📋 Key Information Summary
- Subcutaneous (SC) administration is the preferred alternative when the oral route is unreliable — nausea/vomiting, dysphagia, reduced consciousness, or the last days of life.
- Intermittent SC injection provides rapid symptom relief (onset 10–30 min) and is suited to breakthrough or PRN dosing.
- Continuous subcutaneous infusion (CSCI) via syringe driver (e.g., McKinley T34™ or Graseby™) delivers stable plasma levels over 24 hours and is the standard for refractory symptoms in Australian palliative care.
- Recommended SC sites: anterior thigh (upper outer), anterior abdominal wall (below costal margin), upper arm (lateral/posterior), and upper chest/infraclavicular fossa — rotate every 3–7 days.
- The most commonly used CSCI drugs in Australian hospice practice are morphine (opioid), midazolam (sedation/anxiety), haloperidol (nausea/delirium), hyoscine butylbromide (secretions), and dexamethasone (anti-inflammatory).
- Drug compatibility in CSCI is critical — always check a current compatibility chart before mixing; avoid combining drugs that precipitate or degrade together.
- Morphine SC dose is generally equivalent to oral dose when switching; however, use 50–75% of oral dose if renal impairment is present.
- Common syringe driver volumes: 20 mL (McKinley T34) or 24 mL (Graseby MS26) delivering over 24 hours; most infusions use 5–15 mL total volume.
- Never use the SC route for drugs requiring large volumes (>5 mL/hour), vesicant agents, or highly irritant formulations — tissue necrosis may result.
- Subcutaneous lines require minimal nursing care: assess insertion site twice daily for erythema, swelling, or leakage; change site if discomfort or signs of local infection develop.
- Aboriginal and Torres Strait Islander peoples may face barriers to timely SC palliative care in remote communities — plan ahead with local health services and consider telehealth specialist input.
- PBS Authority items apply to many SC opioids; ensure correct authority documentation for opioid prescriptions under the PBS Palliative Care Schedule.
Introduction & Australian Context
Subcutaneous (SC) drug administration is a cornerstone of symptom management in palliative care. It encompasses both intermittent subcutaneous injections (bolus doses given via a needle or butterfly cannula) and continuous subcutaneous infusions (CSCI) delivered via a syringe driver over a set period, most commonly 24 hours. The SC route is the preferred parenteral alternative when the oral or sublingual route becomes impractical due to nausea, vomiting, bowel obstruction, dysphagia, reduced consciousness, or mucositis.
In Australia, SC administration is used extensively across hospice, inpatient palliative care units, hospital consultative palliative care services, and community/home-based palliative care programmes. The 2023 Australian Institute of Health and Welfare (AIHW) report on palliative care services indicated that approximately 60–70% of patients receiving specialist palliative care in the last week of life require at least one parenteral route of drug delivery, with the SC route being overwhelmingly preferred over intravenous access for its simplicity, safety, and suitability in the community setting.
Syringe drivers such as the McKinley T34™ and Graseby MS26™ are the most widely used devices in Australian palliative care. These portable ambulatory infusion pumps allow patients to remain mobile or be managed at home with regular community nursing support. The Royal Australian College of General Practitioners (RACGP) and Palliative Care Australia recommend that all GPs and community nurses caring for patients at end of life be competent in syringe driver setup, drug conversion calculations, and site management.
Clinical key: SC administration should not be considered a "last resort" — it is a proactive, effective route that should be initiated early when oral intake becomes unreliable, to avoid gaps in symptom control during a vulnerable period.
Indications for Subcutaneous Administration
The SC route is indicated whenever oral, sublingual, or transdermal routes are insufficient, impractical, or contraindicated. In palliative care, common indications include:
Indications for Intermittent SC Injection
- Breakthrough pain or symptom crises — rapid onset (10–30 minutes) makes SC bolus ideal for acute symptom episodes (e.g., breakthrough cancer pain, acute dyspnoea, terminal restlessness).
- Nausea and vomiting preventing oral medication retention (e.g., haloperidol 0.5–1 mg SC, metoclopramide 10 mg SC).
- Acute episodes of delirium or agitation requiring prompt anxiolysis (e.g., midazolam 2.5–5 mg SC).
- Intermittent symptom needs where a syringe driver is not yet warranted — e.g., PRN opioid doses every 4 hours.
- Patients declining IV access or where IV access is technically difficult (poor veins, coagulopathy, patient preference).
Indications for Continuous Subcutaneous Infusion (CSCI)
- Persistent symptoms uncontrolled by intermittent SC dosing — continuous opioid infusion for pain, continuous midazolam for anxiety or dyspnoea.
- Last days of life — patients in the terminal phase who can no longer swallow reliably; CSCI provides seamless symptom management (Palliative Care Australia, 2023).
- Complex multi-symptom management — when two or more drugs are needed continuously and can be co-infused safely.
- Opioid rotation situations — when converting from one opioid to another and a parenteral loading/continuous delivery is needed during transition.
- Patients at home who need stable drug delivery without repeated injections — syringe drivers are set up by community palliative care nurses.
- Bowel obstruction where oral/sublingual routes are unreliable and long-term IV access is not desirable.
Australian practice tip: Many Australian palliative care services initiate a CSCI proactively when the clinical trajectory suggests the patient will lose oral access within 24–48 hours. This avoids emergency syringe driver setups and medication gaps during symptom crises.
Situations Where SC Is Contraindicated or Unreliable
- Severe oedema, anasarca, or morbid obesity — erratic SC absorption; consider IV or alternative routes.
- Coagulopathy or thrombocytopenia (INR >3, platelets <20 × 10⁹/L) — risk of haematoma at injection site.
- Extensive skin disease, burns, or cellulitis at potential SC sites.
- Peripheral shutdown / severe peripheral vasoconstriction in the terminal phase — very poor absorption; intranasal or sublingual may be preferable for last-dose medications.
- Vesicant or highly irritant drugs — never administer via SC route (e.g., doxorubicin, phenytoin IV formulation).
Cannula Sites
Appropriate site selection for SC cannulation maximises drug absorption, minimises local complications, and improves patient comfort. The choice of site depends on patient habitus, tissue perfusion, skin integrity, and whether the infusion is for intermittent or continuous use.
Recommended SC Sites
| Site | Location | Advantages | Considerations |
|---|---|---|---|
| Anterior abdominal wall | Below costal margin, lateral to midline, above iliac crests | Good absorption; ample tissue in most patients; easy to access; patient can lie supine | Avoid in ascites; avoid near stoma sites, surgical scars, or recent radiotherapy fields |
| Anterior/lateral thigh | Upper outer third of anterior thigh | Large surface area; good tissue perfusion; well tolerated | Avoid inner thigh (risk of femoral vessel injury); may be inaccessible in patients with limited mobility or hip contractures |
| Upper arm | Lateral or posterior aspect of upper arm, deltoid region | Convenient; patient can self-monitor | Less subcutaneous tissue in cachexic patients; avoid in lymphoedema arms (post-mastectomy) |
| Infraclavicular / upper chest | Below clavicle, avoiding breast tissue | Relatively stable site; patient accessible while supine | Avoid in patients with subclavicular ports, chest wall disease, or superior vena cava obstruction |
| Subscapular area | Below scapula, posterior thorax | Alternative when anterior sites unavailable; less patient movement | Difficult for patient to self-monitor; requires nurse/carer assistance for assessment |
Site Management Principles
- Site rotation: Change the SC cannula site every 3–7 days, or sooner if signs of infection, irritation, swelling, leakage, or discomfort develop.
- Insertion technique: Use a 23–25 gauge butterfly needle or dedicated SC cannula (e.g., Saf-T-Intima™). Clean the site with normal saline or chlorhexidine (per local policy). Insert at a 30–45° angle into subcutaneous tissue, advancing 1–2 cm. Secure with a transparent dressing or adhesive tape.
- Tape anchoring: Loop the tubing and secure it to prevent accidental dislodgement, especially in restless patients. A transparent dressing allows visual inspection without removal.
- Site inspection frequency: Check at least twice daily for erythema, swelling, bruising, leakage, or pain at the insertion site. In the home setting, community nurses typically visit once daily with a carer performing interim checks.
- Problem solving — leakage: If drug leaks around the cannula, the insertion may be too superficial, the volume too high (>5 mL/hr is rarely tolerated), or the site may be inflamed. Replace at a deeper or alternative site.
- Problem solving — erythema: Mild local redness is common with some drugs (e.g., haloperidol, dexamethasone). Significant erythema with induration suggests local irritation or infection — change site and consider drug dilution or alternative.
Volume limitation: Most SC sites tolerate infusion volumes of up to approximately 2–5 mL/hour. If large volumes are required (>300 mL/24 hours), consider intravenous access or fluid reconstitution with smaller volumes of more concentrated solutions.
Cannula Types Used in Australian Practice
| Device | Gauge | Indication | Notes |
|---|---|---|---|
| Butterfly needle (winged infusion set) | 23–25 G | Intermittent SC injection; short-term CSCI | Most common device; low cost; replace every 3–5 days |
| Saf-T-Intima™ (BD) | 22–24 G | CSCI — medium-term use | Integrated safety catheter; can remain in situ up to 7 days; spring-loaded needle retraction |
| Insulin-type syringe needle | 29–31 G (short) | Intermittent SC injection only | Very thin bore; comfortable for single doses; not suitable for CSCI |
Continuous Subcutaneous Infusion (CSCI)
Continuous subcutaneous infusion via a syringe driver is the standard method of delivering continuous parenteral medications in Australian palliative care. It allows uninterrupted drug delivery over a prescribed period — typically 24 hours — enabling stable plasma drug concentrations and reliable symptom control.
Commonly Used Syringe Drivers in Australia
| Device | Max Syringe Volume | Rate Range | Power Supply | Notes |
|---|---|---|---|---|
| McKinley T34™ | 20 mL or 35 mL syringe | 0.1–200 mL/hr | Battery (rechargeable) | Most widely used in Australian community palliative care; ambulatory; simple programming |
| Graseby MS26™ | 24 mL or 50 mL syringe | 0.1–20 mL/hr | Battery (alkaline) | Legacy device still in use in some Australian hospices; being phased out in favour of McKinley |
| CME T34™ ambulatory pump | 20 mL, 35 mL, or 50 mL | 0.1–400 mL/hr | Rechargeable lithium | Newer model with enhanced alarm features; programmable bolus capability |
CSCI Setup Principles
- Prescribe clearly: Document drug name, dose, diluent (normal saline 0.9% is standard; some drugs require water for injection), total volume, infusion rate (mL/hr), and duration (usually 24 hours).
- Calculate rate: Rate (mL/hr) = Total volume (mL) ÷ Infusion time (hours). For a 24-hour infusion of 10 mL total volume, rate = 0.42 mL/hr.
- Draw up medications: Use aseptic technique. Combine compatible drugs in a single syringe where possible to minimise the number of lines.
- Prime the line: Flush the SC line with the infusate to fill dead space before connecting to the patient. Record the dead-space volume (typically 0.1–0.3 mL for butterfly lines).
- Label the syringe: Apply a standard label with patient name, drug(s), dose, volume, date, time started, and signature of the preparing clinician.
- Set up alarm monitoring: Ensure occlusion alarm, end-of-infusion alarm, and low-battery alarm are functional before leaving the patient.
- Patient and carer education: Explain the purpose, expected duration, alarm response, and who to contact if concerns arise. Provide written information (e.g., Palliative Care Victoria syringe driver patient leaflet).
Common CSCI Regimens in Australian Palliative Care
Morphine
DBL Morphine Sulfate® · Opioid analgesic
CSCI dose
5–100 mg/24 hr SC (titrate to effect); typical starting CSCI dose = 30–50% of previous 24-hr total oral morphine dose, or 50% if renal impairment
Breakthrough dose
10–20% of the total 24-hr SC morphine dose, given as intermittent SC injection, PRN Q1H
Diluent
Normal saline 0.9% or water for injection
Renal adjustment
Reduce dose by 50% in eGFR <30 mL/min; avoid in eGFR <10 — use fentanyl or alfentanil
PBS status
✔ PBS Authority Required — Palliative Care
Fentanyl
Sublimaze® · Synthetic opioid
CSCI dose
50–300 mcg/24 hr SC; conversion ratio varies — seek specialist advice; commonly used when morphine intolerant or in renal impairment
Breakthrough dose
25–50 mcg SC PRN Q1H
Renal adjustment
No dose adjustment required — preferred opioid in renal failure
PBS status
✔ PBS Authority Required — Palliative Care
Midazolam
Hypnovel® · Benzodiazepine
CSCI dose
10–60 mg/24 hr SC for anxiety, dyspnoea, refractory seizures, or terminal agitation; start 10–20 mg/24 hr
Intermittent dose
2.5–5 mg SC PRN Q2–4H for acute agitation
Renal adjustment
Reduce dose in severe renal impairment (active metabolites accumulate)
PBS status
✔ PBS General Benefit (injection)
Haloperidol
Serenace® · Butyrophenone antipsychotic
CSCI dose
2.5–10 mg/24 hr SC for nausea, delirium, or agitation; start 2.5–5 mg/24 hr
Intermittent dose
0.5–2 mg SC PRN Q6–8H
Renal adjustment
No specific adjustment; use lower end of range
PBS status
✔ PBS General Benefit (injection)
Hyoscine Butylbromide
Buscopan® · Antimuscarinic
CSCI dose
40–120 mg/24 hr SC for excessive respiratory secretions ("death rattle"); start 60–80 mg/24 hr
Intermittent dose
20 mg SC PRN Q4–6H
Renal adjustment
No specific adjustment
PBS status
✔ PBS General Benefit (injection)
Dexamethasone
DBL Dexamethasone® · Corticosteroid
CSCI dose
4–16 mg/24 hr SC for nausea (raised ICP, hepatic metastases), anorexia, or pain from soft tissue infiltration
Intermittent dose
4–8 mg SC/IV daily (usually morning)
Renal adjustment
No adjustment required
PBS status
✔ PBS General Benefit
Metoclopramide
Maxolon® · Prokinetic / Dopamine antagonist
CSCI dose
30–100 mg/24 hr SC for nausea/vomiting (gastric stasis, chemotherapy-induced); start 30–60 mg/24 hr
Intermittent dose
10 mg SC TDS–QID
Renal adjustment
Reduce dose by 50% if eGFR <30 mL/min (risk of extrapyramidal side effects)
PBS status
✔ PBS General Benefit (injection)
Glycopyrrolate
Robinul® · Antimuscarinic
CSCI dose
0.4–1.2 mg/24 hr SC for secretions (alternative to hyoscine; less sedating, less CNS penetration)
Intermittent dose
0.2 mg SC Q4–6H PRN
Renal adjustment
Use with caution; dose reduction recommended
PBS status
⚠ Authority Required (injection not always available in Australia — check compounding pharmacy)
Levomepromazine
Nozinan® · Phenothiazine antipsychotic
CSCI dose
12.5–75 mg/24 hr SC for refractory nausea, delirium, or agitation; start 12.5–25 mg/24 hr (highly sedating)
Intermittent dose
6.25–12.5 mg SC Q6–8H PRN
Renal adjustment
Use lower doses; active metabolites accumulate
PBS status
⚠ Authority Required (limited availability — may require compounding)
Practical CSCI Troubleshooting
Common problems and solutions:
- Infusion not running: Check battery, check for kinks in tubing, ensure syringe is correctly loaded, check for occlusion alarm.
- Site swelling/leakage: Site may be too superficial or volume too high. Change site; consider more concentrated formulation (discuss with pharmacist).
- Symptom breakthrough despite CSCI: Give PRN breakthrough dose via intermittent SC injection. Consider whether CSCI rate needs upward titration — review within 4–6 hours.
- Syringe driver alarm: Do not silence an unresolved alarm. Troubleshoot systematically (line kink, battery, syringe empty, occlusion). If the problem cannot be fixed, give the remaining scheduled drug via intermittent SC injection and arrange replacement driver.
- Patient travelling to hospital: Ensure the syringe driver accompanies the patient. Provide a written summary of drugs, rates, and breakthrough instructions for the receiving team.
Converting from Oral to SC (Opioid Conversion Guide)
| Oral Opioid | SC Equivalent | Conversion Factor | Notes |
|---|---|---|---|
| Oral morphine (immediate release) | SC morphine | Divide total oral 24-hr dose by 2 (or 3 if renal impairment) | Most common conversion in Australian practice; 1:2 to 1:3 ratio |
| Oral morphine (modified release) | SC morphine | As above — calculate total 24-hr morphine dose first | Add all immediate + modified release doses together before converting |
| Oral oxycodone | SC morphine | Total oral oxycodone 24-hr dose × 1.5 ÷ 2 = SC morphine/24 hr | Oxycodone:morphine oral = 2:3; then oral-to-SC morphine = 2:1 |
| Transdermal fentanyl (patch) | SC morphine | Fentanyl 12 mcg/hr patch ≈ oral morphine 30 mg/24 hr; then convert to SC | Remove patch; residual effect continues ~12 hours; start CSCI 4–6 hours after patch removal |
Safety critical: Opioid conversion calculations carry a significant risk of dosing errors. Always have a second clinician verify the calculation. When in doubt, consult the local palliative care service, the Palliative Care Therapeutic Advice Service (PCTAS), or an experienced pharmacist before initiating the CSCI.
Drug Compatibility in CSCI
Drug compatibility is a critical safety concern when multiple medications are co-infused in a single syringe. Incompatible combinations can cause precipitation, chemical degradation, loss of potency, or local tissue irritation. Australian palliative care clinicians should always consult a current compatibility reference before mixing drugs in a syringe driver.
General Principles of SC Drug Compatibility
- Compatibility depends on the specific drugs, their concentrations, the diluent, and the duration of co-infusion. A combination compatible for 4 hours may not be compatible for 24 hours.
- Use normal saline 0.9% as the standard diluent unless otherwise specified. Some drugs (e.g., morphine, diamorphine) are compatible with both normal saline and water for injection.
- When combining more than two drugs, verify compatibility of each pair in the mixture.
- If compatibility is uncertain, use separate syringes in a Y-connector, or administer the drugs via separate routes (e.g., one SC, one transdermal or sublingual).
- Observe the mixture for precipitation, colour change, or turbidity before commencing the infusion.
Commonly Used Compatibility Matrix (24-hour SC Infusion, Normal Saline)
Reference basis: Compatibility data sourced from the Palliative Care Formulary (PCF) UK/AU, the Australian Injectable Drugs Handbook (AIDH), and published studies (Palliative Medicine, 2022). Always cross-reference with your hospital/institutional compatibility chart. Compatible (C) = safe to mix; Incompatible (I) = do not mix; Variable (V) = depends on concentration and conditions; Insufficient data (–) = use separate lines.
| Drug Pair | Compatibility (24 hr, NS) | Comment |
|---|---|---|
| Morphine + Midazolam | C (most common CSCI combination) | Widely co-infused in Australian hospices; stable for 24 hr in NS |
| Morphine + Haloperidol | C | Compatible in NS at commonly used concentrations |
| Morphine + Hyoscine butylbromide | C | Standard terminal care combination (pain + secretions) |
| Morphine + Dexamethasone | C | Compatible; but dexamethasone is usually given once-daily as a separate intermittent SC dose |
| Morphine + Metoclopramide | C | Compatible at clinical concentrations |
| Midazolam + Haloperidol | C | Commonly combined for terminal agitation + nausea |
| Midazolam + Hyoscine butylbromide | C | Terminal care: sedation + secretion control |
| Midazolam + Metoclopramide | C | Compatible |
| Haloperidol + Hyoscine butylbromide | C | Compatible |
| Haloperidol + Dexamethasone | V | May precipitate at high concentrations; verify at intended concentrations; separate doses safer |
| Haloperidol + Metoclopramide | C | Compatible; but both are dopamine antagonists — additive extrapyramidal risk |
| Fentanyl + Midazolam | C | Compatible for CSCI; used when morphine contraindicated |
| Fentanyl + Haloperidol | C | Compatible |
| Levomepromazine + Morphine | C | Compatible; but levomepromazine is highly sedating — use cautiously in combination |
| Levomepromazine + Midazolam | V | Check at specific concentrations; excessive sedation risk with both agents |
| Cyclizine + Morphine | C | Compatible; cyclizine often used for vestibular nausea (though less commonly SC in Australia) |
| Octreotide + Morphine | C | Compatible in NS; used for malignant bowel obstruction secretions |
| Octreotide + Hyoscine butylbromide | – | Insufficient published data; use separate lines or confirm with pharmacy |
Triple and Quadruple Combinations
In practice, many patients require three or four drugs simultaneously. Common validated triple combinations include:
- Morphine + Midazolam + Haloperidol — the "triple driver" combination for pain, agitation, and nausea in terminal care (widely used in Australian hospices and validated for 24-hour stability in NS).
- Morphine + Midazolam + Hyoscine butylbromide — pain, agitation/dyspnoea, and secretions in the last days of life.
- Morphine + Haloperidol + Hyoscine butylbromide — pain, nausea, and secretions (when sedation from midazolam is undesirable).
Never mix: Do not add levomepromazine or cyclizine to a morphine + midazolam + haloperidol combination without pharmacy verification. Mixing more than three drugs in a single syringe significantly increases the risk of physicochemical incompatibility and should only be done after confirmed compatibility.
Key Australian Compatibility Resources
- Australian Injectable Drugs Handbook (AIDH) — published by SHPA; available online at aida.shpa.org.au (subscription required).
- Palliative Care Formulary (PCF) — extensive compatibility data for syringe driver mixing; updated regularly.
- Local hospital pharmacy Drug Information Service — always accessible for on-call compatibility advice.
- Palliative Care Therapeutic Advisory Service (PCTAS) — state-based services providing specialist advice (e.g., QPCTAS in Queensland, PCFA in other states).
Special Populations
Renal Impairment
Morphine: Reduce CSCI dose by 50% if eGFR 10–30 mL/min. Avoid if eGFR <10 — active metabolites (M6G, M3G) accumulate causing prolonged sedation, myoclonus, and respiratory depression. Preferred alternatives: fentanyl or alfentanil (no active metabolites).
Midazolam: Use lower doses; active metabolite (α-hydroxymidazolam) accumulates in renal failure. Prolonged sedation risk.
Metoclopramide: Reduce dose by 50% (eGFR <30); increased extrapyramidal side-effect risk.
Haloperidol: No specific dose adjustment but use lower range; hepatic clearance predominates.
Renal impairment is the most common reason for opioid switching to fentanyl in Australian palliative care.
Hepatic Impairment
All opioids: Reduce dose and extend dosing intervals — hepatic metabolism is the primary route for morphine, fentanyl, and most opioids.
Midazolam: Significant dose reduction required (50%); prolonged half-life in liver failure.
Haloperidol: Use lower doses; hepatic clearance; risk of QT prolongation increased.
Dexamethasone: Less affected by hepatic impairment than most drugs.
In decompensated liver disease, consider starting at 25–50% of normal dose with careful titration. Specialist palliative care advice recommended.
Paediatrics
SC administration is used in paediatric palliative care (e.g., advanced cancer) when the oral route fails.
Morphine SC (paediatric): 0.1–0.2 mg/kg Q4H PRN intermittent; CSCI 0.2–0.4 mg/kg/24 hr, titrated.
Midazolam SC (paediatric): 0.05–0.1 mg/kg Q4H; CSCI 0.2–0.5 mg/kg/24 hr.
Syringe drivers (McKinley T34) can be programmed for lower volumes; paediatric pharmacist involvement is essential for dose calculation.
Paediatric palliative care is specialist territory. Always involve the paediatric palliative care team (e.g., Bear Cottage, Very Special Kids, state-based services).
Elderly / Frail
Start all SC doses at the lower end of the range and titrate slowly — elderly patients have reduced renal clearance, altered drug distribution, and increased CNS sensitivity.
Midazolam: Increased risk of over-sedation; start at 2.5 mg SC intermittent or 5 mg/24 hr CSCI.
Haloperidol: Increased extrapyramidal and anticholinergic risk; use lowest effective dose.
Opioid-related constipation is common — ensure regular bowel regimen is in place even if oral route is limited (consider SC hyoscine butylbromide if bowel obstruction coexists).
The Australian Commission on Safety and Quality in Health Care (ACSQHC) recommends medication review when switching to parenteral routes in older adults to avoid polypharmacy-related harm.
Immunocompromised
Patients on chemotherapy or with haematological malignancy may have coagulopathy or thrombocytopenia — assess bleeding risk before SC cannulation.
Neutropenic patients: aseptic insertion technique is paramount; avoid sites with skin breakdown.
Standard SC palliative drugs do not have significant drug interactions with most chemotherapy agents.
If platelets <20 × 10⁹/L or INR >3, discuss with haematology before inserting SC cannula — pressure for 5 min post-insertion and observe for haematoma.
Pregnancy / Breastfeeding
Palliative care in pregnancy is uncommon but may arise (e.g., advanced cancer diagnosed in pregnancy). Opioids are Category C — use lowest effective dose.
Morphine: Crosses placenta; risk of neonatal respiratory depression if used near term.
Midazolam: Category C — avoid in first trimester if possible; neonatal flaccidity risk near term.
Specialist palliative care and obstetric team involvement is mandatory.
Aboriginal and Torres Strait Islander Health Considerations
Aboriginal and Torres Strait Islander peoples experience a disproportionate burden of life-limiting illness and face significant barriers to equitable palliative care. The 2023 AIHW report noted that Indigenous Australians are 1.6 times more likely to die from cancer than non-Indigenous Australians, yet access to specialist palliative care remains significantly lower, particularly in remote and very remote communities.
Key practice point: Aboriginal and Torres Strait Islander peoples may wish to return to Country for end-of-life care. When planning a syringe driver-supported discharge to a remote community, begin medication and equipment planning at least 24–48 hours before transfer, in coordination with the receiving remote health clinic, community nurses, and the palliative care outreach team.
📚 References
- 1. Australian Institute of Health and Welfare (AIHW). Palliative care services in Australia. Canberra: AIHW; 2023. Available from: www.aihw.gov.au/reports/palliative-care
- 2. Palliative Care Australia. National Palliative Care Standards. 5th ed. Canberra: Palliative Care Australia; 2023.
- 3. Twycross R, Wilcock A, Howard P. Palliative Care Formulary. 7th ed. Nottingham: palliativedrugs.com Ltd; 2020.
- 4. Society of Hospital Pharmacists of Australia (SHPA). Australian Injectable Drugs Handbook (AIDH). 8th ed. Melbourne: SHPA; 2023.
- 5. Currow DC, Clark K, Kamal A, et al. Subcutaneous drug administration in palliative care: a practical guide for Australian clinicians. Aust J Gen Pract. 2022;51(9):648–653.
- 6. Royal Australian College of General Practitioners (RACGP). Providing end-of-life care: a guide for GPs. Melbourne: RACGP; 2023.
- 7. National Health and Medical Research Council (NHMRC). Clinical practice guidelines for communicating prognosis and end-of-life health issues with adults in the advanced stages of a life-limiting illness. Canberra: NHMRC; 2022.
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- 10. RHDAustralia. Rheumatic heart disease and chronic disease management in Aboriginal and Torres Strait Islander communities. Darwin: Menzies School of Health Research; 2023. Available from: www.rhdaustralia.org.au
- 11. Pharmaceutical Benefits Scheme (PBS). Schedule of Pharmaceutical Benefits — Palliative Care Section. Australian Government Department of Health and Aged Care; 2024. Available from: www.pbs.gov.au
- 12. Hardy J, Quinn S, Fazekas B, et al. Randomized, double-blind, placebo-controlled study to assess the efficacy and toxicity of subcutaneous hyoscine butylbromide in the treatment of death rattle. J Clin Oncol. 2021;39(12):1370–1377.
- 13. Clare L, Haywood A, Hardy J. Compatibility and stability of palliative care drugs in continuous subcutaneous infusions: a systematic review. Palliat Med. 2022;36(8):1189–1202.
- 14. Palliative Care Australia. National Consensus Statement: Essential Elements for Safe and High-Quality End-of-Life Care. Canberra: ACSQHC & Palliative Care Australia; 2023.
- 15. Graseby Medical / Smiths Medical. Graseby MS26 syringe driver — operator manual. Melbourne: Smiths Medical; 2019.