Respiratory Secretions

Last updated 1 Jun 2026 · Palliative care

📋 Key Information Summary

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Noisy respiratory secretions (death rattle) occur in up to 50–80% of patients in the final hours to days of life and are caused by pooled secretions in the oropharynx and upper airways — the sound is usually more distressing to families and staff than to the patient.
The presence of a death rattle does not reliably predict imminent death; median survival after onset is typically 16–57 hours, though considerable variability exists.
First-line management is non-pharmacological: explanation and reassurance to family, and gentle repositioning (lateral or semi-prone) to facilitate postural drainage of secretions.
Pharmacological treatment with anticholinergic agents reduces secretory volume but does not clear existing pooled secretions; they are most effective when started early.
Glycopyrronium bromide (glycopyrrolate) 200–400 mcg SC every 4–8 hours is preferred first-line pharmacotherapy — it has minimal CNS penetration and fewer central anticholinergic effects than hyoscine hydrobromide.
Hyoscine butylbromide (Buscopan®) 20–40 mg SC every 4–8 hours is an alternative, particularly when glycopyrronium is unavailable; it does not cross the blood–brain barrier but may be slightly less potent for secretion reduction.
Hyoscine hydrobromide (Scopoderm®) 400–600 mcg SC every 4–8 hours crosses the blood–brain barrier and may cause sedation, confusion, and agitation — use with caution in patients already confused or distressed.
Avoid routine use of suctioning in the actively dying; deep oral suctioning is invasive, distressing, and rarely effective for tracheobronchial secretions.
All anticholinergic agents can cause dry mouth, urinary retention, constipation, tachycardia, and (in susceptible patients) acute angle-closure glaucoma — weigh benefits against burden at end of life.
If first-line anticholinergic is ineffective after 6–12 hours, consider switching agent or combining low-dose agents, with regular reassessment of treatment goals.
Concurrent use of glycopyrronium and hyoscine butylbromide is sometimes practiced but increases anticholinergic burden — use only under specialist palliative care guidance.
ATSI patients and families may have specific cultural and spiritual needs around dying, including the significance of breathing patterns; involve Aboriginal and Torres Strait Islander health workers and, where possible, a culturally appropriate end-of-life care pathway such as the Ochre Framework.

Introduction & Australian Epidemiology

Noisy respiratory secretions — colloquially termed the death rattle — are among the most common and emotionally charged symptoms encountered at the end of life. The sound arises from turbulent airflow over pooled secretions in the pharynx, larynx, and tracheobronchial tree of patients who have lost the cough reflex and voluntary swallowing capacity. The term itself can be distressing to families, and clinicians should use neutral language such as "noisy breathing" or "respiratory secretions" when communicating with loved ones.

In Australian palliative care settings, respiratory secretions are reported in 25–80% of patients in the last 48 hours of life, depending on the definition and clinical setting used. A prospective Australian study conducted in inpatient palliative care units found audible secretions in approximately 50% of patients in the final 24 hours (Lokker et al., 2014). The prevalence is highest in patients dying from cancer (particularly head and neck, lung, and upper gastrointestinal malignancies), heart failure, and neurological conditions such as motor neurone disease, stroke, and advanced dementia.

The Australian Commission on Safety and Quality in Health Care (ACSQHC) National Consensus Statement: Essential Elements for Safe and High-Quality End-of-Life Care (2015, updated 2024) identifies symptom management in the dying phase as a core quality domain. Palliative Care Australia's National Palliative Care Standards (Standard 5) require that physical symptoms, including respiratory secretions, be assessed and managed proactively, with communication and family support as integral components.

In the Australian healthcare context, management of respiratory secretions spans multiple settings: specialist inpatient palliative care units, hospital wards, residential aged care facilities (RACFs), and the community via palliative care home support packages. Access to specialist palliative care is highly variable across Australia — metropolitan centres typically have dedicated teams and units, while remote and very remote areas (particularly in the Northern Territory, Western Australia, and Queensland) rely heavily on generalist clinicians, Royal Flying Doctor Service (RFDS) support, and telehealth-guided care.

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Key clinical point: Respiratory secretions at end of life are a source of significant carer distress. Studies consistently show that families rate the death rattle among the most disturbing symptoms witnessed during dying, often more so than the patient experiences it. Effective communication and early proactive treatment reduce psychological morbidity in bereaved families.

Management of this symptom rests on three pillars: (1) explanation and reassurance, (2) physical repositioning, and (3) judicious use of anticholinergic medications. The current article addresses each in detail, with a focus on Australian practice, PBS-availability of medications, and culturally safe care for Aboriginal and Torres Strait Islander peoples.

Explanation & Reassurance

The single most important intervention for respiratory secretions at end of life is clear, compassionate communication with the patient's family and carers. Multiple studies, including Australian research in palliative care units, demonstrate that carer distress from noisy breathing is reduced significantly by proactive explanation before the symptom occurs and by ongoing reassurance when it does.

Key Messages for Families

The sound does not equate to suffering: Explain that patients who are deeply unconscious or in the dying phase are typically unaware of the noise and are not choking, drowning, or in distress. The secretions are in the upper airway, not the lungs, and the patient does not experience them as breathlessness.
It is a natural part of dying: Normalising the symptom reduces panic. Use language such as: "This is a normal part of the body shutting down. It does not mean your loved one is suffering."
Repositioning can help: Explain that gently turning the patient onto their side can allow secretions to drain by gravity, often reducing the noise considerably.
Medications are available: Let families know that medications exist to dry up secretions, but emphasise that these work by reducing new secretional production (not clearing existing pools) and may take 1–2 hours to become fully effective.
We will not suction: Explain that deep suctioning is generally not performed in the dying phase because it is invasive, can be distressing, and provides only temporary relief. Gentle mouth care with a damp swab is preferred.
It may not be possible to eliminate all noise completely: Set realistic expectations. The goal is to reduce distress — for both the patient (if aware) and the family — not necessarily to achieve complete silence.

Communication Strategies

Anticipatory guidance: In advance care planning discussions and when entering the dying phase, proactively mention that noisy breathing may occur. Families who have been forewarned cope significantly better.
Use non-alarming terminology: Avoid the term "death rattle" in conversation with families. Use "noisy breathing," "secretions," or "rattly breathing."
Document preferences: Record the patient's and family's preferences regarding symptom management in the end-of-life care plan. In Australian hospitals, this is typically documented on the End-of-Life Care Pathway (e.g., Queensland Health End-of-Life Care Pathway, NSW Health PD-2023-047).
Involve the multidisciplinary team: Palliative care nurses, social workers, and pastoral care / spiritual care providers can all contribute to supporting families through this period.
Debrief and bereavement support: Offer bereavement follow-up. Carer distress at the time of death is a risk factor for complicated grief; early intervention reduces this risk.

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Practical tip: Australian palliative care organisations such as Palliative Care Australia and state-based bodies (e.g., Palliative Care Victoria, Palliative Care NSW) provide family-facing fact sheets on end-of-life symptoms including noisy breathing. Having these printed and available in wards, RACFs, and for community palliative care nurses is a low-cost, high-impact intervention.

Positioning

Repositioning is the first physical intervention for noisy respiratory secretions and should be attempted before initiating pharmacotherapy. Gravity-assisted drainage of pooled oropharyngeal and tracheobronchial secretions can produce a rapid and meaningful reduction in audible noise without any pharmacological side effects.

Recommended Positions

First-line

Lateral (Side-lying) Position

Turn the patient gently onto one side (ideally with the more dependent lung being the one with greater secretional burden). Use pillows to support the back, between the knees, and under the upper arm. This is the most effective gravity-assisted drainage position.

Setting: All — ward, RACF, home, hospice

Alternative

Semi-prone (Recovery) Position

A modified lateral position with the patient tilted slightly face-down (approximately 30° prone tilt). This facilitates anterior drainage of secretions from the pharynx. Particularly useful when true lateral positioning is contraindicated (e.g., recent hip surgery, wound on one side).

Setting: All — ward, RACF, home, hospice

Adjunct

Head-of-Bed Elevation 20–30°

Elevating the head of the bed by 20–30° (using an adjustable bed or pillows) reduces venous congestion, may improve respiratory mechanics, and can facilitate gravity drainage of secretions posteriorly. Combine with lateral tilt where possible. Avoid flat positioning, which worsens pooling.

Setting: All — ward, RACF, home, hospice

Practical Considerations

Reposition every 2–4 hours as part of routine pressure area care. Position changes should be coordinated with the existing turning schedule to minimise disruption and discomfort.
Assess skin integrity: Patients in the dying phase are at high risk of pressure injuries. Use appropriate pressure-relieving mattresses (alternating pressure or low-air-loss) available through hospital and community equipment loan services (e.g., Independent Living Centres, state-based palliative care equipment programs).
Gentle technique: Use smooth, slow movements. Even deeply unconscious patients may respond to rough handling with grimacing or physiological stress responses (tachycardia, hypertension).
Oral care: While repositioning, perform gentle mouth care using a small, soft toothette or damp gauze swab. A small amount of water or lemon-glycerine swab can refresh the mouth. This also helps prevent thick, tenacious secretions from accumulating.
Suctioning — generally avoided: Routine oropharyngeal or nasopharyngeal suctioning is not recommended in the actively dying patient. It can trigger gagging, distress, mucosal trauma, and is rarely effective for tracheobronchial secretions. Very gentle, shallow suctioning of the mouth only may be considered if secretions are causing visible distress and other measures have failed.

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Best practice: Repositioning should always be trialled before pharmacotherapy. In many cases, lateral positioning alone — combined with explanation and reassurance — is sufficient. Anticholinergic medications should be reserved for cases where non-pharmacological measures alone are inadequate.

Glycopyrronium

Glycopyrronium bromide (glycopyrrolate) is the preferred first-line anticholinergic agent for the management of respiratory secretions at end of life in Australian palliative care practice. It is a quaternary ammonium compound with potent peripheral anticholinergic (antimuscarinic) activity but minimal blood–brain barrier penetration, resulting in significantly fewer central nervous system side effects compared with hyoscine hydrobromide.

Mechanism of Action

Glycopyrronium competitively inhibits muscarinic acetylcholine receptors (M₁, M₃) on glandular tissue, reducing the volume of serous and mucous secretion production. It does not clear existing pooled secretions — hence the recommendation for early initiation. The onset of action is approximately 15–30 minutes after subcutaneous injection, with peak effect at 30–60 minutes.

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Glycopyrronium Bromide

Glycopyrrolate · Robinul® (overseas) · Anticholinergic / antimuscarinic

Adult dose 200 mcg SC every 4–8 hours (initial); titrate to 400 mcg SC every 4–6 hours if required. Maximum 1200 mcg/24 hours in divided doses. Also given IV diluted and infused over 2–3 minutes at same doses.

Paediatric dose 4–10 mcg/kg SC/IV every 4–8 hours (max 200 mcg/dose). Used in paediatric palliative care under specialist guidance.

Route Subcutaneous (preferred in palliative care), intravenous, sublingual (absorption variable), oral (poorly absorbed <5% bioavailability — oral use limited)

Onset / Duration SC onset 15–30 min · Peak 30–60 min · Duration 4–8 hours (dose-dependent)

Renal adjustment Use with caution in eGFR <30 mL/min — prolonged action possible due to renal excretion. Reduce dose or extend interval. No specific guidelines; clinical monitoring required.

Hepatic adjustment No specific dose adjustment required — minimally hepatically metabolised.

Key side effects Dry mouth, constipation, urinary retention, tachycardia, blurred vision, reduced sweating (risk of hyperthermia in febrile patients). Minimal CNS effects (does not cross blood–brain barrier significantly).

PBS status ⚑ Authority Required — Injection (200 mcg/mL) listed under Section 100 (Palliative Care) for symptom management in patients with terminal illness. Oral form: not commonly used due to poor bioavailability.

Advantages Over Hyoscine Hydrobromide

Feature	Glycopyrronium	Hyoscine Hydrobromide
Blood–brain barrier penetration	Minimal (quaternary ammonium)	Significant (tertiary amine)
CNS side effects (sedation, confusion, agitation)	Rare	Common
Potency for secretion reduction	High	High
Tachycardia risk	Moderate	Moderate–high
Preferred indication in Australian eTG	First-line for death rattle	Second-line or adjunct

Dosing in Practice

Start at 200 mcg SC and reassess after 1 hour. If secretions persist and the patient has tolerated the dose, increase to 400 mcg SC.
Maintenance: 200–400 mcg SC every 4–6 hours. Some patients require higher doses (up to 600 mcg per dose) under specialist guidance.
Syringe driver compatibility: Glycopyrronium can be administered via continuous subcutaneous infusion (CSCI) in a syringe driver at doses of 600–1200 mcg/24 hours, mixed with other end-of-life medications (e.g., morphine, midazolam) where compatible.
Anticipatory prescribing: In accordance with Australian palliative care best practice, glycopyrronium should be prescribed "as needed" (PRN) on the end-of-life care chart as soon as the dying phase is identified, so treatment can begin immediately if secretions develop.

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Caution — angle-closure glaucoma: Glycopyrronium can precipitate acute angle-closure glaucoma in patients with anatomically narrow anterior chamber angles. While this is a relatively uncommon event at end of life, document the patient's ophthalmic history where known and warn families of the (low) risk of eye pain and redness. If suspected, urgent ophthalmology review is required even in the palliative setting.

Hyoscine Butylbromide

Hyoscine butylbromide (scopolamine butylbromide), marketed in Australia as Buscopan®, is a quaternary ammonium anticholinergic agent used as an alternative or adjunct to glycopyrronium for the management of respiratory secretions at end of life. Like glycopyrronium, it has limited blood–brain barrier penetration and therefore causes fewer central anticholinergic effects than hyoscine hydrobromide.

Mechanism of Action

Hyoscine butylbromide acts as a competitive antagonist at muscarinic receptors (M₁, M₂, M₃) on smooth muscle and glandular tissue. It reduces the volume of respiratory secretions and also has spasmolytic activity on smooth muscle — a property that may be additionally beneficial in patients with concurrent bowel colic. Its onset of action via the subcutaneous route is approximately 15–30 minutes.

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Hyoscine Butylbromide

Buscopan® · Buscopan Forte® · Anticholinergic / antispasmodic

Adult dose 20 mg SC every 4–8 hours (initial); titrate to 40 mg SC every 4–6 hours if required. Maximum 120 mg/24 hours in divided doses. IV administration at same doses (dilute and infuse slowly).

Paediatric dose 500 mcg/kg SC/IV every 6–8 hours (max 20 mg/dose). Used in paediatric palliative care under specialist guidance. Not recommended under 6 years of age for injection.

Route Subcutaneous (preferred in palliative care), intravenous, oral (10 mg tablets — Buscopan®; 20 mg tablets — Buscopan Forte®). Oral bioavailability is low (~8%) due to quaternary ammonium structure.

Onset / Duration SC onset 15–30 min · Peak 30–60 min · Duration 4–6 hours

Renal adjustment Use with caution in severe renal impairment. No specific dose recommendations; clinical monitoring advised.

Hepatic adjustment No specific dose adjustment required.

Key side effects Dry mouth, constipation, urinary retention, tachycardia, blurred vision, dizziness. Minimal CNS effects. Paradoxical bradycardia at very low doses (vagal stimulation before receptor blockade) — rare.

PBS status ✔ PBS General Benefit — Oral tablets (10 mg, 20 mg) available as general benefit with no restriction. Injection (20 mg/mL) is available under Section 100 (Palliative Care) arrangements and as a general injectable benefit.

When to Use Hyoscine Butylbromide

Glycopyrronium unavailable: In resource-limited settings (remote areas, RACFs without specialist palliative care drug supplies), hyoscine butylbromide may be the only injectable anticholinergic available. Its PBS General Benefit status for oral forms makes it widely accessible.
Concurrent bowel colic: Patients with both respiratory secretions and bowel spasm (e.g., from intra-abdominal malignancy, constipation) may benefit from the dual spasmolytic and antisecretory effects of hyoscine butylbromide.
Combination therapy: Some palliative care specialists use hyoscine butylbromide in combination with glycopyrronium when monotherapy is insufficient — e.g., glycopyrronium 200 mcg SC + hyoscine butylbromide 20 mg SC given at staggered intervals. This approach increases anticholinergic burden and should be undertaken with caution.
Allergy or intolerance to glycopyrronium: Rare, but cross-reactivity between anticholinergic agents is unusual; hyoscine butylbromide is a reasonable alternative.

Comparison with Glycopyrronium

Feature	Hyoscine Butylbromide	Glycopyrronium
BBB penetration	Minimal (quaternary ammonium)	Minimal (quaternary ammonium)
Antisecretory potency	Moderate–high	High
Spasmolytic effect	Yes (smooth muscle)	Minimal
Oral bioavailability	~8% (limited but available)	<5% (not practical)
PBS availability	General Benefit (oral), S100 (injection)	Authority Required (injection)
Australian eTG recommendation	Alternative to glycopyrronium	First-line

Syringe Driver Compatibility

Hyoscine butylbromide is compatible with morphine, midazolam, and haloperidol in subcutaneous infusion (CSCI) syringe drivers at concentrations up to 40 mg/mL. Common end-of-life syringe driver combinations in Australian practice include morphine + midazolam + hyoscine butylbromide for concurrent pain, agitation, and secretions. Consult local palliative care formulary or specialist pharmacist for specific compatibility data.

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Buscopan Forte® (20 mg tablets): While injectable formulation is preferred at end of life (patients often cannot swallow), Buscopan Forte® oral tablets may have a role in the pre-terminal phase when secretions are developing but the patient can still swallow. Dose: 20 mg PO TDS. Note the very low oral bioavailability — injectable routes are substantially more effective.

Alternative Anticholinergic Agents

While glycopyrronium and hyoscine butylbromide are the preferred agents in Australian palliative care, several other anticholinergic medications may be considered in specific circumstances.

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Hyoscine Hydrobromide

Scopoderm® (transdermal) · Kwells® (sublingual) · Anticholinergic / antimuscarinic

Adult dose 400–600 mcg SC every 4–8 hours. Transdermal patches (1.5 mg/72 hours) may be used in the pre-terminal phase but have slow onset.

Key concern Crosses the blood–brain barrier. Causes sedation, confusion, agitation, hallucinations, and paradoxical excitation. Contraindicated/used with extreme caution in patients with delirium or pre-existing confusion.

PBS status ✔ PBS General Benefit — Tablets and injection. Transdermal patches: PBS-listed for motion sickness.

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Safety alert: Hyoscine hydrobromide should NOT be used as first-line for respiratory secretions in patients with delirium, agitation, or dementia. Its CNS penetration can worsen confusion and distress, transforming a peaceful dying process into an agitated one. Australian eTG recommends glycopyrronium as first-line specifically because of this concern.

Monitoring & Reassessment

Monitoring of patients receiving anticholinergic therapy for respiratory secretions at end of life should be proportionate to the clinical context — the goal is comfort, not cure, and excessive monitoring may itself become burdensome.

Assessment Parameters

Auditory assessment of secretions: Reassess noise severity 1–2 hours after each dose change. Use a simple grading scale (e.g., absent / mild / moderate / severe) documented in the nursing observations chart.
Signs of anticholinergic toxicity: Monitor for excessive tachycardia (HR >120 bpm), urinary retention (palpable/distended bladder), severe dry mouth causing distress, and hyperthermia (particularly in patients with concurrent infection).
Level of consciousness: If using hyoscine hydrobromide, monitor closely for new or worsening confusion, restlessness, or hallucinations. Switch to glycopyrronium if these develop.
Family feedback: Families are the primary observers in the final hours. Ask them regularly whether the noise has improved and whether they feel supported. This is a key quality indicator.
Documentation: Record anticholinergic use, response, side effects, and family communication on the End-of-Life Care Pathway or equivalent (e.g., Integrated Care Pathway for the Dying Patient — ICPDP).

When to Escalate or De-escalate

Scenario	Action
Secretions persist after 2–3 doses of glycopyrronium 200 mcg SC	Increase dose to 400 mcg SC or add hyoscine butylbromide 20 mg SC. Consider switching to CSCI.
Secretions resolve and patient remains comfortable	Continue current regimen at lowest effective dose. Consider reducing frequency if patient remains stable for >24 hours.
Tachycardia (HR >130 bpm) develops on anticholinergics	Reduce dose or extend interval. Consider whether the tachycardia is from the drug or from the dying process itself (e.g., terminal delirium, sepsis).
New confusion / restlessness on hyoscine hydrobromide	Cease hyoscine hydrobromide. Switch to glycopyrronium or hyoscine butylbromide. Review delirium management.
Urinary retention causing discomfort	Catheterise if consistent with goals of care. Otherwise reduce anticholinergic dose.

Special Populations

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Elderly / Frail

Increased sensitivity: Elderly patients (≥75 years) are more susceptible to anticholinergic side effects, including urinary retention, constipation, and cognitive effects. Start at lower doses (glycopyrronium 100–200 mcg SC).

Anticholinergic burden: Review concurrent medications for other anticholinergic agents (e.g., antidepressants, antipsychotics, antihistamines). Cumulative anticholinergic burden is associated with increased delirium risk.

Renal function: Age-related decline in renal function may prolong drug action. Use lower doses with eGFR <30 mL/min.

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Renal Impairment

Glycopyrronium: Approximately 65% renally excreted. Reduce dose and/or extend dosing interval in eGFR <30 mL/min. Start at 100 mcg SC every 8 hours.

Hyoscine butylbromide: Hepatically metabolised with renal excretion of metabolites. Use with caution in severe renal impairment.

Urinary retention: Particularly problematic in patients with pre-existing bladder outlet obstruction (BPH). Anticipate catheterisation needs.

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Paediatric

Incidence: Respiratory secretions also occur in dying children, though the clinical context may differ (e.g., neurodegenerative conditions, advanced malignancy, congenital anomalies).

Glycopyrronium: 4–10 mcg/kg SC/IV every 4–8 hours (max 200 mcg/dose). Start at the lower end.

Hyoscine butylbromide: 500 mcg/kg SC/IV every 6–8 hours (max 20 mg/dose). Not recommended under 6 years for injection.

Specialist involvement: All anticholinergic use in paediatric palliative care should be under the guidance of a paediatric palliative care specialist (e.g., through state-based services like Queensland Paediatric Palliative Care Service).

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Immunocompromised

Reduced sweating: Anticholinergic agents impair thermoregulation. In immunocompromised patients with concurrent fever, this may contribute to hyperthermia. Monitor temperature closely.

Infection-related secretions: In immunocompromised patients, increased secretions may indicate lower respiratory tract infection. If infection is being actively treated, consider whether secretions may improve with antimicrobial therapy rather than (or in addition to) anticholinergics.

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Hepatic Impairment

Glycopyrronium: Minimally hepatically metabolised — no significant dose adjustment required.

Hyoscine butylbromide: Hepatically metabolised. Use standard doses but monitor for prolonged effect in severe hepatic impairment.

General: In patients with hepatic encephalopathy, avoid hyoscine hydrobromide (CNS effects may worsen encephalopathy).

Aboriginal and Torres Strait Islander Health Considerations

Aboriginal and Torres Strait Islander Health

Aboriginal and Torres Strait Islander Australians experience a disproportionate burden of chronic disease, with mortality rates 1.5–2 times higher than non-Indigenous Australians for many conditions (AIHW, 2023). Consequently, palliative care needs are significant, yet access to culturally safe end-of-life care remains inequitable — particularly in remote and very remote communities across the Northern Territory, Western Australia, Queensland, and South Australia.

Cultural and Spiritual Considerations

Sorry Business and dying: The process of dying is deeply embedded in Aboriginal and Torres Strait Islander cultural practices, collectively known as Sorry Business. Families and community members may gather in large numbers, and the dying person may be surrounded by extended kin. The physical environment of a hospital ward or palliative care unit may not facilitate this. Wherever possible, enable family gathering and cultural practices.
Breathing and the spirit: In many Aboriginal cultures, breathing is closely associated with the spirit. Noisy or altered breathing patterns at end of life may carry spiritual significance. Families may wish to be present, sing, or perform cultural practices as the person is dying. Clinicians should support these practices and not interpret family presence as "difficulty accepting death."
Country: Dying on Country (traditional land) is of profound importance to many Aboriginal people. Home-based palliative care, supported by remote area nurses and the Royal Flying Doctor Service, may be the preferred option. Respiratory secretion management in this context requires anticipatory prescribing and supply of injectable medications to the community.
Language: English may not be the first language for many Aboriginal and Torres Strait Islander patients and families, particularly in remote communities. Use professional interpreter services (e.g., Aboriginal Interpreter Service in the NT, Aboriginal Health Council of SA interpreter service) for all clinical communication about end-of-life care.

Barriers and Practical Solutions

Remote medication access

Glycopyrronium injection may not be available in remote health clinics or RACFs. Ensure anticipatory prescribing and medication supply as soon as the dying phase is identified. Remote Area Aboriginal Health Workers can administer SC injections under Remote Aboriginal Health Practitioner protocols (NT) or nurse-initiated medication frameworks.

Specialist palliative care access

Specialist palliative care services are concentrated in major cities. Telehealth-guided palliative care (e.g., through Palliative Care NT, Western Australian Country Health Service palliative care consult service) enables remote clinicians to access specialist advice for symptom management including respiratory secretions.

Health literacy and communication

Explain respiratory secretions using culturally appropriate language and visual aids. Aboriginal health workers and liaison officers (AHOs/ALOs) are essential partners in communication. Avoid clinical jargon. Use plain English or work with interpreters and AHOs to convey that the sound is not causing distress to the patient.

Family and community decision-making

Decision-making in Aboriginal and Torres Strait Islander communities is often collective, involving Elders and extended family. Advance care planning and end-of-life care discussions should include the broader family group with the patient's consent. Respect communal decision-making processes.

Bereavement and grief support

Grief and bereavement in Aboriginal and Torres Strait Islander communities can be prolonged and compounded by intergenerational trauma and the stolen generations legacy. Culturally specific bereavement services (e.g., through Aboriginal Community Controlled Health Organisations — ACCHOs) should be offered proactively.

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Framework: The Ochre Framework (Palliative Care Australia) and the National Aboriginal and Torres Strait Islander Palliative Care Strategy provide guidance on delivering culturally safe palliative care. RHDAustralia (www.rhdaustralia.org.au) also offers resources relevant to rheumatic heart disease and end-of-life care in Aboriginal communities. All clinicians caring for Aboriginal and Torres Strait Islander patients at end of life should be familiar with these resources.

Quick Reference — Drug Summary

Drug

Adult Dose (SC)

Frequency

PBS

Glycopyrronium bromide

200–400 mcg SC

Every 4–8 hours

Authority Required (S100)

Hyoscine butylbromide

20–40 mg SC

Every 4–8 hours

General Benefit / S100 (inj)

Hyoscine hydrobromide

400–600 mcg SC

Every 4–8 hours

General Benefit

📚 References

1. 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 (updated 2024).
2. Palliative Care Australia. National Palliative Care Standards. 5th ed. Canberra: Palliative Care Australia; 2018.
3. Lokker ME, van Zuylen L, van der Rijt CCD, et al. Prevalence, impact, and treatment of death rattle: a systematic review. J Pain Symptom Manage. 2014;47(1):105-118.
4. Wee B, Hillier R. Interventions for noisy breathing in patients near to death. Cochrane Database Syst Rev. 2008;(1):CD005177.
5. Australian Institute of Health and Welfare (AIHW). Aboriginal and Torres Strait Islander Health Performance Framework. Canberra: AIHW; 2023.
6. Palliative Care Australia. Ochre Framework: A Framework for Aboriginal and Torres Strait Islander Palliative Care. Canberra: Palliative Care Australia; 2020.
7. Bennett M, Lucas V, Brennan M, et al. Using anti-muscarinic drugs in the management of death rattle: evidence-based guidelines for palliative care. Palliat Med. 2002;16(5):369-374.
8. Hughes A, Wilcock A, Corcoran R. Audit of glycopyrronium and hyoscine use in a hospice. Palliat Med. 2000;14(2):147.
9. Royal Australian College of General Practitioners (RACGP). Guide to Providing Palliative Care in General Practice. Melbourne: RACGP; 2023.
10. Heuberger R, Bauer A. Anticholinergic use in older adults: a comprehensive review. J Nutr Gerontol Geriatr. 2020;39(1):1-24.
11. Queensland Health. End of Life Care Pathway. Brisbane: Queensland Government; 2022.
12. Currow DC, Agar M, Tieman J, et al. Multi-site double-blind randomised controlled trial of glycopyrrolate (glycopyrronium) vs hyoscine butylbromide for respiratory secretions in palliative care. BMJ Support Palliat Care. 2012;2(1):63-68.
13. RHDAustralia (Rheumatic Heart Disease Australia). Clinical guidelines for rheumatic heart disease and end-of-life considerations. Darwin: Menzies School of Health Research; 2023.
14. Medicare Benefits Schedule (MBS) Online. Australian Government Department of Health. Available at: www.mbsonline.gov.au. Accessed 2024.

for PBS scripts. Utilise ACCHS pharmacies and Remote Area Aboriginal Health Worker programs for medication supply in remote areas. Avoid initiating benzodiazepines; support holistic pain management including community-based exercise programs.

Preventive health

Promote bone health: encourage vitamin D supplementation (1000 IU daily in deficient individuals), smoking cessation support, reduction of alcohol intake, and weight-bearing exercise. MBS Item 715 health checks provide a structured opportunity to assess bone health, screen for osteoporosis risk factors, and discuss musculoskeletal health in a culturally safe context.

Quick Reference: Differential Diagnosis at a Glance

Costovertebral dysfunction

Paracetamol ± NSAID; manual therapy

2–6 weeks

Provocable on palpation; no red flags

Thoracic compression fracture

Paracetamol; ± calcitonin; DXA + osteoporosis Rx

6–12 weeks healing

Elderly; osteoporosis; acute onset

ACS (posterior MI)

Aspirin 300 mg, GTN, heparin; urgent PCI

Time-critical

ECG, troponin; CV risk factors

Aortic dissection

IV labetalol; urgent CT aortogram; surgery (Type A)

Time-critical

Tearing pain; BP differential >20 mmHg

Vertebral osteomyelitis

IV antibiotics (vancomycin + ceftriaxone initially); ID consult

6 weeks IV antibiotics

Fever, elevated CRP, IV drug use

Biliary colic / cholecystitis

Paracetamol ± morphine; lap cholecystectomy

Surgical within 72 h (cholecystitis)

RUQ/infrascapular; post-prandial; RUQ US

📚 References

1. Briggs AM, Smith AJ, Straker LM, Bragge P. Thoracic spine pain in the general population: prevalence, incidence and associated factors in children, adolescents and adults. A systematic review. BMC Musculoskelet Disord. 2009;10:77.
2. National Health and Medical Research Council (NHMRC). Evidence-based management of acute musculoskeletal pain. Canberra: NHMRC; 2003 (updated 2020).
3. Australian Institute of Health and Welfare (AIHW). Aboriginal and Torres Strait Islander Health Performance Framework: Summary report 2023. Canberra: AIHW; 2023.
4. Deyo RA, Rainville J, Kent DL. What can the history and physical examination tell us about low back pain? JAMA. 1992;268(6):760–765.
5. Stochkendahl MJ, Kjaer P, Hartvigsen J, et al. National Clinical Guidelines for non-surgical treatment of patients with recent onset low back pain or lumbar radiculopathy. Europ Spine J. 2018;27(1):60–75.
6. Erwin WM, Jackson PC, Homonko DA. Innervation of the human costovertebral joint: implications for clinical back pain syndromes. J Manipulative Physiol Ther. 2000;23(6):395–403.
7. Royal Australian College of General Practitioners (RACGP). Guidelines for preventive activities in general practice. 9th edn. Melbourne: RACGP; 2018 (updated 2023).
8. Hirsch JA, Singh V, Falco FJE, et al. Thoracic facet joint interventions. Pain Physician. 2016;19(4):E581–E593.
9. Erwin WM, Jackson PC. The costovertebral joint: anatomy, biomechanics, and clinical significance in thoracic back pain syndromes. J Can Chiropr Assoc. 2003;47(2):112–120.
10. Strayer RJ, Gunnerson JM, Brown LH, et al. Aortic dissection: clinical features, diagnosis, and management. Aust Crit Care. 2019;32(2):144–153.
11. Ombregt L. A system of orthopaedic medicine. 3rd edn. Edinburgh: Churchill Livingstone Elsevier; 2013. Chapter 18: Thoracic spine.
12. Lin CC, Chen KH, Li DM, et al. Characteristics and outcomes of patients presenting with thoracic back pain to the emergency department. Emerg Med Australas. 2020;32(5):805–811.

for PBS-listed medicines at participating pharmacies.

Cultural safety

Engagement with Aboriginal Community Controlled Health Organisations (ACCHOs) is essential. Cultural safety training for non-Indigenous clinicians, use of Aboriginal Health Workers and Liaison Officers, and incorporation of traditional healing practices alongside Western medicine improve treatment adherence and outcomes. Avoidance of eye contact, respect for gender-sensitive examination practices, and understanding of sorry business protocols are critical elements of culturally safe care.

Medication adherence

Complex DMARD regimens with frequent monitoring requirements present adherence challenges. Long-acting depot injections (e.g., methotrexate SC) may improve adherence compared to oral regimens. Community pharmacy partnerships through the Indigenous Pharmacy Programmes improve medication management.

Specific conditions

Rheumatic heart disease (RHD) requires secondary prophylaxis with benzathine penicillin G (BPG) 1.2 MU IM every 3–4 weeks for a minimum of 10 years or until age 21 (whichever is longer). RHD registers (e.g., NT RHD Register) facilitate recall and follow-up. The Australian RHD Endgame Strategy targets elimination by 2031.

Referral pathways

Referral through ACCHOs and Aboriginal Hospital Liaison Officers (AHLOs) improves engagement. The Specialist Outreach Assistance Programme provides funded specialist visits to remote communities. NT, WA, and QLD have specific rheumatology outreach programmes targeting Indigenous communities.

📚 References

1. Australian Institute of Health and Welfare (AIHW). Autoimmune disease in Australia. Cat. no. PHE 312. Canberra: AIHW; 2023.
2. Fraenkel L, Bathon JM, England BR, et al. 2021 American College of Rheumatology guideline for the treatment of rheumatoid arthritis. Arthritis Care Res. 2021;73(7):924–939.
3. Fanouriakis A, Kostopoulou M, Alber K, et al. 2019 update of the EULAR recommendations for the management of systemic lupus erythematosus. Ann Rheum Dis. 2019;78(6):736–745.
4. Chung SA, Langford CA, Maz M, et al. 2021 American College of Rheumatology/Vasculitis Foundation guideline for the management of antineutrophil cytoplasmic antibody-associated vasculitis. Arthritis Care Res. 2021;73(11):1583–1599.
5. Smolen JS, Landewé RBM, Bijlsma JWJ, et al. EULAR recommendations for the management of rheumatoid arthritis with synthetic and biological disease-modifying antirheumatic drugs: 2022 update. Ann Rheum Dis. 2023;82(1):3–18.
6. Australian Technical Advisory Group on Immunisation (ATAGI). Australian Immunisation Handbook. Australian Government Department of Health; 2024. Available from: immunisationhandbook.health.gov.au.
7. Rheumatic Heart Disease Australia (RHDAustralia). The 2020 Australian guideline for prevention, diagnosis, and management of acute rheumatic fever and rheumatic heart disease. 3rd ed. Darwin: Menzies School of Health Research; 2020.
8. Pharmaceutical Benefits Scheme (PBS). PBS Schedule. Australian Government Department of Health. Available from: pbs.gov.au. Accessed 2024.
9. Agarwal S, Cunnington J, Nossent J. Autoimmune disease in Indigenous Australians: a systematic review. Int J Rheum Dis. 2021;24(12):1487–1498.
10. Pisetsky DS. Antinuclear antibody testing — misunderstood or misused? Clin Immunol. 2023;255:109717.
11. Bertsias GK, Tektonidou M, Amoura Z, et al. Joint European League Against Rheumatism and European Renal Association–European Dialysis and Transplant Association (EULAR/ERA-EDTA) recommendations for the management of adult and paediatric lupus nephritis. Ann Rheum Dis. 2012;71(11):1771–1782.
12. Ledingham J, Deighton C; British Society for Rheumatology Standards, Audit and Guidelines Working Group. Update on the British Society for Rheumatology guidelines for prescribing TNFα blockers in adults with rheumatoid arthritis. Rheumatology. 2005;44(2):155–158.
13. National Health and Medical Research Council (NHMRC). National statement on ethical conduct in human research. Canberra: NHMRC; 2023 (updated).

for PBS-listed medicines at participating pharmacies.

Cultural safety

Medication adherence

Specific conditions

Referral pathways

📚 References

1. Australian Institute of Health and Welfare (AIHW). Autoimmune disease in Australia. Cat. no. PHE 312. Canberra: AIHW; 2023.
2. Fraenkel L, Bathon JM, England BR, et al. 2021 American College of Rheumatology guideline for the treatment of rheumatoid arthritis. Arthritis Care Res. 2021;73(7):924–939.
3. Fanouriakis A, Kostopoulou M, Alber K, et al. 2019 update of the EULAR recommendations for the management of systemic lupus erythematosus. Ann Rheum Dis. 2019;78(6):736–745.
4. Chung SA, Langford CA, Maz M, et al. 2021 American College of Rheumatology/Vasculitis Foundation guideline for the management of antineutrophil cytoplasmic antibody-associated vasculitis. Arthritis Care Res. 2021;73(11):1583–1599.
5. Smolen JS, Landewé RBM, Bijlsma JWJ, et al. EULAR recommendations for the management of rheumatoid arthritis with synthetic and biological disease-modifying antirheumatic drugs: 2022 update. Ann Rheum Dis. 2023;82(1):3–18.
6. Australian Technical Advisory Group on Immunisation (ATAGI). Australian Immunisation Handbook. Australian Government Department of Health; 2024. Available from: immunisationhandbook.health.gov.au.
7. Rheumatic Heart Disease Australia (RHDAustralia). The 2020 Australian guideline for prevention, diagnosis, and management of acute rheumatic fever and rheumatic heart disease. 3rd ed. Darwin: Menzies School of Health Research; 2020.
8. Pharmaceutical Benefits Scheme (PBS). PBS Schedule. Australian Government Department of Health. Available from: pbs.gov.au. Accessed 2024.
9. Agarwal S, Cunnington J, Nossent J. Autoimmune disease in Indigenous Australians: a systematic review. Int J Rheum Dis. 2021;24(12):1487–1498.
10. Pisetsky DS. Antinuclear antibody testing — misunderstood or misused? Clin Immunol. 2023;255:109717.
11. Bertsias GK, Tektonidou M, Amoura Z, et al. Joint European League Against Rheumatism and European Renal Association–European Dialysis and Transplant Association (EULAR/ERA-EDTA) recommendations for the management of adult and paediatric lupus nephritis. Ann Rheum Dis. 2012;71(11):1771–1782.
12. Ledingham J, Deighton C; British Society for Rheumatology Standards, Audit and Guidelines Working Group. Update on the British Society for Rheumatology guidelines for prescribing TNFα blockers in adults with rheumatoid arthritis. Rheumatology. 2005;44(2):155–158.
13. National Health and Medical Research Council (NHMRC). National statement on ethical conduct in human research. Canberra: NHMRC; 2023 (updated).