The fundamental paradox in the grief literature: a critical reflection. Omega (Westport). 2011;63(3):199–218.
11. Royal Australian College of General Practitioners. Supporting patients who are bereaved: A guide for GPs. Melbourne: RACGP; 2020.
12. Hudson P, Hall C, Boughey A, Roulston A. Bereavement support standards and bereavement care pathway for quality palliative care. Palliat Support Care. 2018;16(4):375–387.
13. Hall C, Hudson P, Boughey A. Bereavement support needs before and after a death: a survey of palliative care providers in Australia. Aust J Prim Health. 2020;26(3):237–242.
14. Australian Commission on Safety and Quality in Health Care. National Safety and Quality Health Service Standards. 2nd ed. Sydney: ACSQHC; 2021.
15. Shear MK, Simon N, Wall M, et al. Complicated grief and related bereavement issues for DSM-5. Depress Anxiety. 2011;28(2):103–117.

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).