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Palliative Care, Capacity, Ethics and Advance Care Planning

Last updated 1 Jun 2026 · Geriatric medicine

📋 Key Information Summary

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  • Palliative care should be integrated early in the trajectory of advanced multimorbidity, frailty and dementia — not reserved for the last days of life.
  • Goals-of-care conversations should be initiated when prognosis is uncertain, function is declining or the person expresses preferences, and documented using a nationally recognised form (e.g. Goals of Patient Care, Resuscitation Plan).
  • Advance care planning (ACP) is a legally supported process in every Australian state and territory; completed documents should be uploaded to My Health Record and communicated across care settings.
  • Capacity is decision-specific and time-specific; a diagnosis of dementia does not automatically equate to incapacity — a structured assessment (e.g. MacCAT-T) is required.
  • Symptom control in palliative care follows the WHO analgesic ladder; opioids remain the mainstay for moderate-to-severe pain with renal and hepatic dose adjustments essential in the elderly.
  • Subcutaneous midazolam (0.25–0.5 mg SC) is first-line for terminal agitation; haloperidol (0.5–1 mg SC) for nausea/vomiting when oral route is lost.
  • Australian state and territory guardianship legislation appoints substitute decision-makers in a defined hierarchy (e.g. spouse → adult child → parent → sibling); clinicians must know the local hierarchy.
  • Safeguarding obligations require clinicians to recognise and report elder abuse under mandatory reporting provisions and state-specific Adult Safeguarding Acts.
  • Medication review and deprescribing are core competencies in palliative geriatrics — cease non-essential preventive medications when goals shift to comfort.
  • Aboriginal and Torres Strait Islander peoples face unique barriers including distrust of institutional care, geographic isolation and the need for culturally safe, family-centred palliative models.
  • The Palliative Care Outcomes Collaboration (PCOC) and Australian Atlas of Healthcare Variation highlight significant inequities in palliative care access, particularly in rural and remote areas.
  • Clinicians should proactively discuss resuscitation status, artificial nutrition, hospital transfer and preferred place of death as part of structured goals-of-care documentation.

Introduction & Australian Epidemiology

Palliative geriatric care integrates prognosis estimation, patient values elicitation, capacity assessment, family communication and structured end-of-life planning. It applies to all older Australians living with advanced chronic illness, frailty or dementia — not only those with a cancer diagnosis. The goal is to maximise quality of life, manage distressing symptoms and ensure that medical interventions align with what matters most to the individual.

In Australia, people aged ≥65 years account for approximately 70% of all deaths each year, yet access to specialist palliative care services remains inequitable. The Australian Institute of Health and Welfare (AIHW) reports that while around 74,000 Australians received specialist palliative care in 2021–22, many older adults — particularly those in residential aged care facilities (RACFs) and rural/remote settings — receive suboptimal end-of-life care.

Dementia is the second leading cause of death in Australia and the leading cause in women. People with dementia often have prolonged dying trajectories with complex symptom burden, yet they are less likely to receive palliative care referrals compared with cancer patients. 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 provides a framework for all health service organisations.

Key Australian organisations and frameworks relevant to this topic include:

  • Palliative Care Australia (PCA) — National Palliative Care Standards (2018)
  • ACSQHC — National Consensus Statement for End-of-Life Care
  • Advance Care Planning Australia (ACPA) — national ACP framework
  • Palliative Care Outcomes Collaboration (PCOC) — national benchmarking
  • Australian Guardianship and Administration Acts (state/territory-specific)
  • Aged Care Quality Standards — Standard 2 (Ongoing Assessment and Planning), Standard 3 (Personal Care and Clinical Care)

Symptom Control and Comfort Care

Effective symptom management is the foundation of palliative geriatric care. Older adults frequently present with multiple concurrent symptoms including pain, dyspnoea, nausea, delirium, agitation, constipation and anorexia. Pharmacotherapy must be adjusted for age-related changes in renal clearance, hepatic metabolism, body composition and polypharmacy risk.

Pain Management

Pain in older adults is commonly under-recognised due to cognitive impairment, stoicism and atypical presentations. Assessment should use validated tools (e.g. Abbey Pain Scale for non-verbal patients, Numeric Rating Scale for verbal patients).

Mild Pain
WHO Step 1
Paracetamol 500 mg–1 g PO QID (max 3 g/day in elderly or hepatic impairment). Consider topical NSAIDs for localised musculoskeletal pain.
Setting: Community / RACF
Moderate Pain
WHO Step 2
Tramadol 25–50 mg PO BD–TDS, titrate slowly. Avoid in seizure history, SSRI/MAOI use. Alternatively low-dose morphine (2.5–5 mg PO BD) as per eTG guidance.
Setting: Community / RACF / Hospital
Severe Pain
WHO Step 3
Morphine 2.5–5 mg PO every 4 hours (elderly start low). Oxycodone 2.5–5 mg PO. For renal impairment, use fentanyl or buprenorphine patches. Hydromorphone as alternative.
Setting: Hospital / Specialist palliative care
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Morphine (oral solution)
Ordine® · Oramorph® · Opioid analgesic
Adult dose (elderly) 2.5–5 mg PO every 4 hours; titrate by 30–50% every 24–48 h. Use immediate-release for initial titration.
Renal adjustment eGFR 10–50: reduce dose/extend interval; eGFR <10: avoid — use fentanyl or hydromorphone. Active metabolites (M6G) accumulate.
Route Oral (solution, tablet); subcutaneous (continuous infusion or PRN for breakthrough); rectal
PBS status ✔ PBS General Benefit
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Fentanyl (transdermal patch)
Durogesic® · Opioid analgesic
Adult dose (elderly) 12 µg/h patch every 72 hours (starting dose after opioid stabilisation). For opioid-naive, use lower doses with caution.
Renal adjustment Preferred in renal impairment (eGFR <30) — no active metabolites. Start at lowest dose, titrate cautiously.
Route Transdermal; also available as sublingual (Abstral®) and intranasal (Instanyl®) for breakthrough pain
PBS status ⚠ PBS Authority Required
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Paracetamol
Panadol® · Panamax® · Non-opioid analgesic
Adult dose (elderly) 500 mg–1 g PO/IV every 4–6 hours; maximum 3 g/day in elderly and those <50 kg
Hepatic adjustment Max 2 g/day in significant hepatic impairment, active hepatitis or chronic alcohol use
Route Oral, IV, rectal
PBS status ✔ PBS General Benefit

Dyspnoea

Breathlessness in advanced illness is often multifactorial (cardiac failure, COPD, pleural effusion, deconditioning, anxiety). Non-pharmacological interventions are first-line: fan therapy, positioning, relaxation techniques and pacing. Pharmacologically, low-dose opioids are evidence-based for refractory breathlessness.

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Opioid safety in the elderly: Start at 50% of standard adult doses. Reduce dose by 25–50% in renal impairment (eGFR <30). Monitor for sedation, respiratory depression and constipation. Always co-prescribe aperients (e.g. docusate + senna, or macrogol). Avoid pethidine — its metabolite norpethidine causes neurotoxicity with accumulation.

For dyspnoea: morphine 2.5–5 mg PO or 1–2.5 mg SC every 4 hours; nebulised saline for secretion comfort. Avoid routine oxygen in non-hypoxic breathlessness — a fan directed to the face is equally effective.

Nausea and Vomiting

Choose anti-emetic based on the underlying mechanism:

Mechanism First-line Agent Dose (elderly)
Chemoreceptor trigger zone (opioid-induced, metabolic) Haloperidol 0.5–1 mg PO/SC OD–BD
Gastric stasis / gastroparesis Metoclopramide 5–10 mg PO/SC TDS (before meals); caution in extrapyramidal side-effects
Vestibular / motion-related Cyclizine 25–50 mg PO/SC TDS; anticholinergic — avoid in delirium
Raised intracranial pressure / bowel obstruction Dexamethasone 4–8 mg PO/IV OD (morning)
Serotonin-mediated (chemotherapy) Ondansetron 4–8 mg PO/IV OD–BD; watch for constipation

Terminal Agitation and Delirium

Terminal agitation (also called terminal restlessness) occurs in up to 42% of patients in the last days of life. It is characterised by restlessness, moaning, grimacing, myoclonus and altered consciousness. Reversible causes should be excluded where clinically appropriate (urinary retention, faecal impaction, medication effects including opioids).

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Midazolam
Hypnovel® · Benzodiazepine (sedative)
Adult dose (elderly) 2.5–5 mg SC stat; then 10–30 mg SC over 24 hours via continuous subcutaneous infusion (CSCI). Start low, titrate to effect.
Renal / hepatic Start at lower end of range in hepatic impairment; renal adjustment less critical but use with care if eGFR <15.
Route Subcutaneous (preferred in terminal care); buccal; IV
PBS status ✔ PBS General Benefit
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Haloperidol
Serenace® · Butyrophenone antipsychotic
Adult dose (elderly) 0.5–2 mg PO/SC/IM OD–BD. Use lowest effective dose. Monitor QTc if IV use.
Cautions Risk of extrapyramidal symptoms, QTc prolongation, neuroleptic malignant syndrome. Avoid in Lewy body dementia — severe sensitivity.
Route Oral, subcutaneous, intramuscular, IV
PBS status ✔ PBS General Benefit

Constipation

Opioid-induced constipation is predictable and must be prevented, not treated reactively. All patients commenced on opioids should receive a co-prescribed aperient:

  • First-line: docusate sodium 100 mg + senna 8–12 mg PO at night
  • Second-line: macrogol 3350 (1–2 sachets PO daily); lactulose 15–30 mL BD if needed
  • Refractory: subcutaneous methylnaltrexone (Relistor®) 8 mg SC every other day — specifically for opioid-induced constipation unresponsive to standard aperients

Secretion Management (Death Rattle)

Noisy upper airway secretions in the dying patient are distressing for families. Non-pharmacological measures (repositioning, gentle suctioning if accessible) are first-line. If persistent, glycopyrrolate 200 µg SC or hyoscine butylbromide 20 mg SC every 4–6 hours may reduce secretion volume. Explain to families that the patient is unlikely to be distressed by the sound.

Deprescribing in Palliative Care

As goals shift from disease modification to comfort, clinicians should systematically review and deprescribe medications that no longer align with goals of care. Examples include statins, antihypertensives (if hypotensive), anticoagulants (when risk of bleeding exceeds benefit), oral hypoglycaemics and bisphosphonates. The STOPPFrail criteria provide a structured framework for deprescribing in frail older adults with limited life expectancy.

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Deprescribing principle: Do not abruptly cease benzodiazepines, opioids, corticosteroids or anticonvulsants — taper over days to weeks depending on duration of use and dose, to avoid withdrawal symptoms.

Advance Care Planning and Goals of Care

Advance care planning (ACP) is a process of discussion and documentation that enables a person to express their values, preferences and wishes for future health care. In Australia, ACP is supported by all state and territory governments and endorsed by Advance Care Planning Australia (ACPA), a national program funded by the Australian Government.

When to Initiate ACP

ACP conversations should be initiated proactively, ideally in the community or early in an admission, rather than during a crisis. Trigger points include:

  • Diagnosis of advanced or life-limiting illness (e.g. heart failure NYHA III–IV, COPD GOLD stage IV, advanced dementia, metastatic cancer)
  • Increasing frailty (Clinical Frailty Scale ≥5) with recurrent hospitalisations
  • Transition to residential aged care
  • Patient or family-initiated request
  • Before a major surgical or interventional procedure
  • During comprehensive geriatric assessment (CGA)

Key Components of ACP

1
Explore Understanding
Assess the person's understanding of their illness, prognosis and treatment options. Use open-ended questions: "What do you understand about your condition?"
2
Elicit Values and Preferences
Identify what matters most to the person — independence, being at home, avoiding hospitals, spending time with family, spiritual practices, cultural obligations.
3
Discuss Scenarios
Explore preferences for cardiopulmonary resuscitation, ICU admission, artificial nutrition/hydration, antibiotics for infection, hospital transfer from RACF.
4
Document and Communicate
Complete a Goals of Patient Care (GoPC) form or Advance Care Directive (ACD) per state/territory legislation. Distribute copies to GP, family, RACF and upload to My Health Record.
5
Review Regularly
Review ACP documents after any significant change in health status, hospital admission or at least annually. ACP is a dynamic, ongoing process — not a one-off event.

Australian ACP Documentation

Document Purpose Legal Status
Advance Care Directive (ACD) Legally binding document stating the person's instructions for future treatment; may include refusals of treatment Legally binding under state/territory legislation (e.g. Medical Treatment Planning and Decisions Act 2016 Vic; Advance Health Directive Act 1997 Qld)
Goals of Patient Care (GoPC) / Resuscitation Plan (RP) Clinical document specifying treatment goals, ceiling of care and resuscitation orders in the current clinical context Not a substitute for ACD but guides clinical decision-making; part of the medical record
Substitute Decision-Maker Appointment Formal appointment of a person to make decisions on behalf of the individual if they lose capacity Varies by jurisdiction — e.g. Power of Attorney (Medical Treatment) Vic; Enduring Power of Guardianship WA
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Clinical governance: ACP documents must be accessible at the point of care. In acute deterioration, a valid ACD refusing treatment must be honoured. If a patient lacks capacity and has no ACD, treatment decisions default to the substitute decision-maker or the clinician acting in the patient's best interests under relevant guardianship legislation.

Preferred Place of Care and Death

Australian data (PCOC, AIHW) consistently shows that the majority of older Australians prefer to die at home or in their RACF rather than in hospital. However, approximately 50% of deaths in those aged ≥65 still occur in acute hospitals. Structured ACP, combined with adequate community palliative care resources, can help align care with patient preferences.

Ethics, Safeguarding and Substitute Decision-Making

Ethical Principles in Palliative Geriatric Care

Clinical decision-making in palliative geriatrics is guided by four foundational ethical principles, applied in the context of Australian law and professional standards:

Principle Application in Geriatric Palliative Care
Autonomy Respect the person's right to make informed decisions, including refusal of treatment. Honour advance care directives. Support decision-making through ACP, even when capacity is impaired.
Beneficence Act in the patient's best interest — provide effective symptom management, prevent suffering and support quality of life.
Non-maleficence Avoid futile or harmful interventions. Withhold or withdraw treatments that cause disproportionate burden without benefit (e.g. repeated hospital transfers for a person with end-stage dementia who is comfort-focused).
Justice Ensure equitable access to palliative care regardless of diagnosis, geography, socioeconomic status or cultural background.

Common Ethical Dilemmas

  • Artificial nutrition and hydration (ANH): In advanced dementia, tube feeding does not improve survival, reduce aspiration or improve comfort. Hand-feeding is preferred. Artificial hydration via subcutaneous infusion may be considered in selected cases but is not routine.
  • Antibiotics for recurrent infections in dementia: Treatment decisions should be guided by goals of care. In comfort-focused care, oral antibiotics for symptom relief may be appropriate; parenteral antibiotics and hospital transfer may not be.
  • Double effect: Administering opioids or sedatives for symptom control that may, as a secondary effect, hasten death is ethically and legally permissible when the intention is to relieve suffering, the dose is proportionate to symptom severity and the decision is documented.
  • Withholding vs withdrawing treatment: Ethically equivalent. There is no legal or ethical distinction between not starting a treatment and stopping a treatment that has become futile or non-beneficial.
  • Clinician conscientious objection: Clinicians may hold personal views but must not impose them on patients. If unable to participate, they must facilitate timely transfer of care.
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Voluntary Assisted Dying (VAD): VAD is now lawful in all Australian states (Vic 2019, WA 2021, SA 2021, Qld 2023, NSW 2023, Tas 2022) with eligibility criteria including being an adult with decision-making capacity, an advanced disease expected to cause death within a defined timeframe and suffering that cannot be relieved. VAD is distinct from palliative care and is subject to rigorous safeguards. Clinicians should be aware of their state's legislation and referral pathways.

Substitute Decision-Making

When a person lacks capacity and has no valid ACD, decisions are made by a substitute decision-maker (SDM). The hierarchy of SDMs is defined by state and territory legislation and generally follows this order (varies by jurisdiction):

  1. Appointed guardian or medical treatment decision-maker (if formally appointed under state/territory legislation)
  2. Spouse or domestic partner
  3. Adult child (or eldest child, depending on jurisdiction)
  4. Parent
  5. Adult sibling
  6. Other relative or close friend

The SDM must act in accordance with the person's known wishes and values, not their own preferences. Where wishes are unknown, the SDM must act in the person's best interests, considering the person's values, cultural background and the medical evidence.

Elder Abuse and Safeguarding

Elder abuse includes physical, psychological, financial, sexual abuse and neglect. In Australia, the National Plan to Respond to the Abuse of Older Australians (Elder Abuse) 2019–2023 provides a framework. Key considerations for clinicians:

  • Red flags include unexplained injuries, withdrawal, fear of a carer, sudden changes in financial arrangements, medication non-adherence due to carer withholding, and inadequate care in RACF settings
  • Mandatory reporting applies to all forms of abuse in residential aged care under the Aged Care Act 1997
  • State-based mandatory reporting provisions vary — in SA, NT and Queensland, there are specific elder abuse reporting frameworks
  • Each state and territory has an Adult Safeguarding Unit or equivalent body for reporting and support
  • The Older Persons Advocacy Network (OPAN) provides free, independent advocacy services nationally

Clinical Ethics Consultation

When ethical dilemmas cannot be resolved through standard clinical and family meetings, clinical ethics consultation should be sought. Most Australian tertiary hospitals have clinical ethics committees or access to ethics consultation services. The Australasian Association of Bioethics and Health Law (AABHL) and the Clinical Ethics Network and Research Australasia (CENTRA) provide directories of ethics resources.

Monitoring and Ongoing Assessment

Monitoring in palliative geriatric care shifts from disease-focused investigation to symptom-focused assessment. The frequency and intensity of monitoring should be aligned with goals of care and the patient's preferences.

Essential Symptom assessment scales Edmonton Symptom Assessment System (ESAS), Abbey Pain Scale (non-verbal), Palliative Care Problem Severity Score (PCPSS) — used in PCOC
Essential Functional status Palliative Performance Scale (PPS) or Australia-modified Karnofsky Performance Status (AKPS) — serial measurement
Available Renal function (eGFR, urea, creatinine) Guide opioid and medication dosing; may choose to discontinue monitoring if goals are comfort-only
Available Electrolytes, glucose Monitor if relevant to symptom control (e.g. hyponatraemia causing confusion, hyperglycaemia in steroid use)
Available Medication review STOPPFrail criteria, Beers Criteria — structured deprescribing at each clinical review
Specialist PCOC assessment Standardised intake and outcome measures for patients accessing specialist palliative care services nationally
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Prognostic indicators: The "surprise question" ("Would you be surprised if this patient died in the next 12 months?") is a practical screening tool. Formal prognostic tools include the Palliative Prognostic Score (PaP), the Palliative Prognostic Index (PPI) and the Clinical Frailty Scale (CFS ≥7 = severe frailty).

Special Populations

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Elderly / Frail

All opioids: Start at 50% of standard adult dose; titrate slowly. Renal function is often impaired — prefer fentanyl or buprenorphine if eGFR <30.
Anticholinergic medications: Avoid cyclizine and hyoscine in patients with cognitive impairment — risk of precipitating or worsening delirium.
Falls risk: Opioids, benzodiazepines, antipsychotics all increase falls risk. Balance symptom control with safety. Use bed rails, falls alarms and environmental modification.
Comprehensive geriatric assessment (CGA) should be integrated into palliative care for older adults with multimorbidity and frailty.
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Renal Impairment

Morphine: Avoid in eGFR <15 mL/min — active metabolites (M3G, M6G) accumulate causing neurotoxicity (myoclonus, seizures, prolonged sedation).
Preferred agents: Fentanyl (no active metabolites), hydromorphone (less accumulation), buprenorphine transdermal.
Paracetamol: No adjustment required — safe in all stages of CKD.
Renal monitoring may be ceased if goals of care are purely comfort-focused and investigations would not change management.
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Hepatic Impairment

Opioids: Reduce dose by 50% and extend interval in significant hepatic impairment (Child-Pugh B/C). Morphine clearance is reduced; use with caution.
Paracetamol: Maximum 2 g/day in chronic liver disease.
Midazolam: Prolonged half-life in hepatic failure — use lower doses and monitor closely.
Avoid NSAIDs. Monitor for hepatic encephalopathy precipitated by opioid use.
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Dementia

Pain assessment: Use Abbey Pain Scale or PAINAD — verbal scales are unreliable. Treat pain on suspicion if behavioural changes are observed (agitation, guarding, grimacing).
Comfort feeding: Hand-feeding with modified textures. Do not commence PEG/NG tube feeding in advanced dementia — no survival benefit and increased complications.
Antipsychotics: Haloperidol and risperidone may be used for severe agitation in dementia at the lowest effective dose with documented informed consent. Monitor for stroke risk (TGA black box warning in elderly with dementia).
The Dementia Support Australia (DSA) helpline (1800 699 799) provides 24/7 specialist support for managing behavioural and psychological symptoms of dementia (BPSD).
🛡️

Immunocompromised

Infection management: Goals-of-care discussions should include whether to investigate and treat suspected infections. In comfort-focused care, oral antibiotics for symptom relief may be appropriate; parenteral treatment and hospital transfer may not.
Steroids: Long-term corticosteroid use (common in haematological malignancies, COPD) requires gradual tapering — abrupt cessation risks adrenal crisis.
Vaccination status and infection control measures should be reviewed in the context of RACF palliative care.

Aboriginal and Torres Strait Islander Health Considerations

Aboriginal and Torres Strait Islander Health

Aboriginal and Torres Strait Islander peoples experience significantly higher rates of chronic disease, earlier onset of multimorbidity and a median age of death approximately 8 years younger than non-Indigenous Australians. Palliative care access and utilisation remain markedly lower for Indigenous Australians, particularly those in remote communities.

Cultural understanding of dying
Many Aboriginal and Torres Strait Islander peoples hold specific cultural and spiritual beliefs about death and dying, including "Sorry Business" protocols. Dying on Country (returning to traditional lands to die) may be of profound importance. Clinicians must respect these wishes and facilitate repatriation where possible. Avoid discussing death directly with some communities — use culturally appropriate language and intermediaries (e.g. Aboriginal health practitioners, liaison officers).
Family and community decision-making
Decision-making may involve extended family and Elders, not just the nuclear family. Western models of individual autonomy and substitute decision-making may conflict with communal decision-making processes. Engage Aboriginal health workers and liaison officers early to navigate these dynamics respectfully.
Geographic and service barriers
Remote and very remote communities have limited access to specialist palliative care, GP palliative medicine and pharmacy services. The Royal Flying Doctor Service (RFDS), palliative care telehealth and Aboriginal Community Controlled Health Organisations (ACCHOs) are critical in bridging these gaps. The Program of Experience in the Palliative Approach (PEPA) builds workforce capacity in Indigenous health settings.
Mistrust of mainstream health services
Historical and ongoing experiences of racism and cultural insensitivity in health care contribute to reluctance to engage with institutional palliative care. Culturally safe care requires: trained staff, Indigenous health workers embedded in palliative care teams, use of Indigenous language interpreters, and acknowledgment of the Stolen Generations' legacy on trust in health systems.
Medication access
Remote pharmacies and Remote Area Aboriginal Health Services (RAAHS) may have limited formulary access. Opioid prescribing in remote communities is complicated by concerns about diversion and stigma. The Remote Area Aboriginal Health Services Program assists with medication supply. Ensure adequate opioid availability for pain management as per the National Palliative Care Standards.
Advance care planning
ACP uptake is very low among Aboriginal and Torres Strait Islander peoples. Culturally adapted ACP tools (e.g. "Yarning about Dying" resources developed with Indigenous communities) are available through Advance Care Planning Australia. National Aboriginal Community Controlled Health Organisation (NACCHO) supports integration of ACP into primary care through ACCHOs.
✅
Cultural safety actions for clinicians: Engage Aboriginal health practitioners and liaison officers as early as possible. Allow time for Sorry Business. Use plain language. Ask about Country, family structure and cultural preferences before initiating ACP. Support dying on Country where it aligns with patient wishes and can be done safely. Refer to the Indigenous-specific resources from Palliative Care Australia and RHDAustralia.

📚 References

  1. 1. Palliative Care Australia. National Palliative Care Standards. 5th edn. Canberra: PCA; 2018.
  2. 2. Australian Commission on Safety and Quality in Health Care (ACSQHC). National Consensus Statement: Essential Elements for Safe and High-Quality End-of-Life Care. Sydney: ACSQHC; 2015.
  3. 3. Advance Care Planning Australia. National Framework for Advance Care Planning. Melbourne: ACPA; 2021. Available at: advancecareplanning.org.au.
  4. 4. Australian Institute of Health and Welfare (AIHW). Palliative care services in Australia. AIHW; 2023. Cat. no. HWV 84.
  5. 5. Palliative Care Outcomes Collaboration (PCOC). National Palliative Care Outcomes Collaboration Benchmarking Report. Wollongong: University of Wollongong; 2023.
  6. 6. Appelbaum PS. Assessment of patients' competence to consent to treatment. N Engl J Med. 2007;357(18):1834–1840.
  7. 7. Grisso T, Appelbaum PS. MacArthur Competence Assessment Tool for Treatment (MacCAT-T). Sarasota, FL: Professional Resource Press; 1998.
  8. 8. Etchells E, Darzins P, Silberfeld M, et al. Assessment of patient capacity to consent to treatment. J Gen Intern Med. 1999;14(1):27–34.
  9. 9. Gallagher P, Ryan C, Byrne S, Kennedy J, O'Mahony D. STOPP (Screening Tool of Older Person's Prescriptions) and START (Screening Tool to Alert doctors to Right Treatment): consensus validation. Int J Clin Pharmacol Ther. 2008;46(2):72–83.
  10. 10. Lavan AH, Gallagher P, Parsons C, O'Mahony D. STOPPFrail: screening tool of older persons' prescriptions in frail adults with limited life expectancy — a consensus validation study. Eur J Clin Pharmacol. 2021;77(7):1043–1051.
  11. 11. Mitchell SL, Teno JM, Kiely DK, et al. The clinical course of advanced dementia. N Engl J Med. 2009;361(16):1529–1538.
  12. 12. Abernethy AP, Currow DC, Frith P, Fazekas BS, McHugh A, Bui C. Randomised, double blind, placebo controlled crossover trial of sustained release morphine for the management of refractory dyspnoea. BMJ. 2003;327(7414):523–528.
  13. 13. Detering KM, Hancock AD, Reade MC, Silvester W. The impact of advance care planning on end of life care in elderly patients: randomised controlled trial. BMJ. 2010;340:c1345.
  14. 14. National Aboriginal Community Controlled Health Organisation (NACCHO). Providing palliative care for Aboriginal and Torres Strait Islander peoples: Practice Guide. Canberra: NACCHO; 2022.
  15. 15. Australian Government Department of Health. National Plan to Respond to the Abuse of Older Australians (Elder Abuse) 2019–2023. Canberra: Commonwealth of Australia; 2019.
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. 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.

📚 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, 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. 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 — 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 TNFα 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.

📚 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, 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. 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 — 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 TNFα 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).