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Home Palliative Care Care of the Deceased’s Body

Care of the Deceased’s Body

Last updated 1 Jun 2026 · Palliative care

📋 Key Information Summary

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  • Last offices (care of the body after death) should begin as soon as practicable after death is confirmed, ideally within 1–2 hours, to preserve dignity and prevent deterioration of the body.
  • The process must be conducted with the same dignity, privacy, and respect afforded to the person during life, regardless of diagnosis, social status, or background.
  • Cultural, spiritual, and religious rites must be identified early and accommodated wherever possible — ask the family and consult cultural liaison officers if available.
  • Family participation in last offices (washing, dressing, positioning) is encouraged where desired and culturally appropriate, with staff guidance and support.
  • Coronial referral is mandatory when death is unexpected, violent, unnatural, occurred in custody, or the cause is unknown — the body must not be disturbed until the coroner authorises release.
  • Standard precautions (gloves, gown, eye protection if risk of body fluid exposure) apply during last offices; enhanced precautions are required for notifiable infectious diseases.
  • Pacemakers and implantable cardioverter-defibrillators (ICDs) must be removed before cremation to prevent explosion risk; document removal in the medical record.
  • Mortuary and funeral director transfer arrangements should be coordinated promptly, respecting the family's choice of funeral provider and any religious timeframes (e.g., burial within 24 hours in Islam and Judaism).
  • Aboriginal and Torres Strait Islander cultural practices around death are diverse and deeply significant — smoking ceremonies, avoidance practices, and sorry business must be respected and facilitated.
  • Healthcare organisations must have clear policies for last offices, including checklists, coronial referral pathways, infection control procedures, and staff support resources.
  • Documentation of death, last offices performed, belongings returned, and any devices removed must be thorough and contemporaneous.
  • Staff wellbeing is essential — debriefing and access to employee assistance programmes should be available, particularly after traumatic or paediatric deaths.

Introduction & Australian Context

Care of the deceased's body — commonly referred to as last offices, laying out, or post-mortem care — encompasses all physical, emotional, cultural, and legal procedures carried out after a person's death. This process is one of the final acts of care a healthcare team provides and carries profound significance for the bereaved family, the clinical team, and the broader community.

In Australia, approximately 171,000 deaths were registered in 2022 (Australian Bureau of Statistics), the majority occurring in hospitals (54%), residential aged care facilities (32%), and at home or in hospice settings (14%). Each of these settings requires staff who are trained, competent, and supported in performing last offices with cultural sensitivity and procedural rigour.

Australia's multicultural population — encompassing over 300 ancestries and home to the world's oldest continuous living cultures in Aboriginal and Torres Strait Islander peoples — means that care of the body after death is far from a uniform process. Religious, cultural, and spiritual practices vary enormously, and healthcare workers must be prepared to accommodate diverse needs while navigating legislative and coronial requirements.

This article provides a comprehensive, Australian-contextualised guide to the care of the deceased's body, covering dignity and respect, cultural rites, family participation, coronial restrictions, infection control, practical procedures, special populations, and Aboriginal and Torres Strait Islander health considerations.

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Key Australian statistics: In 2022, the Australian Bureau of Statistics recorded 171,469 deaths. Coronial investigations were initiated in approximately 12–15% of all deaths nationally. Aboriginal and Torres Strait Islander peoples experience age-standardised mortality rates 1.6 times that of non-Indigenous Australians, with significant implications for culturally safe end-of-life and post-mortem care.

Dignity & Respect

The fundamental principle underpinning all care of the deceased's body is that the person retains their dignity and humanity after death. This is enshrined in the National Safety and Quality Health Service (NSQHS) Standards, the Aged Care Quality Standards, and the professional codes of conduct of all Australian health practitioner boards (AHPRA).

Core Principles

  • Treat the body as you would a living patient: Use the person's preferred name, speak respectfully, maintain privacy with curtains drawn and doors closed, and handle the body gently.
  • Preserve appearance: Close the eyes, position the mouth naturally (a rolled towel under the chin may assist), straighten limbs, remove lines and drains where permissible, and clean any soiling.
  • Protect personal belongings: Inventory, label, and securely store all valuables (jewellery, watches, wallets, phones, hearing aids, dentures, prostheses). Document on the belongings register and arrange return to the NOK or estate.
  • Minimise environmental exposure: Cover the body respectfully with a sheet or culturally appropriate shroud. Do not leave the body exposed or in a public area.
  • Time sensitivity: Begin last offices as soon as possible to prevent discolouration, rigor mortis (onset 2–6 hours), livor mortis, and decomposition, all of which can distress bereaved families.

Practical Steps — Last Offices Checklist

Step Action Notes
1. Confirm death Two medical practitioners (or one in some jurisdictions) confirm death and complete the Medical Certificate of Cause of Death (MCCD) Death confirmed by absence of cardiac sounds, absent pupillary reflex, absent respiration, absence of central pulse for ≥ 5 min
2. Notify family/NOK Contact next of kin sensitively; offer the option to view/be present during last offices Use private space; offer social work or spiritual care support
3. Remove devices Remove IV lines, urinary catheters, drains, nasogastric tubes; leave in situ if coronial referral required Pacemakers/ICDs must be removed before cremation — arrange if applicable
4. Clean and position Wash the body, close eyes, position mouth, comb hair, apply clean gown or shroud Use standard precautions; absorbent pad beneath perineum
5. Apply identification Attach identification band (wrist or ankle) with name, DOB, UR number, date/time of death Required by all state/territory health regulations
6. Document Record time of death, time last offices commenced/completed, staff involved, devices removed, belongings inventory Contemporaneous documentation in clinical record
7. Transfer to mortuary Cover with shroud, transfer on mortuary trolley to refrigerated mortuary or arrange funeral director collection Refrigeration (2–4°C) should occur within 4–6 hours if autopsy or delayed funeral
8. Return belongings Return belongings to NOK with signed receipt; unclaimed items held per facility policy Valuables may require two-person verification
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Infection control: Standard precautions (gloves, plastic apron, eye protection if splash risk) must be worn during all last offices. For notifiable infectious diseases (e.g., COVID-19, tuberculosis, viral haemorrhagic fever), enhanced precautions apply — consult the Infection Prevention and Control team and state/territory public health unit. The body should not be washed if an autopsy is anticipated and infection risk exists.

Cultural Rites

Australia is one of the most culturally and religiously diverse nations globally. In the 2021 Census, over 30% of Australians were born overseas, and more than 100 religions are practised. Healthcare facilities must be prepared to accommodate a wide range of post-mortem cultural and religious practices.

Key Cultural and Religious Practices

Faith / Culture Key Post-Mortem Practices Time Considerations Facility Accommodations
Islam Ritual washing (ghusl) by same-gender family or community members; body wrapped in white shroud (kafan); face turned towards Mecca (right side); no embalming preferred Burial within 24 hours strongly preferred Provide private room for washing; allow family access promptly; accommodate qibla orientation
Judaism Ritual washing (tahara) by the chevra kadisha (burial society); simple white shroud (tachrichim); no embalming; no autopsy unless legally mandated; shomer (guardian) stays with the body continuously Burial within 24 hours; avoid Shabbat (Friday sunset–Saturday sunset) Allow chevra kadisha access; facilitate shomer presence; avoid autopsy unless coronial requirement
Hinduism Body washed and dressed by family; placed on the floor or in a specific position; may be anointed with sandalwood, turmeric, or oils; cremation preferred; organs generally not donated (varies) Cremation ideally within 24 hours Provide floor space if requested; allow anointing rituals; facilitate prompt release
Buddhism Body should not be touched for several hours after death (traditionally 4–8 hours); monks or family may chant; body washed and dressed in simple clothing; cremation common Allow 4–8 hours of non-disturbance if possible Leave body undisturbed for requested period; accommodate chanting; allow incense if fire regulations permit
Christianity (varied) Prayer and blessing by clergy; body washed and dressed; viewing/visitation common; embalming and open casket acceptable in many denominations Flexible; burial or cremation within days Allow clergy access; facilitate family viewing; accommodate specific denominational requests
Sikhism Body washed and dressed by family; prayers (Sukhmani Sahib) recited; cremation preferred; no embalming; Kirpan (ceremonial dagger) may be present Cremation ideally within 24–72 hours Allow family washing; accommodate prayer; facilitate prompt transfer to funeral home
Chinese cultural practices Body washed and dressed; white clothing for mourning; coins or jade may be placed with the body; red clothing avoided; viewing and vigils common Variable; may be several days Allow family participation; accommodate placement of personal items; respect specific taboos (e.g., mirror avoidance near the body)
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Best practice: Do not assume a person's cultural or religious practices based on their name or appearance. Always ask the family (or the person's documented advance care plan) about their specific wishes. Cultural liaison officers, hospital chaplains, and multicultural health workers are invaluable resources.

Facility Preparedness

  • Maintain a current cultural and religious resource directory with local contacts for major faith communities.
  • Ensure mortuary and viewing rooms can accommodate religious requirements (e.g., qibla direction, floor-level positioning).
  • Stock culturally appropriate shrouds, white sheets, and privacy screens.
  • Train all staff involved in last offices on cultural safety, including basic awareness of major religious practices around death.
  • Display culturally inclusive signage and information about bereavement support services in multiple languages.

Family Participation

Involving family members in the care of the deceased's body is a therapeutic intervention that can significantly support the grief process. Research consistently shows that families who participate in or witness last offices report lower rates of complicated grief, greater acceptance of the death, and a stronger sense of having honoured their loved one.

Principles of Family Participation

  • Offer, don't impose: Inform families that they are welcome to participate in washing, dressing, and positioning the body, but never pressure them. Some families may decline, and this must be respected.
  • Guide and support: A nurse or healthcare worker should be present to guide the family, answer questions, manage practical aspects (water temperature, positioning), and provide emotional support.
  • Accommodate extended family and community: In many cultures (e.g., Aboriginal and Torres Strait Islander, Pacific Islander, Middle Eastern, South Asian), extended family or community members may wish to participate or be present. Facilitate this with appropriate space and privacy.
  • Allow time: There is no rush. Families may wish to sit with the body, talk, pray, sing, or simply be still. Allow as much time as is practically possible.
  • Support children: Children who wish to see or participate should be supported with age-appropriate preparation. Evidence shows that honest, supported exposure to death can reduce childhood anxiety and promote healthy grief processing.

Viewing the Body

Viewing should be facilitated whenever requested and is safe to do so. Best practice includes:

  • Prepare the body and the environment before the family arrives — ensure the person looks peaceful, the room is clean and private, and lighting is soft.
  • Brief the family on what to expect (e.g., coolness of the skin, colour changes, presence of medical devices that could not be removed).
  • Offer the family time alone with the body if desired.
  • In cases of traumatic death, offer to cover disfigured areas and discuss with the family what they may see. Consider involving a bereavement counsellor or social worker.
  • Document the viewing in the clinical record, including who attended and any concerns raised.
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Evidence base: A systematic review by Lundorff et al. (2017) in Death Studies found that viewing the body after death was associated with lower levels of avoidance and intrusion symptoms in bereaved adults, provided it was a voluntary and supported experience.

Coronial Restrictions

In Australia, each state and territory has its own Coroners Act that defines the circumstances under which a death must be reported to the coroner. Understanding these requirements is critical for all healthcare professionals, as failure to report a reportable death is a legal offence in all Australian jurisdictions.

When to Refer to the Coroner

A death is reportable to the coroner when any of the following apply (broadly consistent across all Australian jurisdictions):

  • The cause of death is unknown.
  • The death was violent, unnatural, or unexpected.
  • The death occurred during or as a result of an anaesthetic procedure.
  • The death occurred in custody or in care (e.g., prison, immigration detention, mental health facility, aged care).
  • The death was due to an industrial disease or occurred in the course of employment.
  • The death occurred in suspicious circumstances.
  • The identity of the deceased is unknown.
  • A Medical Certificate of Cause of Death (MCCD) cannot be issued (e.g., the treating doctor is unable to determine the cause).
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Critical rule: When a coronial referral is made, the body must NOT be washed, moved, or otherwise disturbed until authorised by the coroner or police. All lines, drains, tubes, and medical devices must be left in situ unless clinically contraindicated (e.g., a central line that may contaminate a crime scene, as directed by police). Failure to preserve the body may constitute an offence and compromise the investigation.

Impact on Last Offices

Aspect Standard Death Coronial Referral
Washing the body Performed as part of last offices Do NOT wash until coroner authorises
Removing devices/lines Remove IV lines, catheters, drains Leave all devices in situ unless directed otherwise
Dressing the body Clean gown or shroud applied Cover with sheet only; do not dress
Positioning Limbs straightened, mouth closed Body left as found; minimal handling
Identification Wrist/ankle identification band Identification band applied; police may also attach tags
Transfer to mortuary Facility mortuary or funeral director State/territory coronial mortuary (e.g., Victorian Institute of Forensic Medicine)
Autopsy Only if requested by family or clinically indicated Coroner-authorised autopsy; may include forensic examination, toxicology, histology
Organ/tissue donation Australian Organ Donor Register checked; family approached Donation may still proceed with coroner approval — contact DonateLife early
Release timeline Generally within 24–48 hours Variable; can be days to weeks depending on investigation complexity

State and Territory Coronial Contacts

Jurisdiction Coronial Authority 24-Hour Contact
NSW NSW State Coroner's Court 1300 889 030
VIC Coroners Court of Victoria / VIFM 1300 309 525
QLD Queensland Courts — Coronial 1300 304 605
WA State Coroner's Office WA (08) 9425 2900
SA SA Courts — Coronial 1800 671 183
TAS Tasmanian Coronial Office (03) 6165 7500
NT NT Coroner's Office (08) 8999 6270
ACT ACT Coroner's Court (02) 6207 1896
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Organ and tissue donation: Coronial referral does NOT automatically preclude organ or tissue donation. Contact the DonateLife agency (1800 693 666) as early as possible to discuss eligibility. The coroner must give consent for organ recovery, but this is frequently granted. Time-critical donations (e.g., heart, lungs, liver) require urgent coordination between the coroner, DonateLife, and the transplant team.

Infection Control Considerations

Bodies of deceased persons may harbour transmissible pathogens. While the risk to healthcare workers performing last offices is generally low with standard precautions, enhanced measures are required in specific circumstances.

Risk Categories

Standard Risk
Routine Deaths
Deaths from known chronic illness, cancer, cardiovascular disease with no active infection
Precautions: Standard — gloves, plastic apron, hand hygiene
Moderate Risk
Known Blood-Borne Virus or MRSA
HIV, hepatitis B/C, multi-drug resistant organisms (MDRO), active MRSA colonisation
Precautions: Gloves, fluid-resistant gown, eye protection if splash risk; minimise handling; double-bag body
High Risk
Notifiable Infectious Disease
COVID-19, tuberculosis, viral haemorrhagic fever (VHF), measles, pertussis
Precautions: Full PPE per IPC guidelines; body placed in sealed leak-proof bag; no washing or viewing without IPC approval; consult state/territory public health unit

Pacemaker and ICD Removal

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Cremation safety: Pacemakers and ICDs must be removed before cremation. The lithium battery can explode under cremation temperatures, damaging the crematorium and posing a risk to staff. A medical officer or trained technician should remove the device, and the removal must be documented. This is mandated by all Australian state and territory cremation regulations.

Handling Deceased Persons with Notifiable Diseases

  • COVID-19: Place body in a body bag within the room; seal the bag; do not wash or perform mouth-to-mouth procedures; limit personnel; use N95/P2 respirator, gown, gloves, eye protection during handling.
  • Tuberculosis (active pulmonary): Body bagging recommended; limit autopsy and embalming exposure; notify the funeral director of diagnosis.
  • Viral haemorrhagic fever (e.g., Ebola): Body must remain in the isolation room; only trained personnel in full PPE may handle the body; immediate notification to the Chief Health Officer and state/territory public health unit; cremation may be mandated.

Special Populations

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Paediatric Deaths
Stillbirths, neonatal deaths, and childhood deaths require exceptional sensitivity and specialised support.
Offer parents the opportunity to hold, bathe, dress, and photograph their child. Memory-making (hand/footprints, locks of hair, photography) is strongly encouraged and is standard practice in Australian neonatal and paediatric units.
A CuddleCot™ (cooling mattress) may be available to allow extended time with the baby's body at the bedside.
Perinatal deaths should be managed according to the Perinatal Society of Australia and New Zealand (PSANZ) guidelines, including placental examination and autopsy discussion.
Coronial referral is mandatory for sudden infant death (SIDS/SUDI) — do not disturb the sleeping environment; follow the SIDS investigation protocol.
Staff support: Paediatric and neonatal deaths are emotionally devastating for healthcare workers. Routine debriefing and access to employee assistance programmes (EAPs) must be provided.
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Elderly / Residential Aged Care
Deaths in residential aged care facilities (RACFs) account for approximately one-third of all Australian deaths. Staff in RACFs may have limited training in last offices.
Aged care facilities must have clear policies aligned with the Aged Care Quality Standards (Standard 8 — Organisational Governance) for care after death.
Many residents have documented advance care plans that may include preferences for care after death — consult the plan.
Families of aged care residents may wish to take the deceased home for a vigil before transfer to the funeral director — this is legally permissible in all Australian jurisdictions and should be supported.
Ensure documentation includes the time of the last welfare check, the time death was discovered, and the circumstances of discovery (expected vs. unexpected).
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Renal Dialysis Patients
Patients on dialysis may have arteriovenous fistulae (AVF) or central venous catheters (CVC) that should be removed or documented before transfer.
For AVF, no specific post-mortem intervention is required, but the site should be noted. For CVCs, removal and site dressing is standard unless coronial referral applies.
Dialysis patients may have complex medication regimens — ensure the medication chart is available for the MCCD.
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Immunocompromised Patients
Patients who were immunocompromised (e.g., transplant recipients, chemotherapy patients, HIV/AIDS) may have been treated with precautions during life.
Bodies of immunocompromised patients may harbour unusual or resistant organisms — maintain standard precautions and consult IPC if there is concern.
Transplanted organs may remain viable for tissue donation post-mortem — contact DonateLife if appropriate.
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Patients with Implanted Devices
Pacemakers, ICDs, deep brain stimulators, cochlear implants, insulin pumps, and other implanted devices require specific post-mortem management.
Pacemakers/ICDs: Must be removed before cremation. May be left in situ for burial.
Deep brain stimulators, spinal cord stimulators: Remove before cremation; may be left for burial.
Cochlear implants: Generally left in situ for both burial and cremation (minimal risk).
All device removals must be documented by a medical officer and recorded in the clinical notes.
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Maternal Deaths
All maternal deaths in Australia are notifiable to the relevant state/territory maternal mortality audit committee and, in many jurisdictions, to the coroner.
If the mother was pregnant at the time of death, the viability of the fetus and the possibility of emergency caesarean section should be considered immediately after maternal death is confirmed.
Maternal death reviews are conducted by the Australasian Maternity Outcomes Surveillance System (AMOSS) and contribute to national quality improvement.
Ensure coordination between the coroner, the maternity team, and the family regarding any post-mortem examination.

Aboriginal and Torres Strait Islander Health Considerations

Aboriginal and Torres Strait Islander Health

Death, dying, and care of the deceased's body are among the most culturally significant events in Aboriginal and Torres Strait Islander communities. Practices surrounding sorry business are deeply spiritual, vary significantly between communities and language groups, and are often governed by strict cultural protocols. Healthcare workers must approach these situations with humility, respect, and a willingness to follow community guidance.

Key Cultural Considerations

  • Sorry business: The period of mourning (sorry business) is a communal event that may involve extended family, community elders, and ceremonial practices over days to weeks. The term "sorry business" encompasses all mourning activities and should be used respectfully.
  • Avoidance of the deceased's name: In many communities, it is culturally inappropriate to speak the name of the deceased person or display their photograph after death. This practice may persist for months or indefinitely. Staff should ask the family about this protocol and comply.
  • Smoking ceremony: A smoking ceremony (burning of native plants such as eucalyptus or sandalwood) may be performed to cleanse the body, the room, or the ward. Facilities should accommodate this wherever fire safety can be managed — consider outdoor or well-ventilated spaces.
  • Keeping the body close: Many Aboriginal and Torres Strait Islander families wish to remain with the body continuously from death until burial. This may involve large numbers of family members staying in or near the room, sometimes for extended periods. Facilitate this with appropriate space, seating, and cultural support.
  • Skin name and kinship obligations: In some communities, specific kinship obligations govern who may touch, wash, or prepare the body. Ask the family or an Aboriginal Health Worker (AHW) or Aboriginal Liaison Officer (ALO) about these protocols.
  • Return to country: Many Aboriginal and Torres Strait Islander people have a strong desire to be returned to their country (traditional land) for burial. This may involve long-distance transport arrangements and coordination with community. Funeral costs for returning to country can be significant — refer families to relevant support services (e.g., Aboriginal Community Controlled Health Organisations, state/territory Aboriginal funeral assistance schemes).
  • Autopsy reluctance: Autopsy may be culturally distressing and is often opposed. Where a coronial autopsy is required, explain the legal obligation sensitively and involve an AHW/ALO or cultural liaison officer in the conversation.
  • Artwork and cultural objects: Sacred or ceremonial objects, ochre, or other cultural items may need to be placed with or near the body. Facilitate this where safe and practical.

Systemic Barriers and Solutions

Remote and rural access
Deaths in remote communities may occur far from healthcare facilities. Ensure community health centres have adequate last offices supplies, training, and 24-hour access to medical officers for death certification. The Royal Flying Doctor Service (RFDS) may assist with medical certification and body transfer.
Funeral cost burden
Funeral costs, particularly for return to country, can be prohibitive. Aboriginal and Torres Strait Islander families may access state/territory funeral assistance (e.g., Aboriginal Funeral Assistance programs), Indigenous-specific grants, and community fundraising. Social workers should be involved early.
Cultural safety in hospitals
Hospitals can be culturally unsafe environments for Aboriginal and Torres Strait Islander families during sorry business. Provide dedicated culturally safe spaces, avoid restricting family access, employ Aboriginal Health Workers and Liaison Officers, and display Acknowledgement of Country signage.
Coronial investigations
Aboriginal and Torres Strait Islander people are disproportionately represented in coronial investigations, including deaths in custody. This can compound grief and mistrust of the health and legal systems. Advocate for culturally informed coronial processes and support families through the investigation.
Workforce training
All staff involved in last offices must receive cultural safety training that includes specific content on Aboriginal and Torres Strait Islander sorry business. This should be co-designed with Aboriginal and Torres Strait Islander communities and delivered by Aboriginal educators where possible.
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Key resource: The Australian Indigenous HealthInfoNet (healthinfonet.ecu.edu.au) provides culturally appropriate resources for healthcare workers. The Aboriginal Community Controlled Health Organisation (ACCHO) network can provide local cultural guidance and support for bereaved families. Always involve an Aboriginal Health Worker or Liaison Officer when caring for Aboriginal and Torres Strait Islander patients and families during sorry business.

Staff Wellbeing & Organisational Governance

Caring for the deceased's body can be emotionally taxing, particularly after prolonged illness, traumatic death, paediatric death, or when the deceased is known to the staff member. Organisations have a duty of care to support their staff.

Organisational Requirements

  • Policies and procedures: Every healthcare facility must have a current, evidence-based policy for care of the deceased's body that covers all aspects outlined in this article, including coronial referral pathways, infection control, cultural safety, and device removal.
  • Checklists: Standardised last offices checklists should be available at every point of care (wards, emergency departments, operating theatres, aged care facilities). Checklists reduce error and ensure consistency.
  • Training: All clinical staff should receive training in last offices during orientation and at regular intervals. Training should include cultural safety, coronial processes, infection control, and communication with bereaved families.
  • Debriefing: Formal debriefing should be offered after all paediatric deaths, traumatic deaths, multiple simultaneous deaths, and any death that significantly affects the team. Access to Employee Assistance Programmes (EAPs) must be readily available.
  • Spiritual and pastoral care: Multifaith chaplaincy or spiritual care services should be available 24/7 to support both families and staff.
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NSQHS Standards alignment: Care of the deceased's body aligns with NSQHS Standard 1 (Clinical Governance), Standard 2 (Partnering with Consumers — family participation), Standard 5 (Comprehensive Care), and Standard 8 (Recognising and Responding to Acute Deterioration — in the context of death recognition and documentation).

📚 References

  1. 1. Australian Bureau of Statistics. Deaths, Australia, 2022. ABS Cat. No. 3302.0. Canberra: ABS; 2023.
  2. 2. Australian Commission on Safety and Quality in Health Care (ACSQHC). National Safety and Quality Health Service Standards. 2nd ed. Sydney: ACSQHC; 2021.
  3. 3. Lundorff M, Holmgren H, Zachariae R, et al. Prevalence of prolonged grief disorder in adult bereavement: a systematic review and meta-analysis. J Affect Disord. 2017;212:138–149.
  4. 4. Coroner's Court of Victoria. Guidance for medical practitioners: reportable deaths and coronial processes. Melbourne: Coroners Court of Victoria; 2022.
  5. 5. Australian Institute of Health and Welfare (AIHW). Aboriginal and Torres Strait Islander Health Performance Framework: Summary report 2023. Cat. No. IHPF 2. Canberra: AIHW; 2023.
  6. 6. Perinatal Society of Australia and New Zealand (PSANZ). Clinical Practice Guideline for Perinatal Mortality. 3rd ed. PSANZ; 2018.
  7. 7. DonateLife Australia. National Protocol for Donation after Circulatory Death. Canberra: Organ and Tissue Authority; 2022.
  8. 8. World Health Organization (WHO). Infection prevention and control of epidemic- and pandemic-prone acute respiratory infections in health care. Geneva: WHO; 2014. Updated guidance for COVID-19, 2020.
  9. 9. Aged Care Quality and Safety Commission. Aged Care Quality Standards. Canberra: Australian Government; 2019.
  10. 10. Aboriginal Health & Medical Research Council of NSW (AH&MRC). Cultural Respect Guide 2024: A guide for health services working with Aboriginal communities. Sydney: AH&MRC; 2024.
  11. 11. Royal Australian College of General Practitioners (RACGP). Supporting patients who are dying: A guide for GPs. 4th ed. Melbourne: RACGP; 2020.
  12. 12. Australasian College for Emergency Medicine (ACEM). Policy on management of death in the emergency department. Melbourne: ACEM; 2021.
  13. 13. Department of Health and Aged Care. National Palliative Care Strategy 2018. Canberra: Australian Government; 2018.
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).