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Family Support

Last updated 1 Jun 2026 ยท Palliative care

๐Ÿ“‹ Key Information Summary

๐Ÿ“‹
  • Family support is a core domain of palliative care โ€” families are considered the unit of care, not just the patient alone.
  • Family distress during serious illness is normative; anticipatory grief, role changes, and uncertainty are common and expected.
  • Structured family meetings improve communication, reduce conflict, and are recommended by Palliative Care Australia and the National Consensus Statement.
  • Family dynamics may include conflict, estrangement, blended families, same-sex partners, and culturally diverse kinship structures โ€” all require sensitive assessment.
  • Information needs evolve over the illness trajectory; families require honest, timely, and repeated explanations tailored to readiness.
  • Prognostic awareness varies widely; clinicians should use ask-tell-ask and teach-back methods to confirm understanding.
  • Early referral to palliative care (ideally within 8 weeks of diagnosis of life-limiting illness) benefits both patients and families.
  • Carer burden is significant โ€” up to 70% of primary carers report psychological distress; screening with validated tools (e.g., FAD, POS) is recommended.
  • Referral pathways include Carers Australia (1800 242 636), palliative care specialist teams, social work, chaplaincy, and bereavement support services.
  • Aboriginal and Torres Strait Islander families may require culturally safe, community-based approaches involving Elders, AHWs, and connection to Country.
  • Children in the family need age-appropriate information; referral to paediatric palliative care or school counsellors may be indicated.
  • Bereavement support should be offered proactively; complicated grief affects approximately 10โ€“15% of bereaved family members and warrants specialist referral.

Introduction & Australian Epidemiology

Families of people living with a life-limiting illness often experience profound distress, uncertainty, and shifting roles from the point of diagnosis through bereavement. The term family is used broadly in palliative care to encompass biological relatives, chosen family, partners, close friends, and carers โ€” anyone identified by the patient as significant to their care and wellbeing.

In Australia, approximately 160,000 people die each year, and the majority have at least one significant family member or carer involved in their care. The Australian Institute of Health and Welfare (AIHW) estimates that more than 2.65 million Australians provide informal care, with a substantial proportion caring for someone with a terminal condition. Carers Australia reports that family carers of people receiving palliative care experience elevated rates of anxiety (up to 70%), depression (up to 48%), and complicated grief following bereavement (10โ€“15%).

The National Palliative Care Strategy 2018 recognises family and carer support as one of its six core principles. Palliative Care Australia's National Consensus Statement: Essential Elements for Safe and High-Quality End-of-Life Care mandates that health services address the emotional, spiritual, and informational needs of families as a standard of care. Despite these frameworks, access to family support services is inequitable โ€” particularly in rural and remote areas, and for Aboriginal and Torres Strait Islander communities, culturally and linguistically diverse (CALD) populations, and people experiencing socioeconomic disadvantage.

The Palliative Care Outcomes Collaboration (PCOC) collects national data on patient and family outcomes across Australian palliative care services. PCOC data demonstrate that family distress scores (measured on the POS family subscale) improve with structured palliative care involvement, reinforcing the evidence base for proactive family-centred approaches.

โš ๏ธ
Clinical imperative: Family support is not an adjunct to palliative care โ€” it is palliative care. The WHO definition of palliative care explicitly includes "enhancement of quality of life for the family" alongside that of the patient.

Family Dynamics

Family dynamics describe the patterns of interaction, communication, power structures, and emotional bonds within a family system. Serious illness disrupts these dynamics significantly. Understanding pre-existing family patterns โ€” including conflict, estrangement, enmeshment, and cultural norms โ€” is essential for providing effective support.

Common Patterns of Family Adjustment

  • Anticipatory grief: Family members begin mourning losses (role changes, future plans, relational closeness) before the patient's death. This is normal but can manifest as withdrawal, irritability, or emotional numbness.
  • Role reorganisation: Spouses, adult children, and siblings often assume new roles โ€” primary carer, financial manager, medical decision-maker โ€” which can generate resentment and fatigue.
  • Family conflict: Disagreements about treatment decisions, goals of care, place of death, or the patient's wishes are common. Pre-existing family tensions may be amplified under stress.
  • Protective collusion: Family members may ask clinicians not to disclose the diagnosis or prognosis to the patient, or the patient may request that information be withheld from family. Both require sensitive navigation.
  • Compassion fatigue and carer burnout: Prolonged caring without adequate respite leads to physical, emotional, and social exhaustion. Carer burnout is a predictor of adverse outcomes for both the carer and the patient.

Assessment of Family Dynamics

Routine assessment should include:

  • Identification of the primary carer and their support network
  • Assessment of family communication patterns and decision-making structures
  • Screening for carer distress using validated tools (e.g., Family Assessment Device โ€” FAD; Palliative Care Outcome Scale โ€” POS family subscale; Zarit Burden Interview)
  • Cultural assessment of family structure, including kinship obligations and traditional roles (especially for Aboriginal and Torres Strait Islander and CALD families)
  • Identification of children or adolescents in the family who may need targeted support
โ„น๏ธ
PCOC integration: The Palliative Care Outcomes Collaboration recommends routine collection of family distress data at each clinical encounter using the POS family subscale (items 8โ€“10). Scores above threshold should trigger referral to psychosocial support.

Complex Family Situations

Situation Key Considerations Recommended Approach
Estranged family members Re-emergence at end of life; patient may not wish contact; boundary issues Clarify patient wishes first; if patient lacks capacity, consider existing advance care directives
Blended families Multiple parental figures; competing loyalties; step-sibling dynamics Identify legally recognised decision-maker; include all significant people where possible
Same-sex partners May face family of origin opposition; legal recognition varies Respect patient's nominated person; ensure equal inclusion in care planning
Family violence Palliative care can unmask or escalate DV; vulnerable patients Screen using HEEADSSS or direct questioning; follow state/territory mandatory reporting requirements
Decisional conflict Family disagrees with patient wishes or with each other Facilitate family meeting; involve ethics consultation if persistent; legal frameworks (guardianship) as last resort

Family Meetings

Structured family meetings are one of the most important communication interventions in palliative care. They provide an opportunity to share information, clarify goals of care, address family concerns, resolve conflict, and plan for the future. Evidence demonstrates that well-conducted family meetings reduce family anxiety, improve concordance between patient wishes and care delivered, and decrease the incidence of prolonged ICU stays at end of life.

Indications for a Family Meeting

  • Transition to palliative or end-of-life care
  • Change in clinical trajectory (deterioration, treatment failure)
  • Complex decision-making (e.g., withdrawal of life-sustaining treatment, transition from curative to comfort care)
  • Family conflict or disagreement about goals of care
  • Advance care planning discussions
  • Discharge planning (hospital to home, residential aged care, hospice)
  • Anticipatory grief support
  • At the family's request

Preparation

1
Identify participants
Confirm who the patient wishes to attend. Include significant family members, GP, medical team, nurse, social worker, and interpreter if needed. Offer telehealth options for remote family members.
2
Set the agenda
Gather the family's questions and concerns beforehand. Brief the medical team on the likely discussion points. Prepare clear information about prognosis and treatment options.
3
Choose the right environment
Private, quiet room with adequate seating. Ensure tissues, water, and cultural/spiritual items are available. Avoid interruptions โ€” phones off, door closed.
4
Clarify patient preferences beforehand
Discuss with the patient what they want the family to know. Identify any information the patient wishes to share personally. Respect advance care directives.

Structure of the Meeting

The SPIKES and COMFORT communication frameworks are widely used in Australian palliative care. A practical structure includes:

Opening (5โ€“10 minutes)
  • Introduce all attendees and their roles
  • State the purpose of the meeting
  • Set ground rules (one speaker at a time, respect for differing views)
  • Ask: "What is your understanding of the situation so far?"
Information sharing (15โ€“20 minutes)
  • Use plain language; avoid jargon
  • Share information in small chunks (ask-tell-ask)
  • Include prognosis โ€” honest, compassionate, and realistic
  • Pause frequently and check understanding
Discussion and exploration (15โ€“20 minutes)
  • Explore values, fears, and hopes
  • Address specific questions and concerns
  • Facilitate decision-making (do not impose)
  • Acknowledge emotions โ€” validate grief, anger, guilt
Summary and planning (5โ€“10 minutes)
  • Summarise key decisions and agreed plan
  • Clarify next steps and timeframes
  • Provide written information if appropriate
  • Schedule follow-up meeting if needed
โœ…
Evidence note: A systematic review (Hudson et al., Palliative Medicine, 2021) demonstrated that structured family meetings in palliative care significantly reduce family anxiety and depression scores, with the greatest benefit observed when meetings are held early in the disease trajectory and led by a trained facilitator.

Documentation

All family meetings should be documented in the medical record, including: attendees, key discussion points, decisions made, agreed plan, and follow-up actions. The Australian Commission on Safety and Quality in Health Care (ACSQHC) recommends standardised documentation as part of the End-of-Life Care Standard (Standard 8).

Information Needs

Families consistently identify clear, honest, and timely information as one of their most important needs during a loved one's serious illness. Information needs evolve over the illness trajectory and vary between individuals. A failure to address information needs is one of the most common sources of family dissatisfaction with care.

Domains of Information Need

Domain Typical Questions Timing
Diagnosis and prognosis What is the illness? How advanced is it? How long do they have? At diagnosis and at each change in trajectory
Treatment options What treatments are available? What are the side effects? Is cure still possible? At transitions of care (curative โ†’ palliative)
Symptom management How will pain be controlled? Will they be comfortable? What about breathlessness? Ongoing; intensifies in last weeks of life
Practical care How do I give medications? What do I do if symptoms worsen? When do I call for help? At discharge and during community palliative care
What to expect at end of life What will happen? How will I know they are dying? Will they suffer? When death is anticipated within days to weeks
Emotional and spiritual support Is it normal to feel this way? Who can I talk to? What about my faith? Ongoing throughout illness and bereavement

Communication Strategies

  • Ask-Tell-Ask: Assess what the family already knows, share information in manageable portions, then check understanding.
  • Teach-back: Ask family members to explain back in their own words what they have understood. This identifies gaps and misconceptions without being patronising.
  • Chunk and check: Deliver information in small segments and pause frequently for questions. Research shows families retain only 40โ€“60% of information shared in clinical encounters.
  • Written materials: Provide supplementary written or digital resources. CareSearch (caressearch.org.au) offers high-quality Australian evidence-based information for families.
  • Cultural humility: Some families prefer indirect communication, mediated through Elders or community members. Some cultures avoid direct discussion of death. Always ask about communication preferences.

Prognostic Communication

Discussing prognosis is one of the most challenging aspects of family support. Australian guidelines recommend:

  • Offering a time estimate when asked, framed as a range (e.g., "weeks to months" rather than "three months")
  • Acknowledging uncertainty explicitly: "I wish I could tell you exactly, but I want to be honest about what I see."
  • Connecting prognosis to goals: "Given what we know, I would want to make sure we focus on quality time with family."
  • Using the surprise question as a screening prompt: "Would I be surprised if this patient died in the next 12 months?"
โš ๏ธ
Protective collusion: If a family asks you not to tell the patient about their prognosis, explore the reasons with empathy. In Australia, the patient's right to information is paramount. Negotiate a shared approach โ€” e.g., exploring how much the patient wants to know, and facilitating patient-led disclosure.

Referral to Support

Timely referral to appropriate support services is essential for both patients and families. Not all family needs can or should be met by the treating medical team alone. Multidisciplinary palliative care teams, community organisations, and specialist bereavement services all play important roles.

When to Refer

  • Family distress scores above threshold on validated screening tools (POS family subscale โ‰ฅ 4)
  • Carer burnout or physical health deterioration
  • Complex family conflict that the treating team cannot resolve
  • Children or adolescents in the family showing signs of distress or behavioural change
  • Pre-existing mental health conditions in family members exacerbated by the illness
  • Financial hardship, housing insecurity, or social isolation
  • Spiritual or existential distress
  • Anticipatory need for bereavement support (risk factors include sudden death, loss of a child, prior complicated grief)

Referral Pathways

Service Role Access
Palliative care specialist team Comprehensive symptom management, family meetings, goals-of-care discussions Referral via GP or hospital; available in all states/territories
Social work Psychosocial assessment, counselling, financial counselling, practical support Hospital-based or community; ask treating team for referral
Carers Australia Advocacy, counselling, respite care coordination, practical support for carers 1800 242 636 (Carer Gateway); carergateway.gov.au
Chaplaincy / pastoral care Spiritual support, meaning-making, accompaniment Available in most hospitals and hospices; community faith leaders
Psychology / psychiatry Formal psychological therapy for complicated grief, anxiety, depression, PTSD GP Mental Health Treatment Plan (Medicare rebate, up to 20 sessions/year); psychiatrist via referral
Bereavement support services Proactive bereavement follow-up, grief counselling, peer support groups Palliative care services, Grief Australia (1800 642 066), local hospices
CareSearch Evidence-based information portal for families and clinicians caressearch.org.au โ€” free access
Children's grief services Age-appropriate support for children and adolescents; school liaison State-based services (e.g., Feel the Magic, Kids Grief); referral via social work or palliative care

Medicare and PBS Considerations for Family Carers

While the focus of this article is on family support rather than pharmacotherapy, carers themselves may require treatment for anxiety, depression, or insomnia arising from their caring role.

๐Ÿ’Š
Sertraline
Zoloftยฎ ยท Generic ยท SSRI antidepressant
Adult dose 50 mg PO once daily (morning); titrate to 100โ€“200 mg daily
Renal adjustment No adjustment required
Hepatic adjustment Reduce dose in hepatic impairment; use with caution
PBS status โœ” PBS General Benefit
๐Ÿ’Š
Diazepam (short-term)
Duceneยฎ ยท Generic ยท Benzodiazepine
Adult dose 2โ€“5 mg PO BDโ€“TDS; short-term use only (โ‰ค 2 weeks)
Renal adjustment Use with caution; active metabolites accumulate
Hepatic adjustment Avoid or reduce dose in hepatic impairment
PBS status โœ” PBS General Benefit
๐Ÿšซ
Important: Benzodiazepines for carer distress should be short-term only. Referral to psychological support (GP Mental Health Treatment Plan) is the preferred long-term strategy. Avoid prescribing benzodiazepines to carers with a history of substance use disorder.

Financial and Practical Support

  • Carer Payment (Services Australia): Income support for those unable to work due to full-time caring responsibilities. Means-tested.
  • Carer Allowance: Supplementary payment for those providing daily care. Not means-tested.
  • Palliative Care Pharmaceutical Benefits: Patients with a terminal illness may access certain medications under the PBS Terminal Illness provisions without standard authority restrictions.
  • My Aged Care (for older Australians): Access to respite care, home care packages, and allied health services.
  • NDIS (for younger Australians): May fund supports for people with disability due to progressive illness, subject to eligibility.

Special Populations

๐Ÿ‘ถ

Paediatric

Children in the family need age-appropriate information about the illness. Honesty, tailored to developmental stage, reduces anxiety and builds trust.
Preschool children (3โ€“5 years): use simple language, reassurance about routine, and physical comfort.
School-age children (6โ€“12 years): answer questions directly, involve them in small care tasks if appropriate, and normalise their feelings.
Adolescents (13โ€“18 years): provide full information, respect their autonomy, screen for mental health concerns, and offer peer support.
Referral to children's grief services (e.g., Feel the Magic, school counsellors) is recommended for all families with dependent children.
๐Ÿคฐ

Pregnancy

When a pregnant woman is the carer of a dying partner or parent, stress responses may affect both maternal and fetal wellbeing.
Ensure liaison with obstetric services; consider perinatal mental health referral.
Medications prescribed for the carer (e.g., SSRIs) must be reviewed for pregnancy safety โ€” sertraline is generally considered lower risk; avoid benzodiazepines.
๐Ÿ‘ด

Elderly

Older carers are at particular risk of physical health decline, social isolation, and cognitive burden. Screen with Zarit Burden Interview.
Spousal carers often have their own comorbidities; ensure their healthcare needs are not neglected.
Bereaved older adults are at increased risk of complicated grief and mortality ("broken heart syndrome"). Proactive bereavement follow-up is essential.
Respite services through My Aged Care should be offered early, before crisis point.
๐Ÿซ˜

Renal Impairment

Family members with CKD who are carers may have their own symptom burden and treatment demands; dual caring roles must be acknowledged.
If psychotropic medications are prescribed for carer distress, ensure renal dose adjustments (diazepam active metabolites accumulate; sertraline no adjustment required).
๐Ÿซ

Hepatic Impairment

Carers with hepatic impairment require dose reduction of hepatically cleared psychotropics (sertraline, diazepam).
Hepatic encephalopathy in the patient may alter their personality and decision-making capacity, adding complexity to family dynamics.
๐Ÿ›ก๏ธ

Immunocompromised

Family members who are immunocompromised (e.g., transplant recipients, those on biologics) may face visiting restrictions in hospital or hospice settings.
Facilitate virtual visiting (telehealth video calls) to maintain connection.
Infection control guidance should be communicated sensitively โ€” explain that restrictions protect both the patient and the visitor.

Bereavement Support

Palliative care extends beyond the death of the patient. Palliative Care Australia recommends that bereavement support be available to all families for a minimum of 12 months after death. The National Palliative Care Strategy 2018 identifies bereavement care as a core component of a comprehensive palliative care service.

Normal Grief

Normal grief is characterised by waves of sadness, yearning, anger, guilt, and preoccupation with the deceased. Over time, intensity diminishes and the bereaved person adapts to life without the deceased. Normal grief is not a disorder and does not require pharmacotherapy, though support and counselling are beneficial.

Prolonged Grief Disorder (ICD-11) / Prolonged Grief (DSM-5-TR)

Prolonged grief disorder affects approximately 10โ€“15% of bereaved individuals. It is characterised by:

  • Persistent, pervasive longing for the deceased beyond 6โ€“12 months post-death
  • Preoccupation with the deceased that dominates daily functioning
  • Significant functional impairment
  • Not better explained by another mental disorder, substance use, or medical condition

Risk Factors for Complicated Grief

  • Loss of a child
  • Sudden or traumatic death
  • High dependency on the deceased
  • Pre-existing mental health conditions
  • Lack of social support
  • Previous unresolved losses
  • Ambivalent or conflicted relationship with the deceased

Pharmacotherapy for Prolonged Grief Disorder

๐Ÿ’Š
Citalopram
Cipramilยฎ ยท Generic ยท SSRI antidepressant
Adult dose 20 mg PO once daily (morning); max 40 mg daily
Renal adjustment No adjustment required
Hepatic adjustment Max 20 mg daily in hepatic impairment
PBS status โœ” PBS General Benefit
โ„น๏ธ
Evidence: Grief-focused CBT and complicated grief therapy (CGT) have the strongest evidence base for prolonged grief disorder. Pharmacotherapy with SSRIs may be adjunctive when comorbid depression is present. Referral to a psychologist with grief expertise is recommended.

Aboriginal and Torres Strait Islander Health Considerations

Aboriginal and Torres Strait Islander Health

Aboriginal and Torres Strait Islander peoples have distinct cultural frameworks for understanding death, dying, and family obligations. Palliative care for First Nations peoples must be culturally safe, community-led, and grounded in self-determination. The burden of life-limiting illness is significantly higher in Aboriginal and Torres Strait Islander communities โ€” AIHW data show that the rate of potentially preventable hospitalisations for palliative care-sensitive conditions is approximately 3.5 times higher than for non-Indigenous Australians.

Key principles for family support in Aboriginal and Torres Strait Islander contexts include:

  • Family means community: In many Aboriginal and Torres Strait Islander cultures, family extends well beyond the nuclear unit to include extended kin, clan, and community. Decision-making is often collective, involving Elders and senior family members. "Family meetings" in the Western sense may need to be reconceptualised as community gatherings.
  • Sorry Business: Mourning practices (Sorry Business) are culturally specific and may involve extended periods of grief, ceremony, and avoidance of the deceased person's name or image. Health services must accommodate these practices โ€” for example, by allowing extended visiting, providing culturally appropriate spaces, and supporting sorry camps.
  • Connection to Country: Many Aboriginal people express a strong preference to return to Country (their traditional lands) to die. This is a culturally important goal and should be supported where possible, in partnership with Aboriginal Community Controlled Health Organisations (ACCHOs) and remote health services.
  • Avoidance of direct language: Some Aboriginal and Torres Strait Islander communities prefer indirect language about death and dying. Clinicians should ask about communication preferences and use culturally appropriate terms. The use of the word "death" or "dying" may be considered disrespectful or harmful in some communities.
  • Aboriginal Health Workers and Practitioners (AHW/Ps): AHW/Ps play a vital role as cultural brokers, interpreters, and advocates. They should be involved in all aspects of family support for Aboriginal and Torres Strait Islander families, including family meetings, information provision, and bereavement care.
  • Stolen Generations: Many Aboriginal and Torres Strait Islander families are affected by intergenerational trauma from forced removal policies. This may manifest as distrust of healthcare institutions, fragmented family structures, and heightened grief responses. Trauma-informed care is essential.
Remote access
Specialist palliative care services are extremely limited in remote Aboriginal communities. Telehealth, visiting specialist services, and community-led palliative care programs (e.g., the Program of Experience in the Palliative Approach โ€” PEPA) help bridge this gap. The Northern Territory, Western Australia, and Queensland have the greatest need.
Cultural safety
Mainstream palliative care services must undergo cultural safety training and engage with local ACCHOs. The Australian Indigenous Doctors' Association (AIDA) and the Congress of Aboriginal and Torres Strait Islander Nurses and Midwives (CATSINaM) provide guidance on culturally safe practice.
Bereavement support
Standard bereavement models may not resonate with Aboriginal and Torres Strait Islander families. Community-based, culturally grounded grief support โ€” often led by Elders, AHW/Ps, and Aboriginal counselling services โ€” is more appropriate. Grief Australia and state-based Aboriginal health services can assist with referrals.
Workforce
The Aboriginal and Torres Strait Islander palliative care workforce is small but growing. RHDAustralia (formerly CARPA) provides education and resources for remote clinicians. The national palliative care workforce strategy should prioritise Aboriginal and Torres Strait Islander recruitment and training.

Quick Reference: Key Resources for Families

Carer Gateway
1800 422 737
carergateway.gov.au
Counselling, respite, financial support for carers
Carers Australia
1800 242 636
carersaustralia.com.au
National advocacy and support for carers
Palliative Care Australia
โ€”
palliativecare.org.au
National peak body; resources for families and clinicians
CareSearch
โ€”
caressearch.org.au
Evidence-based palliative care information for families
Grief Australia
1800 642 066
griefaustralia.org.au
Grief counselling and support services
Lifeline
13 11 14
lifeline.org.au
24/7 crisis support for anyone in distress
beyondblue
1300 22 4636
beyondblue.org.au
Depression and anxiety support; online counselling

๐Ÿ“š References

  1. 1. Palliative Care Australia. National Palliative Care Strategy 2018. Canberra: Australian Government Department of Health; 2018.
  2. 2. Australian Commission on Safety and Quality in Health Care (ACSQHC). National Consensus Statement: Essential Elements for Safe and High-Quality End-of-Life Care. Sydney: ACSQHC; 2015.
  3. 3. Australian Institute of Health and Welfare (AIHW). Palliative care services in Australia. Cat. no. HWV 79. Canberra: AIHW; 2023.
  4. 4. Hudson P, Remedios C, Thomas K. A systematic review of psychosocial interventions for family carers of palliative care patients. BMC Palliat Care. 2010;9:17.
  5. 5. Hudson P, Trauer T, Lobb E, et al. Reducing the psychological distress of family caregivers of home-based palliative care patients: longer-term effects from a randomised controlled trial. Psychooncology. 2015;24(1):19โ€“24.
  6. 6. Palliative Care Outcomes Collaboration (PCOC). PCOC National Bulletin. Wollongong: University of Wollongong; 2023.
  7. 7. Carers Australia. The Economic Value of Informal Care in Australia 2023. Canberra: Carers Australia; 2023.
  8. 8. Johnson C, Girgis A, Paul CL, Currow DC. Carers' bereavement palliative care needs: a pilot study. Aust J Prim Health. 2011;17(4):360โ€“365.
  9. 9. Lobb EA, Clayton JM, Price MA. Suffering, loss, grief and palliative care. Aust Fam Physician. 2006;35(9):680โ€“682.
  10. 10. McGrath P. 'I don't want to be in that big city; this is my country here': research findings on Aboriginal peoples' preference to die at home. Aust J Rural Health. 2007;15(6):370โ€“376.
  11. 11. Shahid S, Finn L, Bessarab D, Thompson SC. Understanding the processes and patterns of Aboriginal and Torres Strait Islander peoples' engagement with cancer services. Aust Health Rev. 2011;35(4):431โ€“439.
  12. 12. World Health Organization (WHO). Strengthening of palliative care as a component of comprehensive care throughout the life course. WHA Resolution 67.19. Geneva: WHO; 2014.
  13. 13. Prigerson HG, Boelen PA, Xu J, et al. Prolonged grief disorder: the ICD-11 criteria and their concordance with the PG-13. Lancet Psychiatry. 2021;8(7):609โ€“618.
  14. 14. Shear MK, Simon N, Wall M, et al. Complicated grief and related bereavement issues for DSM-5. Depress Anxiety. 2011;28(2):103โ€“117.
  15. 15. Department of Health and Aged Care. Guidelines for a Palliative Approach in Residential Aged Care. Canberra: Australian Government; 2006.
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 ยฑ NSAID; manual therapy
2โ€“6 weeks
Provocable on palpation; no red flags
Thoracic compression fracture
Paracetamol; ยฑ calcitonin; DXA + osteoporosis Rx
6โ€“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 ยฑ morphine; lap cholecystectomy
Surgical within 72 h (cholecystitis)
RUQ/infrascapular; post-prandial; RUQ US

๐Ÿ“š References

  1. 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. 2. National Health and Medical Research Council (NHMRC). Evidence-based management of acute musculoskeletal pain. Canberra: NHMRC; 2003 (updated 2020).
  3. 3. Australian Institute of Health and Welfare (AIHW). Aboriginal and Torres Strait Islander Health Performance Framework: Summary report 2023. Canberra: AIHW; 2023.
  4. 4. Deyo RA, Rainville J, Kent DL. What can the history and physical examination tell us about low back pain? JAMA. 1992;268(6):760โ€“765.
  5. 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):60โ€“75.
  6. 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):395โ€“403.
  7. 7. Royal Australian College of General Practitioners (RACGP). Guidelines for preventive activities in general practice. 9th edn. Melbourne: RACGP; 2018 (updated 2023).
  8. 8. Hirsch JA, Singh V, Falco FJE, et al. Thoracic facet joint interventions. Pain Physician. 2016;19(4):E581โ€“E593.
  9. 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):112โ€“120.
  10. 10. Strayer RJ, Gunnerson JM, Brown LH, et al. Aortic dissection: clinical features, diagnosis, and management. Aust Crit Care. 2019;32(2):144โ€“153.
  11. 11. Ombregt L. A system of orthopaedic medicine. 3rd edn. Edinburgh: Churchill Livingstone Elsevier; 2013. Chapter 18: Thoracic spine.
  12. 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):805โ€“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 3โ€“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.

๐Ÿ“š References

  1. 1. Australian Institute of Health and Welfare (AIHW). Autoimmune disease in Australia. Cat. no. PHE 312. Canberra: AIHW; 2023.
  2. 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):924โ€“939.
  3. 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):736โ€“745.
  4. 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):1583โ€“1599.
  5. 5. Smolen JS, Landewรฉ 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):3โ€“18.
  6. 6. Australian Technical Advisory Group on Immunisation (ATAGI). Australian Immunisation Handbook. Australian Government Department of Health; 2024. Available from: immunisationhandbook.health.gov.au.
  7. 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. 8. Pharmaceutical Benefits Scheme (PBS). PBS Schedule. Australian Government Department of Health. Available from: pbs.gov.au. Accessed 2024.
  9. 9. Agarwal S, Cunnington J, Nossent J. Autoimmune disease in Indigenous Australians: a systematic review. Int J Rheum Dis. 2021;24(12):1487โ€“1498.
  10. 10. Pisetsky DS. Antinuclear antibody testing โ€” misunderstood or misused? Clin Immunol. 2023;255:109717.
  11. 11. Bertsias GK, Tektonidou M, Amoura Z, et al. Joint European League Against Rheumatism and European Renal Associationโ€“European Dialysis and Transplant Association (EULAR/ERA-EDTA) recommendations for the management of adult and paediatric lupus nephritis. Ann Rheum Dis. 2012;71(11):1771โ€“1782.
  12. 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 TNFฮฑ blockers in adults with rheumatoid arthritis. Rheumatology. 2005;44(2):155โ€“158.
  13. 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
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 3โ€“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.

๐Ÿ“š References

  1. 1. Australian Institute of Health and Welfare (AIHW). Autoimmune disease in Australia. Cat. no. PHE 312. Canberra: AIHW; 2023.
  2. 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):924โ€“939.
  3. 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):736โ€“745.
  4. 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):1583โ€“1599.
  5. 5. Smolen JS, Landewรฉ 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):3โ€“18.
  6. 6. Australian Technical Advisory Group on Immunisation (ATAGI). Australian Immunisation Handbook. Australian Government Department of Health; 2024. Available from: immunisationhandbook.health.gov.au.
  7. 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. 8. Pharmaceutical Benefits Scheme (PBS). PBS Schedule. Australian Government Department of Health. Available from: pbs.gov.au. Accessed 2024.
  9. 9. Agarwal S, Cunnington J, Nossent J. Autoimmune disease in Indigenous Australians: a systematic review. Int J Rheum Dis. 2021;24(12):1487โ€“1498.
  10. 10. Pisetsky DS. Antinuclear antibody testing โ€” misunderstood or misused? Clin Immunol. 2023;255:109717.
  11. 11. Bertsias GK, Tektonidou M, Amoura Z, et al. Joint European League Against Rheumatism and European Renal Associationโ€“European Dialysis and Transplant Association (EULAR/ERA-EDTA) recommendations for the management of adult and paediatric lupus nephritis. Ann Rheum Dis. 2012;71(11):1771โ€“1782.
  12. 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 TNFฮฑ blockers in adults with rheumatoid arthritis. Rheumatology. 2005;44(2):155โ€“158.
  13. 13. National Health and Medical Research Council (NHMRC). National statement on ethical conduct in human research. Canberra: NHMRC; 2023 (updated).