Med2Date β€” Clinical Guidelines
Home Palliative Care Requests to Hasten Death and VAD

Requests to Hasten Death and VAD

Last updated 1 Jun 2026 Β· Palliative care

πŸ“‹ Key Information Summary

πŸ“‹
  • Statements of a desire to die are common in serious illness and palliative care; they should always be explored with compassion and without judgement, as they frequently reflect untreated suffering rather than a fixed wish to die.
  • Desire to die exists on a spectrum β€” from transient wishes during crisis to sustained, well-considered requests β€” and the clinical response must match the nature and persistence of the statement.
  • A structured assessment of physical, psychological, existential, and social suffering is essential before concluding that a desire to die is irremediable.
  • Uncontrolled pain, depression, anxiety, demoralisation, loss of dignity, and fear of being a burden are the most common modifiable drivers of desire to die; most resolve with expert palliative care.
  • Voluntary assisted dying (VAD) is now lawful in all six Australian states and the two territories, with each jurisdiction having its own eligibility criteria, application processes, and safeguards.
  • VAD eligibility generally requires: an adult with decision-making capacity, a disease expected to cause death within a defined timeframe (typically 12 months or 6 months depending on jurisdiction), and suffering that cannot be relieved in a manner acceptable to the person.
  • Clinicians who conscientiously object to VAD have a professional obligation to inform the patient of their objection, provide information about accessing VAD through other pathways, and ensure timely transfer of care without abandonment.
  • Psychiatric assessment is mandatory where there is concern about impaired decision-making capacity, untreated mental illness, or coercion; this should be obtained from a psychiatrist or psychologist experienced in palliative care.
  • Multidisciplinary team debriefing and clinician self-care are critical when managing requests to hasten death; moral distress and burnout are common and must be addressed proactively.
  • Aboriginal and Torres Strait Islander communities may hold distinct cultural, spiritual, and familial perspectives on death, dying, and Country; culturally safe conversations require flexibility, trust, and the involvement of Aboriginal health workers and liaison officers.
  • Withdrawal or withholding of life-sustaining treatment at the patient's request is ethically and legally distinct from VAD; it is a well-established component of patient autonomy and does not require VAD legislation.
  • All clinical encounters relating to desire to die or VAD requests must be meticulously documented, including the patient's own words, the assessment performed, interventions offered, and the reasoning for any clinical decision.

Introduction & Australian Epidemiology

Requests to hasten death and expressions of a desire to die are among the most complex and emotionally charged encounters in clinical medicine. These statements arise across the spectrum of serious illness β€” from advanced cancer to progressive neurological disease, organ failure, and frailty β€” and require a nuanced, compassionate, and systematic clinical response. This topic provides a framework for assessing desire-to-die statements, evaluating suffering, understanding voluntary assisted dying (VAD) legislation in Australia, and supporting the clinical team through these challenging encounters.

In Australia, desire-to-die statements are reported in approximately 15–30% of patients receiving specialist palliative care, though the true prevalence in general practice and other specialties is likely under-recognised. Importantly, a sustained and considered request for assistance to die is less common than transient wishes, and many patients who express a desire to die respond to improvements in symptom management, psychosocial support, and existential care.

Since the passage of the Voluntary Assisted Dying Act 2017 (Vic), all Australian states and territories have enacted VAD legislation β€” Western Australia (2019), Tasmania (2021), South Australia (2021), Queensland (2021), New South Wales (2023), the Australian Capital Territory (2024), and the Northern Territory (2024). Each jurisdiction has distinct eligibility criteria, procedural safeguards, and oversight mechanisms. Clinicians must be familiar with the legislation in their jurisdiction and understand their professional and legal obligations.

⚠️
Key distinction: A request to hasten death is a clinical signal that must be assessed β€” not an instruction to be acted upon or dismissed. The role of the clinician is to understand the suffering behind the request, offer effective interventions, and, where legally available and appropriate, facilitate access to VAD if the request persists after all modifiable factors have been addressed.

The Palliative Care Australia national framework, the Australian Medical Association (AMA) position statements, and the Royal Australian College of General Practitioners (RACGP) guidance all emphasise the primacy of patient-centred communication, thorough assessment of suffering, and respect for autonomy within the bounds of Australian law.

Desire to Die

A desire-to-die (DTD) statement encompasses a broad range of expressions, from fleeting comments such as "I wish this was over" to explicit and sustained requests for assistance to die. Understanding the nature, context, and meaning of these statements is the foundation of an appropriate clinical response.

Phenomenology of Desire-to-Die Statements

DTD statements are not synonymous with suicidal ideation, although they may overlap. They can be understood along several dimensions:

Dimension Transient / Reactive Persistent / Considered
Duration Hours to days; associated with acute crisis Weeks to months; stable over time
Context Follows a pain episode, bad news, loss of function, or social isolation Persists despite optimal symptom control and psychosocial support
Underlying driver Usually identifiable and modifiable (pain, depression, fear) Often existential β€” loss of meaning, dignity, autonomy, or identity
Response to intervention Typically resolves with effective symptom management and support May persist despite best-practice palliative care
Clinical implication Urgent assessment; treat reversible causes; re-evaluate Comprehensive assessment; explore all options including VAD where lawful

Common Drivers of Desire to Die

  • Physical suffering: Uncontrolled pain, dyspnoea, nausea, fatigue, delirium, or other refractory symptoms
  • Psychological distress: Depression, anxiety, post-traumatic stress, adjustment disorders
  • Demoralisation: A distinct syndrome characterised by hopelessness, helplessness, loss of meaning, and a sense of being a burden β€” distinct from major depression and responsive to existential therapies
  • Existential suffering: Loss of purpose, dignity, identity, or spiritual connectedness; fear of the dying process
  • Social factors: Isolation, loss of role, perceived or actual burden on family, financial stress, inadequate carer support
  • Loss of autonomy: Dependence on others for activities of daily living; institutionalisation
  • Fear: Of suffering, of losing control, of being alone at death, of indignity

Initial Clinical Response

1
Listen without judgement
Acknowledge the statement with empathy. Avoid immediately reassuring ("Don't say that") or complying ("I'll help you die"). Use open-ended questions: "Tell me more about what you mean by that."
2
Clarify the meaning
Distinguish between wishes to be dead, passive suicidal ideation, active suicidal ideation, and a request for assistance to die. Ask: "Are you thinking about ending your life, or is it more that you want the suffering to stop?"
3
Assess safety
If active suicidal ideation with intent or plan is identified, apply standard suicide risk assessment frameworks (e.g., Columbia Suicide Severity Rating Scale). Ensure immediate safety β€” involve crisis services if needed.
4
Assess and treat reversible causes
Conduct a systematic assessment of pain, symptoms, depression, demoralisation, and social circumstances. Offer concrete interventions for each identified cause.
5
Revisit and document
Reassess after interventions. Document the patient's own words, the assessment findings, the interventions offered and their outcomes, and the evolving clinical plan.
🚨
Never ignore a desire-to-die statement. Failure to explore these statements may result in untreated suffering, missed depression, unaddressed suicidal risk, or abandonment of a patient who may benefit from VAD or other end-of-life options.

Screening and Assessment Tools

Tool Purpose Notes
Edmonton Symptom Assessment System (ESAS-r) Symptom burden screening Validated in palliative care; identifies uncontrolled physical symptoms
Patient Health Questionnaire-9 (PHQ-9) Depression screening Exclude item 9 (suicidality) as a standalone score; assess suicidality separately
Demoralisation Scale-II (DS-II) Demoralisation assessment Australian-developed; distinguishes demoralisation from depression
Columbia Suicide Severity Rating Scale (C-SSRS) Suicidal ideation and behaviour Gold standard for distinguishing passive from active ideation with intent
Schedule of Attitudes toward Hastened Death (SAHD) Intensity of desire for hastened death Research tool; useful in specialist palliative care settings

Assessment of Suffering

A comprehensive, multidimensional assessment of suffering is the cornerstone of the clinical response to any desire-to-die statement. Suffering in advanced illness is rarely unidimensional β€” it encompasses physical, psychological, social, existential, and spiritual domains β€” and a failure to assess all domains risks missing modifiable causes.

Domains of Suffering Assessment

Physical
Symptom Burden
Pain, dyspnoea, nausea/vomiting, fatigue, constipation, delirium, seizures, pruritus, insomnia. Assess severity, treatability, and impact on function and mood.
Use ESAS-r; pain scales (NRS); Memorial Symptom Assessment Scale
Psychological
Emotional Distress
Depression, anxiety, adjustment disorder, post-traumatic stress, grief, anticipatory bereavement. Distinguish clinical depression from demoralisation and grief.
PHQ-9; GAD-7; clinical interview; psychiatric referral if diagnostic uncertainty
Existential / Spiritual
Meaning, Dignity, and Purpose
Loss of meaning, sense of being a burden, loss of dignity, spiritual distress, fear of death or the dying process, unfinished business. Demoralisation is the key construct here.
DS-II; Meaning in Life Questionnaire; spiritual care referral; Dignity Therapy

Distinguishing Depression from Demoralisation

This distinction is clinically critical because the treatments differ substantially:

Feature Major Depression Demoralisation
Mood Pervasive sadness; anhedonia May retain capacity for pleasure (anhedonia absent)
Cognitions Guilt, worthlessness, hopelessness Helplessness, loss of meaning, sense of failure
Self-worth Globally diminished Intact but feels unable to cope
Engagement Social withdrawal; psychomotor retardation May engage socially but feels alienated
Duration β‰₯2 weeks of pervasive symptoms Variable; often fluctuating with circumstances
First-line treatment Antidepressants + psychotherapy Meaning-centred therapy, Dignity Therapy, narrative approaches; antidepressants are not first-line

Interventions for Suffering

For each domain of suffering identified, offer specific interventions:

  • Physical: Opioid rotation or dose titration (see eTG Palliative Care); adjuvant analgesics; interventional pain procedures (nerve blocks, intrathecal pumps); symptom-specific pharmacotherapy (antiemetics, bronchodilators, antipsychotics for delirium)
  • Psychological: Cognitive behavioural therapy (CBT); acceptance and commitment therapy (ACT); supportive psychotherapy; pharmacotherapy for depression (SSRIs β€” sertraline 50–200 mg daily or escitalopram 10–20 mg daily; avoid TCAs in the elderly or those at risk of anticholinergic toxicity)
  • Existential: Dignity Therapy (developed by Harvey Max Chochinov β€” available in Australian palliative care services); meaning-centred therapy; legacy work; life review
  • Social: Social work referral; carer support; financial counselling; respite care; Centrelink/community services; addressing isolation
  • Spiritual: Pastoral care; chaplaincy; Aboriginal health worker or cultural liaison for First Nations patients; patient's own faith community
βœ…
Research evidence: Studies consistently show that up to 60–80% of desire-to-die statements resolve or diminish when modifiable causes of suffering are systematically identified and treated. This underscores the importance of thorough assessment before concluding that a request is irremediable.

Assessing Decision-Making Capacity

For any patient making a request related to end-of-life care or VAD, formal assessment of decision-making capacity is essential. Capacity is decision-specific and time-specific. The four legal criteria (applicable across Australian jurisdictions) are:

  1. The patient can understand the information relevant to the decision
  2. The patient can retain that information long enough to make a decision
  3. The patient can weigh the information and appreciate its consequences
  4. The patient can communicate the decision by any means

Where there is doubt about capacity, formal assessment by a psychiatrist, geriatrician, or neuropsychologist should be sought. Capacity may fluctuate β€” particularly in delirium, hepatic encephalopathy, or medication effects β€” and reassessment may be needed.

Voluntary Assisted Dying

Voluntary assisted dying (VAD) is the administration of a prescribed substance by a person to themselves (self-administration) or by a medical practitioner (practitioner administration) for the purpose of causing death, in accordance with the wishes of a person with a disease or condition that is advanced, progressive, and will cause death. VAD is now lawful across all Australian states and territories.

Australian VAD Legislation β€” Overview

Jurisdiction Legislation Commencement Expected Death Timeframe Self-Admin Practitioner Admin
Victoria Voluntary Assisted Dying Act 2017 June 2019 ≀12 months βœ” βœ”
Western Australia Voluntary Assisted Dying Act 2019 July 2021 ≀12 months (6 months for some conditions) βœ” βœ”
Tasmania End-of-Life Choices (Voluntary Assisted Dying) Act 2021 October 2022 ≀12 months (6 months for some) βœ” βœ”
South Australia Voluntary Assisted Dying Act 2021 January 2023 ≀12 months (6 months for some) βœ” βœ”
Queensland Voluntary Assisted Dying Act 2021 January 2023 ≀12 months βœ” βœ”
New South Wales Voluntary Assisted Dying Act 2022 November 2023 ≀12 months (6 months for some) βœ” βœ”
ACT Voluntary Assisted Dying Act 2024 November 2025 (expected) To be confirmed βœ” βœ”
Northern Territory Voluntary Assisted Dying Act 2024 2025 (expected) To be confirmed βœ” βœ”
ℹ️
Jurisdictional variation: Clinicians must consult the specific VAD legislation and associated regulations in their state or territory. Eligibility criteria, number of requests required, mandatory assessment steps, oversight boards, and reporting obligations differ between jurisdictions. Contact your state or territory VAD care navigator service for guidance.

General Eligibility Criteria (Common Across Jurisdictions)

  • The person must be an adult (β‰₯18 years) with decision-making capacity
  • The person must have an advanced, progressive disease, illness, or medical condition that is expected to cause death
  • The expected timeframe of death is typically within 12 months (some jurisdictions specify 6 months for certain conditions such as neurodegenerative diseases)
  • The condition must be causing suffering that cannot be relieved in a manner the person considers tolerable
  • The request must be voluntary, without coercion or undue influence
  • The person must be an Australian citizen or permanent resident, ordinarily residing in the relevant jurisdiction

Typical VAD Assessment Process

1
First Request
The person makes a clear, voluntary request to a medical practitioner. The practitioner documents the request, confirms the condition, and provides information about the VAD process and alternatives (palliative care, specialist referral).
2
First Assessment
A coordinating practitioner assesses eligibility β€” confirms diagnosis, prognosis, decision-making capacity, voluntariness, and that suffering cannot be adequately relieved. Referral to a second (consulting) practitioner is made.
3
Second Assessment
An independent consulting practitioner conducts their own assessment of eligibility, confirming all criteria are met. In some jurisdictions, a specialist opinion is required for the prognosis or diagnosis.
4
Second and Third Requests
The person makes additional formal requests, typically with defined waiting periods between each to ensure the request remains consistent. Final request is usually witnessed by two independent witnesses.
5
Administration Permit
Once all criteria are met and the required timeframes have passed, a permit is issued (jurisdiction-specific). The prescribed VAD substance is dispensed by an authorised pharmacist.
6
Administration
Self-administration or practitioner administration occurs. A medical practitioner must be available (present in some jurisdictions, on standby in others) during and after administration. Death is certified by the attending practitioner.

Clinician Roles and Obligations

Under Australian VAD legislation, clinicians may participate in several roles:

  • Coordinating practitioner: Manages the VAD process, conducts the first assessment, coordinates consulting practitioners, applies for the administration permit
  • Consulting practitioner: Conducts an independent eligibility assessment as required by legislation
  • Administering practitioner: Administers the VAD substance to the patient (practitioner administration pathway)
  • Prescribing pharmacist: Dispenses the VAD substance under permit

Conscientious Objection

All Australian VAD legislation recognises the right of any clinician to conscientiously object to participation in VAD. However, conscientious objection carries specific professional obligations:

  • Inform the patient clearly and respectfully that you hold a conscientious objection
  • Provide the patient with information about how to access VAD services (e.g., state VAD navigator service, VAD support phone line)
  • Do not abandon the patient β€” continue to provide all other aspects of care, including palliative care
  • Do not attempt to dissuade the patient, express disapproval, or create barriers to access
  • Facilitate timely transfer of care to a willing practitioner if the patient requests it
  • Document the conscientious objection in the clinical record
⚠️
Common misconception: Conscientious objection does not mean refusing to discuss VAD with the patient. The Medical Board of Australia and the AMA both affirm that a clinician's personal beliefs should not impede a patient's lawful access to VAD. Refusing to provide information or creating barriers may constitute professional misconduct.

VAD Medications and Administration

The specific VAD medication regimens are jurisdiction-specific and determined by the relevant health department. Common agents include:

πŸ’Š
Secobarbital
Common VAD self-administration agent
Route Oral (dissolved in liquid)
Dose As prescribed per jurisdiction protocol β€” typically 10–15 g
Notes Supplied as powder; dissolved at time of administration; onset of death typically within 1–3 hours
πŸ’Š
Phenobarbital
Practitioner-administered VAD agent
Route IV or subcutaneous infusion
Dose As per jurisdiction protocol β€” typically followed by a neuromuscular agent
Notes Used for practitioner administration pathway; onset of death typically within 10–30 minutes
ℹ️
Note: Detailed VAD medication protocols are provided by the relevant state or territory health department and are not available on PBS. Clinicians must complete specific VAD training and authorisation before prescribing or administering VAD substances.

Withdrawal or Withholding of Life-Sustaining Treatment

It is important to distinguish VAD from the withdrawal or withholding of life-sustaining treatment (WLST), which is a separate and well-established element of end-of-life care in Australia:

  • WLST is ethically and legally permissible when the treatment is no longer in the patient's best interests, is medically futile, or when a competent patient (or their substitute decision-maker) declines treatment
  • WLST does not require VAD legislation and is guided by common law, state guardianship/advance directive legislation, and the National Framework for Advance Care Planning (2021)
  • WLST includes decisions such as withdrawal of mechanical ventilation, dialysis, artificial nutrition and hydration, and vasopressors
  • Palliative sedation for refractory symptoms at end of life is also distinct from VAD and is an accepted practice under the doctrine of double effect

Team Support

Managing requests to hasten death and participating in VAD processes places significant emotional, ethical, and psychological demands on the clinical team. Proactive team support is essential β€” not only for clinician wellbeing but to sustain the quality and safety of patient care.

Moral Distress in End-of-Life Care

Moral distress arises when a clinician knows or believes they know the ethically correct action but is constrained from taking it by institutional, legal, or interpersonal factors. In the context of desire-to-die statements and VAD, moral distress may arise from:

  • Providing care that feels futile or contrary to the patient's wishes
  • Conflicting values between the clinician's personal beliefs and the patient's request
  • Perceived inability to relieve suffering despite best efforts
  • Institutional or team conflicts about VAD participation
  • Participating in VAD when it conflicts with personal values (moral residue)
  • Witnessing protracted dying when a patient wishes for a faster death

Structured Debriefing

Structured debriefing should occur after all desire-to-die assessments and VAD-related encounters. Recommended models include:

Schwartz Rounds

Regular, structured forums for all staff (clinical and non-clinical) to reflect on the emotional and social dimensions of caring. Available in many Australian hospitals and palliative care services.

Critical Incident Stress Debriefing (CISD)

Formal debriefing following particularly distressing clinical events. Facilitated by trained peer support or Employee Assistance Programme (EAP) personnel. Should be voluntary, not mandatory.

Practical Team Support Strategies

  • Multidisciplinary team (MDT) meetings: Regular discussion of complex end-of-life cases with input from palliative care medicine, nursing, social work, psychology, chaplaincy, and ethics
  • Clinical ethics consultation: Available through hospital ethics committees or the Australasian Association of Bioethics and Health Law (AABHL); particularly valuable when there are conflicts about goals of care or VAD
  • Peer support programmes: Paired or group peer support for clinicians involved in end-of-life care, with training in active listening and referral
  • Professional supervision: Regular supervision for nurses, social workers, and allied health professionals involved in VAD or end-of-life care β€” provided by experienced practitioners
  • Employee Assistance Programme (EAP): Ensure all team members are aware of EAP access and that it is normalised, not stigmatised
  • Workload management: Ensure clinicians involved in VAD processes have appropriate time allocation; VAD assessments and administration are time-intensive and emotionally demanding
  • Education and training: Ongoing education in communication skills, managing desire-to-die statements, VAD legislation, and self-care; simulation-based training is increasingly used in Australian centres
ℹ️
Organisation-level responsibility: Health services that offer VAD have a duty of care to their staff. The Australian Charter of Health Care Workers' Rights (updated 2022) and NSQHS Standards require organisations to provide systems that support clinician wellbeing, including in the context of end-of-life care and VAD.

Documentation and Medico-Legal Considerations

Meticulous documentation is essential for all desire-to-die and VAD-related clinical encounters:

  • Record the patient's own words β€” use direct quotation where possible
  • Document the clinical context (disease status, symptom burden, psychosocial circumstances)
  • Detail the assessment performed β€” each domain of suffering assessed and findings
  • Record the interventions offered and the patient's response
  • Document capacity assessment findings
  • For VAD: maintain compliance with jurisdiction-specific documentation requirements, including all formal requests, assessment forms, and reporting to the oversight body
  • Retain all VAD-related documentation in a secure, accessible clinical record
  • Contact your medical indemnity insurer if you are uncertain about any medico-legal aspect of VAD participation

Special Populations

🀰

Pregnancy

  • Desire-to-die statements in pregnancy require urgent multidisciplinary assessment involving perinatal psychiatry, obstetrics, and palliative care
  • Underlying drivers may include perinatal mental health conditions, diagnosis of serious illness in pregnancy, or foetal anomaly
  • VAD eligibility in pregnancy is not explicitly addressed in most Australian jurisdictions and raises complex ethical and legal questions regarding the interests of the foetus
  • Consult the state/territory VAD oversight board and clinical ethics service early
  • Key action: Immediate perinatal mental health and palliative care referral; explore all reversible causes
πŸ§’

Paediatrics

  • VAD is not available to persons under 18 years of age in any Australian jurisdiction
  • Desire-to-die statements in children and adolescents with serious illness require age-appropriate exploration with support from paediatric palliative care and child psychology
  • Developmental stage influences how a child expresses suffering and understands death
  • Parental distress and decision-making in paediatric end-of-life care require dedicated psychosocial support
  • Adolescents expressing desire to die should also be assessed for mental health conditions (depression, anxiety) independent of their medical condition
  • Key action: Paediatric palliative care and child/adolescent mental health involvement; clear documentation of discussions with parents/guardians
πŸ‘΄

Elderly

  • Desire-to-die statements in older adults are common and may reflect cumulative losses: bereavement, functional decline, social isolation, and loss of independence
  • Assess for delirium, medication effects (e.g., benzodiazepines, opioids, corticosteroids), and untreated pain
  • Depression is under-recognised in older adults β€” use validated tools (PHQ-9, GDS-15) and screen proactively
  • Frailty and multimorbidity may affect VAD eligibility assessment β€” prognosis is inherently less certain in non-malignant conditions
  • Cognitive decline may affect capacity over time β€” early advance care planning discussions are important
  • Key action: Geriatric assessment; depression and delirium screening; advance care planning; social work for isolation
🫘

Renal Impairment

  • Patients on dialysis with desire-to-die statements should be assessed for adequacy of dialysis, uraemic symptoms, and burden of treatment
  • Withdrawal of dialysis is a recognised and ethically supported option when continued dialysis is no longer in the patient's best interests β€” this is distinct from VAD
  • Medications used in symptom management (opioids, gabapentinoids, benzodiazepines) require dose adjustment in renal impairment
  • Key action: Nephrology and palliative care joint assessment; explore withdrawal of dialysis as a pathway if appropriate
🫁

Hepatic Impairment

  • End-stage liver disease is associated with significant symptom burden (pruritus, ascites, hepatic encephalopathy, fatigue) and high rates of desire-to-die statements
  • Hepatic encephalopathy may impair decision-making capacity β€” assess and treat before evaluating VAD eligibility
  • Medication metabolism is profoundly altered β€” use hepatically safe agents; avoid or reduce opioids, benzodiazepines, and paracetamol doses
  • Key action: Hepatology and palliative care co-management; serial capacity assessment; symptom-focused treatment
πŸ›‘οΈ

Immunocompromised

  • Patients with HIV/AIDS, transplant recipients, and those on immunosuppressive therapy may have unique symptom profiles and psychosocial circumstances influencing desire to die
  • Antiretroviral therapy side effects and pill burden may contribute to suffering
  • Assess for opportunistic infections affecting the CNS (e.g., cryptococcal meningitis, cerebral toxoplasmosis) which may impair cognition and capacity
  • Key action: Infectious disease and palliative care collaboration; review medication burden; capacity assessment if CNS involvement suspected

Aboriginal and Torres Strait Islander Health Considerations

Aboriginal and Torres Strait Islander Health

Discussions about death, dying, desire to die, and voluntary assisted dying require particular cultural sensitivity when engaging with Aboriginal and Torres Strait Islander peoples. There is significant diversity of views, practices, and beliefs across the more than 250 distinct language groups and communities in Australia. A one-size-fits-all approach is inappropriate and potentially harmful.

Cultural Considerations in Death and Dying

  • In many Aboriginal and Torres Strait Islander communities, death and dying are deeply embedded in cultural, spiritual, and kinship systems. The naming of deceased persons, use of images, and discussion of death may be culturally restricted or subject to specific protocols.
  • The concept of "sorry business" (mourning and funeral practices) is central to community life and can profoundly affect a patient's priorities, decision-making, and willingness to engage with end-of-life discussions.
  • Country (connection to ancestral land) is fundamental to health and wellbeing for many Aboriginal peoples. Being on Country at the end of life may be a critical goal, and care planning should accommodate this wherever possible.
  • The idea of "hastening death" may conflict with cultural and spiritual beliefs about the natural course of life, the role of ancestors, and the transition to the spirit world. Conversely, some individuals may hold views that are supportive of autonomy in end-of-life decisions.
  • VAD awareness and acceptance varies significantly across communities. Clinicians must not assume a patient's position based on cultural background β€” ask, listen, and respect.

Barriers to Optimal End-of-Life Care

Access to palliative care
Aboriginal and Torres Strait Islander peoples in remote and very remote areas have significantly reduced access to specialist palliative care services. The majority of specialist palliative care is concentrated in major cities, yet a significant proportion of First Nations Australians live in regional and remote areas.
Cultural safety
Many Aboriginal and Torres Strait Islander patients report feeling culturally unsafe in mainstream health settings. Lack of culturally competent staff, absence of family-centred care models, and institutional racism contribute to delayed presentation and disengagement from services.
Communication
English may not be a first language for some patients, particularly in remote communities. Health literacy levels may be lower. Use of plain language, visual aids, and interpreters (including Aboriginal health workers and liaison officers) is essential.
Distrust of health system
Historical and ongoing experiences of racism, forced removal, and medical experimentation have created significant distrust. Building trust requires time, consistency, honesty, and a commitment to relationship-based care.
VAD in remote communities
Access to VAD processes is significantly limited in remote areas due to the lack of trained and willing practitioners, distance from assessment and administration sites, and infrastructure challenges for medication storage and transport.
Family and community decision-making
Decision-making in many First Nations communities is collective, involving extended family, Elders, and community leaders. Western models of individual autonomous decision-making may not align with community norms. Clinicians should facilitate family-inclusive discussions while respecting the patient's voice.

Practical Strategies for Culturally Safe Care

  • Involve Aboriginal and Torres Strait Islander health workers and liaison officers in all end-of-life discussions β€” they provide cultural brokerage, language support, and advocacy
  • Consult the Aboriginal Community Controlled Health Organisation (ACCHO) in the patient's region for guidance on cultural protocols and available services
  • Allow time and build relationships β€” end-of-life discussions should not be rushed; trust is earned over multiple encounters
  • Ask about cultural preferences β€” including involvement of Elders, restrictions on naming or imagery, preferred location of care, and spiritual practices
  • Use "yarning" as a culturally appropriate communication framework β€” it is a relational, narrative, and non-hierarchical way of sharing information and exploring feelings
  • Support return to Country where this is a patient priority β€” coordinate with Royal Flying Doctor Service (RFDS), Patient Assisted Travel Scheme (PATS), and remote health services
  • Refer to specialist palliative care with cultural competency β€” Palliative Care Australia and state palliative care organisations can assist with finding culturally appropriate services
  • Acknowledge the impact of intergenerational trauma and grief β€” desire to die in the context of a First Nations patient may be intertwined with historical and ongoing trauma, not solely the current medical condition
⚠️
Important: Never assume that a desire-to-die statement in an Aboriginal or Torres Strait Islander patient can be attributed to cultural factors alone, nor should it be minimised. The same standard of assessment for suffering, mental health, and decision-making capacity applies, delivered in a culturally safe manner. Ensure the patient has access to VAD information and services if they request it, regardless of location or background.

πŸ“š References

  1. 1. Palliative Care Australia. National Palliative Care Strategy 2018. Canberra: Commonwealth of Australia; 2018.
  2. 2. Victorian Government. Voluntary Assisted Dying Act 2017. Melbourne: Victorian Government; 2017. Available from: legislation.vic.gov.au.
  3. 3. Department of Health (WA). Voluntary Assisted Dying Act 2019 β€” Guidelines for Health Practitioners. Perth: Government of Western Australia; 2021.
  4. 4. Queensland Government. Voluntary Assisted Dying Act 2021 β€” Clinical Guidance. Brisbane: Queensland Health; 2023.
  5. 5. Medical Board of Australia. Good Medical Practice: A Code of Conduct for Doctors in Australia. Melbourne: Medical Board of Australia; 2020 (updated 2024).
  6. 6. Australian Medical Association. AMA Position Statement: Voluntary Assisted Dying β€” 2023 Update. Canberra: AMA; 2023.
  7. 7. Kissane DW, Clarke DM, Street AF. Demoralization syndrome β€” a relevant psychiatric diagnosis for palliative care. J Palliat Care. 2001;17(1):12–21.
  8. 8. Chochinov HM, Hack T, Hassard T, Kristjanson LJ, McClement S, Harlos M. Dignity therapy: a novel psychotherapeutic intervention for patients near the end of life. J Clin Oncol. 2005;23(24):5520–5525.
  9. 9. Hudson PL, Kristjanson LJ, Ashby M, et al. Desire for hastened death in patients with advanced disease and the evidence base of clinical guidelines: a systematic review. Palliat Med. 2006;20(1):13–24.
  10. 10. Australian Institute of Health and Welfare. Aboriginal and Torres Strait Islander Health Performance Framework: Summary report 2023. Canberra: AIHW; 2023.
  11. 11. Shahid S, Bessarab D, van Schaik KD, Aoun SM, Thompson SC. Improving palliative care outcomes for Aboriginal Australians: a communication tool to initiate discussions about end-of-life care. BMJ Support Palliat Care. 2013;3(3):324–331.
  12. 12. Royal Australian College of General Practitioners. Supportive and Palliative Care β€” RACGP White Book. 6th edn. Melbourne: RACGP; 2020.
  13. 13. Douglas HR, Halliday D, Normand C, et al. Economic evaluation of specialist palliative care: a systematic review. Palliat Med. 2003;17(4):317–327.
  14. 14. National Health and Medical Research Council. National Framework for Advance Care Planning in Australia. Canberra: NHMRC; 2021.
  15. 15. White BP, Willmott L, Close E, et al. Voluntary assisted dying in Australia: a comparative and critical analysis of state laws. UNSW Law J. 2022;45(4):1031–1067.
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

  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):760–765.
  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):60–75.
  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):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).