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Goals of Care Discussions

Last updated 1 Jun 2026 Β· Palliative care

πŸ“‹ Key Information Summary

πŸ“‹
  • Goals of care (GoC) discussions align treatment decisions with the patient's values, preferences, and realistic clinical outcomes in the context of advanced or life-limiting illness.
  • Every Australian adult should be offered the opportunity to complete an Advance Care Directive (ACD) β€” these are legally binding in all states and territories under relevant legislation.
  • Identify the substitute decision-maker (SDM) early; Australian law recognises hierarchy of default SDMs (spouse/partner β†’ adult child β†’ parent β†’ sibling β†’ close friend) in the absence of a formally appointed enduring guardian.
  • Use structured communication frameworks β€” SPIKES for breaking bad news, Ask-Tell-Ask for information exchange, and NURSE statements for responding to emotion.
  • Discuss both best-case and worst-case scenarios using time-limited trials and "hoping for the best, preparing for the worst" language to support realistic expectations.
  • Treatment burden must be weighed against potential benefit at every stage β€” consider treatment toxicity, hospital time, functional decline, and symptom burden against likelihood of meaningful response.
  • Resuscitation plans (Not for Resuscitation / Ceiling of Treatment orders) are medical decisions guided by clinical futility, patient wishes, and state-based legislation β€” they are not simply patient choice alone.
  • Goals of care are dynamic and should be revisited at key transition points: new diagnosis, disease progression, change in functional status, and after acute deterioration or hospitalisation.
  • General care planning includes advance care planning (ACP), anticipatory prescribing, preferred place of care and death, and referral to specialist palliative care where appropriate.
  • Aboriginal and Torres Strait Islander patients face unique barriers including cultural safety, language, geographic isolation, historical mistrust, and differing concepts of "country," kinship, and end-of-life β€” culturally responsive approaches are essential.
  • Document GoC conversations in the medical record and ensure accessibility across care settings β€” use My Health Record, state-based ACD registers, and portable resuscitation/ceiling-of-treatment plans.
  • The surprise question ("Would you be surprised if this patient died in the next 12 months?") is a validated screening tool to trigger timely GoC conversations in primary and hospital care.

Introduction & Australian Context

Goals of care (GoC) discussions are structured conversations between clinicians, patients, and their families or substitute decision-makers that explore values, preferences, and realistic treatment outcomes in the context of serious or life-limiting illness. These conversations form the foundation of person-centred care and are integral to advance care planning (ACP) in Australia.

In Australia, approximately 160,000 people die each year, with around 70–80% of deaths preceded by a period of chronic or serious illness where GoC discussions are relevant. Despite this, fewer than 15% of Australians have a documented advance care directive, and many people die receiving treatments inconsistent with their stated preferences. The National Palliative Care Strategy 2018 identifies improving access to ACP as a key priority.

Shared decision-making in advanced illness requires clinicians to move beyond simply presenting treatment options. It demands exploration of what matters most to the patient β€” their goals, fears, acceptable trade-offs, and definition of quality of life. This topic provides a practical framework for conducting these conversations across the trajectory of serious illness, from early disease through to end-of-life care.

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When to initiate GoC discussions: Do not wait until the terminal phase. The ideal time is when the surprise question yields a "No" answer β€” "Would I be surprised if this patient died in the next 12 months?" Other triggers include new diagnosis of advanced cancer, Stage IV organ failure, frailty with recurrent hospitalisations, or ICU admission with multi-organ dysfunction.

Australian Legislative Framework

Advance care planning legislation varies by state and territory but shares common principles:

State/Territory Key Legislation ACD Term Used SDM Appointment
NSW Powers of Attorney Act 2003; Guardianship Act 1987 Advance Care Directive / Living Will Enduring Guardian
VIC Medical Treatment Planning and Decisions Act 2016 Advance Care Directive Medical Treatment Decision Maker
QLD Powers of Attorney Act 1998; Advance Health Directive Act 1998 Advance Health Directive Enduring Power of Attorney (Health)
WA Advance Health Directive Act 1996 Advance Health Directive Enduring Power of Guardianship
SA Advance Care Directives Act 2013 Advance Care Directive Substitute Decision-Maker (appointed)
TAS Guardian and Administration Act 1995 Advance Care Directive for Health Care Enduring Power of Guardianship
ACT Medical Treatment (Health Directions) Act 2006 Health Direction Enduring Power of Attorney
NT Advance Personal Planning Act 2013 Advance Personal Plan Decision-maker (appointed)

Treatment Options

Goals of care discussions encompass a broad spectrum of treatment decisions, from disease-modifying interventions to purely comfort-focused care. The clinician's role is to present realistic options aligned with prognosis and patient priorities.

Treatment Continuum

Full Active Treatment
Curative-Intent Therapy
All interventions including ICU admission, mechanical ventilation, dialysis, chemotherapy, and surgery aimed at cure or significant life prolongation.
Setting: Tertiary hospital, ICU/HDU
Active Treatment with Limits
Time-Limited Trial / Ceiling of Care
Disease-modifying treatment with agreed limits β€” e.g., "treat the pneumonia but do not intubate," or a 2-week trial of chemotherapy with reassessment.
Setting: General ward, outpatient oncology
Comfort-Focused
Palliative / End-of-Life Care
Symptom management prioritised; no disease-modifying treatment; focus on dignity, comfort, preferred place of care and death.
Setting: Home, hospice, residential aged care

Specific Treatment Decisions

Common treatment decisions requiring GoC alignment include:

Treatment Domain Questions to Explore Key Considerations
Cardiopulmonary resuscitation (CPR) "If your heart were to stop, would you want us to attempt to restart it?" Success rates in advanced illness are <5–10% with meaningful survival; discuss futility honestly
Mechanical ventilation "Would a breathing machine be consistent with what matters to you?" Consider NIV (BiPAP) as a bridge vs. invasive ventilation; discuss likelihood of extubation
Renal replacement therapy "Would dialysis improve your quality of life or add burden?" Consider conservative (non-dialysis) management pathway for elderly with significant comorbidity
Antimicrobials "Would treating this infection help achieve your goals?" Parenteral vs. oral; antibiotics can provide symptom relief even in end-of-life (e.g., for dyspnoea from pneumonia)
Artificial nutrition & hydration "In the dying phase, nutrition may cause more discomfort β€” shall we focus on mouth care?" Parenteral/enteral nutrition rarely beneficial in advanced cachexia; subcutaneous fluids for symptomatic dehydration
Transfusion "Would blood transfusions help you feel better or would the trips to hospital be too much?" Consider community-based transfusion programs; weigh symptom benefit vs. burden of attendance
Palliative chemotherapy / immunotherapy "What are you hoping this treatment will achieve?" Clarify realistic response rates, symptom burden of treatment, and time on treatment vs. time with quality
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CPR is a medical decision: In all Australian jurisdictions, CPR is a medical treatment that can be withheld when clinically futile or not in the patient's best interests. It is not simply a patient choice. Clinicians are not obligated to provide futile CPR. Document decisions clearly using a Resuscitation Plan or Ceiling of Treatment form appropriate to your jurisdiction.

Best-Case & Worst-Case Outcomes

Discussing prognosis requires honesty tempered with empathy. The "best-case / worst-case" framework helps patients and families understand the range of possible outcomes and make decisions consistent with their values.

The Best-Case / Worst-Case Framework

1
Assess Understanding
"What have the other doctors told you about your condition?" Use Ask-Tell-Ask to explore baseline understanding before adding prognostic information.
2
Present the Best Case
"The best case is that treatment works well β€” you respond to the chemotherapy, the cancer shrinks, and you regain strength. This might give you months to years of good-quality life." Use realistic best-case timelines.
3
Present the Worst Case
"The worst case is that the treatment doesn't work, or the side effects are too much. You could spend most of your remaining time in hospital feeling unwell from treatment." Be honest without removing hope.
4
Describe the Most Likely Case
"Most people with your situation fall somewhere in between. Treatment might give you some extra time with reasonable quality, but the disease will eventually progress." Anchor expectations in evidence.
5
Elicit Patient Preference
"Knowing this range, what matters most to you? Would you prefer to try treatment even with the risk of side effects, or focus on quality of time?"

Prognostic Communication Tools

Tool / Metric Use Limitations
The Surprise Question Screening: "Would I be surprised if this patient died in the next 12 months?" Low specificity; should prompt further assessment, not be used alone
PPS (Palliative Performance Scale) Functional status scoring (100% = full function, 0% = death); median survival estimates at each decile Less reliable in non-cancer diagnoses; inter-rater variability
Prognostic indices (e.g., SPICT, GSF-PIG) Identifying patients who need palliative care alongside disease management Designed for generalist use; not a substitute for clinical judgement
Disease-specific scores NYHA Class IV, MELD score, FEV₁ <30%, HFA-ABC staging, Glasgow Prognostic Score Population-level data; individual prognosis varies significantly
Clinician gestalt Experienced clinician estimate ("days to weeks," "weeks to months," "months to a year") Tends to overestimate survival; use alongside objective measures
πŸ’‘
Time-limited trials: A powerful strategy when uncertainty exists: "Let's try this treatment for 2–4 weeks. If things are improving, we continue. If not, we redirect our focus to comfort." This creates a shared decision-making safety net and allows natural transition to palliative goals.

Treatment Burden vs. Benefit

Every treatment decision in advanced illness requires careful assessment of burden against potential benefit. As illness progresses, the threshold for acceptable burden rises and the expected benefit narrows. GoC discussions must explicitly address this balance.

Dimensions of Treatment Burden

Burden Type Examples Assessment Questions
Physical burden Nausea, fatigue, pain, procedures, immobility, incontinence "How do the side effects compare to the symptoms of the disease itself?"
Psychological burden Anxiety, depression, loss of autonomy, fear, existential distress "Is the uncertainty of treatment causing more distress than the illness?"
Social burden Time away from family, inability to attend events, role changes, caregiver exhaustion "What are you missing out on because of treatment?"
Financial burden Out-of-pocket medication costs, travel to appointments, lost income, allied health fees "Are there financial pressures from the treatment that are causing stress?"
Logistical burden Frequent hospital visits, lengthy infusions, multiple medications, monitoring requirements "How manageable is the treatment routine for you and your family?"
Opportunity cost Time spent on treatment vs. time for "what matters most" β€” travel, relationships, goals "If you had 6 months left, how would you want to spend it?"

Communicating Burden–Benefit Trade-offs

Use concrete, specific language rather than general reassurance:

  • Avoid: "This treatment might help." β€” This is vague and may inflate expectations.
  • Prefer: "Out of 100 people who receive this chemotherapy, about 25–30 will see their cancer shrink, but 15–20 will experience significant side effects requiring hospitalisation. The average benefit is an extra 2–3 months of life."
  • Avoid: "We need to fight this." β€” Framing treatment as a battle implies that stopping treatment is "giving up."
  • Prefer: "We want to do what is most aligned with your goals β€” whether that means active treatment or focusing on comfort and time at home."
⚠️
The "therapeutic misconception": Patients frequently overestimate the benefits of treatment and underestimate harms. Studies show 70% of patients with advanced cancer believe chemotherapy is "likely" or "very likely" to cure their disease. It is the clinician's responsibility to correct these misconceptions sensitively and repeatedly.

Frameworks for Benefit Assessment

Response vs. Benefit

A tumour shrinking on CT is a response. The patient feeling better and living longer with good quality is a benefit. Always discuss whether a response translates into meaningful benefit for this individual patient.

The "What If" Conversation

"What if the treatment works β€” what does success look like for you?" and "What if it doesn't work β€” what would you want us to do then?" These two questions frame the entire GoC discussion around the patient's definition of a life worth living.

General Care Planning

Once goals of care have been discussed and agreed upon, they must be translated into a concrete, documented care plan that is accessible across all care settings. Good care planning ensures that the patient's wishes are known and respected, even when the patient can no longer communicate.

Components of a Comprehensive Care Plan

1
Advance Care Directive (ACD)
A legal document recording the patient's values, preferences, and specific instructions for future healthcare. Must be completed while the patient has decision-making capacity. Include nominated SDM(s) and their contact details.
2
Resuscitation / Ceiling of Treatment Plan
A medical order documenting the agreed level of intervention: CPR status, ICU/HDU admission, intubation, vasopressors, NIV, IV antibiotics, blood transfusion, and artificial nutrition/hydration. Use jurisdiction-specific forms (e.g., ReSPECT in some states).
3
Anticipatory Prescribing
Ensure a palliative symptom management kit is available at home or in the residential aged care facility β€” subcutaneous midazolam, morphine, haloperidol, hyoscine butylbromide β€” with clear administration instructions for after-hours use.
4
Preferred Place of Care & Death
Ask explicitly: "Where would you prefer to be if you were becoming more unwell? And where would you prefer to be at the end of your life?" Document this and explore feasibility (carer support, palliative care service availability, equipment needs).
5
Palliative Care Referral
Refer to specialist palliative care when symptom burden is complex, when GoC discussions are proving difficult, or when end-of-life care is anticipated within weeks to months. In Australia, referral can be to hospital-based, community, or consultancy palliative care teams.
6
Communication & Documentation
Ensure GoC decisions are documented in the medical record, communicated to the GP, shared via My Health Record or state ACD registers, and a copy given to the patient, SDM, and residential facility if applicable.

Palliative Care Phases & Planning Implications

Phase Description GoC Focus Medicare Support
Stable Patient's needs are being met by current care plan Review and reaffirm GoC; ensure ACD is current GP Management Plan (MBS 721), Team Care Arrangement (723)
Unstable Unexpected crisis or new issue requiring urgent change in management Reassess GoC urgently; consider ceiling of treatment Palliative Care Support Program (PCSP) β€” additional support days
Deteriorating Progressive decline despite optimal management Community Palliative Care, specialist outreach
Terminal / Dying Death expected within days Comfort care only; anticipatory medications; family support; place-of-death preferences After-hours palliative care support line; GP home visits (MBS 5000–5067)
Bereaved After the patient's death Family/carer grief support; debrief; referral to bereavement services Bereavement support through palliative care services

Communicating with Families

Families are integral to GoC discussions but may have different priorities to the patient. Key strategies include:

  • Family meetings: Structured, multidisciplinary meetings with the patient (if able), family/SDM, and key clinicians. Allocate at least 30–60 minutes. Use SPIKES framework.
  • Managing disagreement: When family members disagree with the patient's wishes or with the clinical team, involve the hospital ethics committee, the Office of the Public Advocate, or seek a second medical opinion.
  • Cultural sensitivity: Explore cultural, spiritual, and religious beliefs that may influence treatment preferences. Allow time for community or family consultation where culturally appropriate.
  • Ongoing updates: Families should receive regular, consistent information. Designate a single point of contact (key worker) to avoid conflicting messages.
βœ…
Australian resources for care planning: Advance Care Planning Australia (advancecareplanning.org.au), Respecting Patient Choices (Austin Health), Palliative Care Australia (palliativecare.org.au), and the Australian Digital Health Agency My Health Record advance care planning documents section.

Communication Frameworks & Skills

Effective GoC discussions depend on skilled communication. Clinicians should be trained in evidence-based communication frameworks and practise these skills regularly.

SPIKES β€” Breaking Bad News & Initiating GoC

Step Action Example Language
Setting Prepare the environment; ensure privacy; invite key people; sit down "I've asked your daughter to join us today because this is an important conversation."
Perception Assess what the patient already knows "What have the other doctors told you about your illness?"
Invitation Ask permission to share information "Would it be okay if I talked to you about what we're facing and what options we have?"
Knowledge Share information in small chunks; use plain language "I'm sorry to say that the scan shows the cancer has spread. [Pause]"
Emotions Acknowledge and respond to emotions using NURSE statements "I can see this is really hard to hear. It's okay to feel upset."
Strategy / Summary Discuss next steps; align on goals; summarise the plan "Let's talk about what matters most to you and how we can make a plan that reflects that."

NURSE Statements β€” Responding to Emotion

  • N β€” Naming: "It sounds like you're feeling scared about what's ahead."
  • U β€” Understanding: "I can understand why you would feel that way."
  • R β€” Respecting: "You've shown incredible strength through all of this."
  • S β€” Supporting: "We will be with you every step of the way."
  • E β€” Exploring: "Tell me more about what worries you the most."

Ask-Tell-Ask β€” Information Exchange

This cyclical framework prevents information overload and ensures patient understanding:

1
Ask
"What would you like to know about your treatment options?" β€” Assess information needs and preferences.
2
Tell
Provide information in plain language, in small chunks, using the best-case/worst-case/most-likely framework.
3
Ask
"What questions do you have? Can you tell me in your own words what you've understood?" β€” Check understanding (teach-back).

Special Populations

πŸ‘Ά

Paediatrics

Assent vs. consentChildren and adolescents should be involved in GoC discussions at an age-appropriate level. Adolescents (generally β‰₯14 years) should be offered the opportunity to participate in decision-making, even if legal consent rests with the parent/guardian.
Parental decision-makingParents may experience profound guilt and distress. Explore their values, fears, and hopes. Acknowledge the uniqueness of their child's situation. Engage paediatric palliative care teams early.
Perinatal palliative careFor life-limiting conditions diagnosed antenatally, GoC discussions should begin before birth. Develop a birth plan incorporating comfort care, family time, and memory-making.
DocumentationUse paediatric-specific ACP tools such as "My Wishes" (developed in Australia). Ensure resuscitation plans are clearly documented in the child's health record.
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Pregnancy

Maternal autonomyThe pregnant patient's autonomous decisions regarding her own healthcare are paramount. While fetal welfare is considered, the mother's right to make informed decisions about her own treatment is legally and ethically established in all Australian jurisdictions.
Dual-patient complexityGoC discussions must address both maternal and fetal/neonatal outcomes. Involve obstetric, neonatal, and palliative care teams in joint discussions where a life-limiting fetal diagnosis coexists.
Timing of deliveryIf a pregnant woman is dying, discuss her wishes regarding timing and mode of delivery, and neonatal resuscitation β€” ideally before the terminal phase.
πŸ‘΄

Elderly / Frail

Frailty assessmentUse the Clinical Frailty Scale (CFS) to guide GoC discussions. Patients with CFS β‰₯5 (mildly frail) or above have significantly reduced physiological reserve and higher mortality from acute illness.
MultimorbidityElderly patients often have multiple conditions competing for treatment priority. GoC discussions should focus on overall trajectory and functional goals rather than individual disease targets.
Cognitive impairmentFor patients with dementia, GoC discussions should occur early (ideally in mild cognitive impairment) while decision-making capacity is preserved. Use dementia-specific ACP tools. When capacity is lost, the SDM must make decisions based on previously expressed wishes or best interests.
Residential aged careRACF residents frequently have undocumented GoC. Ensure resuscitation plans and ceiling-of-treatment orders are in place and accessible to after-hours medical staff and ambulance services.
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Renal Impairment

Dialysis vs. conservative managementPatients with ESKD, particularly those aged >75 with significant comorbidity, should be offered the option of conservative kidney management (non-dialysis pathway). GoC discussions should begin at CKD Stage 4 (eGFR 15–29).
Withdrawing dialysisWithdrawal of dialysis is an ethically and legally accepted decision when it no longer aligns with the patient's goals. Support the patient and family through this process and ensure palliative care is involved.
🫁

Hepatic Impairment

Decompensated cirrhosisPatients with decompensated cirrhosis (Child-Pugh C, MELD >20) have a poor prognosis. GoC discussions should address transplant eligibility, TIPS candidacy, and hepatorenal syndrome management, alongside comfort-focused alternatives.
Hepatic encephalopathyDecision-making capacity may fluctuate with encephalopathy episodes. ACP should be completed during periods of clarity.
πŸ›‘οΈ

Immunocompromised

Transplant patientsPatients who have undergone solid organ or haematopoietic stem cell transplant face unique GoC considerations including graft-vs-host disease, immunosuppression burden, and potential for transplant-related mortality. Discuss quality of life after transplant vs. risks of ongoing treatment.
HIVWith modern ART, most people with HIV have near-normal life expectancy. GoC discussions are relevant when treatment failure, AIDS-defining illness, or comorbidities significantly impact prognosis.

Monitoring & Reassessment

Goals of care are not static documents β€” they must be reviewed regularly and updated as the patient's condition, preferences, or circumstances change.

Triggers for GoC Review

New diagnosis of advanced illness
Within 1–2 weeks of diagnosis
Reassess after staging investigations
Involve specialist palliative care
Disease progression despite treatment
At each oncology/specialist review
Reassess every treatment change
Best-case/worst-case framework
Acute deterioration / hospitalisation
Within 24–48 hours of admission
Review ceiling of treatment
Ensure resuscitation plan is current
Functional decline (new dependency)
At GP review / aged care assessment
Reassess every 1–3 months
Consider ACAT referral
Patient-initiated request
At any time
Honour promptly
Document change and rationale
Transition to end-of-life care
When death expected within days–weeks
Review at each visit
Palliative care phase: terminal

Documentation Standards

  • Document GoC discussions in the medical record with date, participants, key decisions, and rationale.
  • Use structured templates (e.g., Respecting Patient Choices forms, state-specific ACD documents).
  • Upload ACDs and resuscitation plans to My Health Record where possible.
  • Provide copies to the patient, SDM, GP, residential facility, and hospital (if multiple sites of care).
  • Review and re-sign ACDs annually or after significant health changes.
πŸ’‘
Quality indicator: The Australian Commission on Safety and Quality in Health Care (ACSQHC) recommends that all patients admitted to hospital with a life-limiting illness have documented evidence of goals of care discussion within 72 hours of admission. This is embedded in the NSQHS Standards (Comprehensive Care Standard).

Aboriginal and Torres Strait Islander Health Considerations

Aboriginal and Torres Strait Islander Health

Aboriginal and Torres Strait Islander Australians experience significantly higher rates of chronic disease and lower life expectancy than non-Indigenous Australians (gap of approximately 8 years). Goals of care discussions must be conducted with deep cultural awareness and responsiveness to the unique social, historical, and spiritual contexts of Indigenous communities.

Cultural safety
Clinicians must engage in cultural safety training and approach GoC discussions without assumptions. The concept of "health" for Aboriginal and Torres Strait Islander peoples encompasses social, emotional, cultural, and spiritual wellbeing β€” not merely the absence of disease. Engage Aboriginal Health Workers (AHWs) and Aboriginal Liaison Officers (ALOs) as cultural brokers.
Language and communication
Many Aboriginal and Torres Strait Islander people speak English as a second, third, or fourth language. Use interpreters where needed. Avoid medical jargon. "Sorry business" (bereavement) and "sick" may carry different meanings. Allow extended silences β€” these are culturally appropriate and not signs of disengagement.
Kinship and community decision-making
Decisions may involve extended family and community elders, not just the individual patient. Western concepts of individual autonomy may conflict with communal decision-making processes. Allow time and space for family consultation without imposing Western timelines.
Concepts of "country" and death
Many Aboriginal people have a strong connection to country and wish to return to country to die. This may require coordination of transport, accommodation for family, and community-based palliative care services in remote areas. "Sorry business" practices may mean the family needs to leave quickly after death to fulfil cultural obligations.
Naming and avoidance practices
In some Aboriginal cultures, it is culturally inappropriate to speak directly about death or to use the name of a deceased person. Clinicians should ask about cultural preferences around discussing death and adapt language accordingly. Avoid displaying images of the deceased without permission.
Historical mistrust
The legacy of colonisation, the Stolen Generations, and ongoing systemic racism contribute to mistrust of healthcare institutions. Build rapport through consistent relationships, acknowledgment of historical wrongs, and demonstrated cultural humility. Longitudinal GP care improves trust and ACP engagement.
Remote and very remote access
Specialist palliative care services are extremely limited in remote and very remote Australia. AHWs, Remote Area Nurses (RANs), and Royal Flying Doctor Service (RFDS) are essential for GoC discussions and end-of-life care planning in these settings. Telehealth palliative care consultations can bridge specialist gaps.
Advance care planning resources
Use culturally adapted ACP resources β€” the "Dying to Talk" discussion starter (Palliative Care Australia) and the "Yarning About Advance Care Planning" resources developed in partnership with Aboriginal and Torres Strait Islander communities. Involve AHWs in facilitating ACP conversations.
⚠️
Never assume: Ask each patient and family about their cultural preferences for discussing illness, death, and dying. Do not presume that all Aboriginal and Torres Strait Islander people share the same cultural practices β€” there is enormous diversity across communities, language groups, and families. Always ask, never assume.

πŸ“š References

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  2. 2. Palliative Care Australia. National Palliative Care Strategy 2018. Canberra: Australian Government Department of Health; 2018.
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  6. 6. Sudore RL, Lum HD, You JJ, et al. Defining advance care planning for adults: a consensus definition from a multidisciplinary Delphi panel. J Pain Symptom Manage. 2017;53(5):821–832.
  7. 7. Clayton JM, Hancock KM, Butow PN, et al. Clinical practice guidelines for communicating prognosis and end-of-life issues with adults in the advanced stages of a life-limiting illness, and their caregivers. Med J Aust. 2007;186(S12):S77–S108.
  8. 8. Australian Institute of Health and Welfare (AIHW). Aboriginal and Torres Strait Islander Health Performance Framework: Summary report 2023. Cat. no. IHPF 2. Canberra: AIHW; 2023.
  9. 9. Shahid S, Bessarab D, van Schaik KD, Aoun SM, Thompson SC. Improving palliative care outcomes for Aboriginal Australians: service delivery, education and training. Palliat Med. 2013;27(7):623–626.
  10. 10. You JJ, Dodek P, Lamontagne F, et al. What really matters in end-of-life discussions? Perspectives of patients in hospital with serious illness and their families. CMAJ. 2014;186(18):E679–E687.
  11. 11. Mack JW, Weeks JC, Wright AA, Block SD, Prigerson HG. End-of-life discussions, goal attainment, and distress at the end of life: predictors and outcomes of receipt of care consistent with preferences. J Clin Oncol. 2010;28(7):1203–1208.
  12. 12. RACGP. Advance care planning in general practice. East Melbourne: The Royal Australian College of General Practitioners; 2021.
  13. 13. Downar J, You JJ, Bagshaw SM, et al. Nonbeneficial treatment Canada: definitions, causes, and potential solutions from the perspective of healthcare workers. Crit Care Med. 2015;43(2):270–281.
  14. 14. White B, Willmott L, Close E, et al. Legislation improves advance care planning in Australia. Intern Med J. 2020;50(8):954–960.
  15. 15. Palliative Care Australia. Dying to Talk: Discussion Starter. Canberra: Palliative Care Australia; 2019. Available at: dyingtotalk.org.au.
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 Β± NSAID; manual therapy
2–6 weeks
Provocable on palpation; no red flags
Thoracic compression fracture
Paracetamol; Β± 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 Β± morphine; lap cholecystectomy
Surgical within 72 h (cholecystitis)
RUQ/infrascapular; post-prandial; RUQ US

πŸ“š References

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  2. 2. National Health and Medical Research Council (NHMRC). Evidence-based management of acute musculoskeletal pain. Canberra: NHMRC; 2003 (updated 2020).
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  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):395–403.
  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):E581–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):112–120.
  10. 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. 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):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.

πŸ“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):924–939.
  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):736–745.
  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):1583–1599.
  5. 5. Smolen JS, LandewΓ© 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. 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):1487–1498.
  10. 10. Pisetsky DS. Antinuclear antibody testing β€” 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 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. 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 TNFΞ± blockers in adults with rheumatoid arthritis. Rheumatology. 2005;44(2):155–158.
  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 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.

πŸ“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):924–939.
  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):736–745.
  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):1583–1599.
  5. 5. Smolen JS, LandewΓ© 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. 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):1487–1498.
  10. 10. Pisetsky DS. Antinuclear antibody testing β€” 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 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. 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 TNFΞ± blockers in adults with rheumatoid arthritis. Rheumatology. 2005;44(2):155–158.
  13. 13. National Health and Medical Research Council (NHMRC). National statement on ethical conduct in human research. Canberra: NHMRC; 2023 (updated).