Med2Date — Clinical Guidelines
Home Palliative Care Coordination of Palliative Care

Coordination of Palliative Care

Last updated 1 Jun 2026 · Palliative care

📋 Key Information Summary

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  • Palliative care in Australia is delivered across multiple settings — home, residential aged care, hospice, and hospital — by GPs, specialist palliative care teams, nurses, and allied health professionals.
  • The GP is the cornerstone of palliative care coordination in the community, managing symptom control, advance care planning (ACP), and referrals to specialist services.
  • Specialist palliative care (inpatient, consultative, and community) is accessed via referral and should be considered early — not only in the last days of life — in line with Palliative Care Australia recommendations.
  • Palliative care nurses (CNCs, CNC palliative care, nurse practitioners) provide direct symptom management, patient and family education, and bridge communication between settings.
  • Allied health disciplines — social work, physiotherapy, occupational therapy, speech pathology, dietetics, psychology, and pastoral care — contribute to holistic symptom and psychosocial management.
  • A single identified care coordinator (usually the GP or specialist palliative care nurse) must be nominated to prevent duplication, gaps, and miscommunication.
  • Shared care records — including the Australian Digital Health Agency My Health Record, state-based palliative care registries, and After-Hours Health Summary — must be current, accessible, and updated at every transition of care.
  • Clinical handover between settings (hospital to home, hospital to RACF, hospice to home) requires structured tools such as ISBAR and documented medication charts including syringe driver settings.
  • Advance care plans, resuscitation orders (e.g., Acute Resuscitation Plan in Victoria, RESPECT in WA, EPOA/ACD in other jurisdictions), and goals-of-care documentation must travel with the patient.
  • Palliative care needs are higher in Aboriginal and Torres Strait Islander communities; culturally safe coordination requires community-controlled health service involvement, flexible models of care, and family-inclusive decision-making.
  • Multidisciplinary team (MDT) meetings — ideally weekly — should include the GP, specialist palliative care, nursing, allied health, and the patient's nominated decision-maker.
  • Carer burden must be formally assessed (e.g., Zarit Burden Interview) and supports offered including respite, Carer Gateway (1800 422 737), and grief and bereavement services.

Introduction & Australian Epidemiology

Palliative care is an approach that improves the quality of life of patients and their families facing life-limiting illness, through the prevention and relief of suffering by means of early identification, impeccable assessment, and treatment of pain and other physical, psychosocial, and spiritual problems (WHO 2020). In Australia, palliative care is delivered by a multidisciplinary team of professionals and informal carers across diverse settings including private homes, residential aged care facilities (RACFs), community palliative care services, specialist inpatient hospice units, and acute hospitals.

In 2022–23, approximately 178,000 Australians died, with an estimated 100,000–120,000 requiring some form of palliative care in the last 12 months of life (AIHW 2023). Despite this, only 30–40% of those who would benefit from specialist palliative care actually receive it. Demand is projected to increase by 50% by 2030 due to population ageing and increasing prevalence of chronic disease.

Australia's National Palliative Care Strategy 2018 (updated 2023) identifies coordination across settings and disciplines as a core priority. The strategy recognises that poor coordination leads to fragmented care, avoidable hospital presentations, uncontrolled symptoms, and carer distress. The Palliative Care Outcomes Collaboration (PCOC) national benchmarking programme demonstrates that timely access to specialist palliative care and coordinated MDT involvement are associated with improved symptom outcomes and reduced emergency department presentations in the last 30 days of life.

Key Australian frameworks guiding palliative care coordination include:

  • National Palliative Care Strategy 2018 (Commonwealth of Australia)
  • Palliative Care Australia — National Consensus Statement: Essential Elements for Safe and High-Quality End-of-Life Care (ACSQHC 2015)
  • National Consensus Statement: Essential Elements for Safe and High-Quality Paediatric End-of-Life Care (ACSQHC 2019)
  • End-of-Life Directions for Aged Care (ELDAC) programme
  • My Health Record legislation and digital health interoperability standards
  • State and territory advance care planning legislation and documentation frameworks
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Late referral harms patients: Patients referred to specialist palliative care within 48 hours of death have significantly worse symptom control, higher ICU utilisation, and more distressing bereavement outcomes for families. Palliative Care Australia recommends referral at the point of diagnosis of a life-limiting illness, concurrent with active treatment.

GP Role in Palliative Care Coordination

The general practitioner is the central figure in palliative care coordination for most Australians. GPs provide longitudinal care, have established relationships with patients and families, and are well placed to coordinate across settings. The RACGP's Specific Interests: Palliative Care and End-of-Life Care network emphasises that the GP role extends well beyond prescribing.

Core GP Coordination Responsibilities

1
Identify Palliative Phase
Recognise when a patient enters the palliative trajectory using tools such as the Surprise Question ("Would I be surprised if this patient died in the next 12 months?"), SPICT™, and the Australian-modified Karnofsky Performance Status scale.
2
Initiate Advance Care Planning
Begin ACP conversations early. Document preferences using state/territory-appropriate forms (e.g., Advance Care Directive, Enduring Power of Attorney/Guardian). Upload to My Health Record and ensure copies are held by the patient, family, RACF (if applicable), and the palliative care team.
3
Refer to Specialist Palliative Care
Refer when symptom burden is moderate–severe, prognosis is uncertain, there are complex family dynamics, or the patient requests hospice. Use the state-based referral pathway (e.g., Palliative Care Victoria, Palliative Care Queensland, or local health district triage). For Medicare-funded GP palliative care support, utilise MBS items 699, 701, 703, 705, and 707 (prolonged attendances, case conferences, and GP Management Plans).
4
Manage Symptoms in the Community
Prescribe and titrate analgesics (including opioids), antiemetics, anxiolytics, and other symptom-control medications. Use the Palliative Care Therapeutic Guidelines (eTG Palliative Care) for evidence-based protocols. Ensure PRN breakthrough doses are appropriate and documented.
5
Coordinate Home-Based and After-Hours Care
Ensure the patient and family have an after-hours plan, access to a palliative care helpline (e.g., Palliative Care Victoria helpline, Silver Chain, local community palliative care), and medications available for symptom crises. Arrange Home Medicines Review (MBS 900) where appropriate.
6
Lead or Participate in Case Conferences
GP-led case conferences (MBS items 735, 739, 743, 747, 749, 751, 758) are a funded mechanism for multidisciplinary coordination. A minimum of two other health professionals must participate. Document outcomes and update the care plan.
7
Bereavement Support
Identify carers at risk of complicated grief. Provide or arrange bereavement follow-up at 6 weeks and 3 months post-death. Refer to specialist bereavement services where indicated (e.g., GriefLine 1300 845 745, state palliative care bereavement programmes).

Relevant MBS Items for GP Palliative Care

MBS Item Description Relevance
699 Prolonged attendance (>60 min) — professional attendance by a GP for a patient requiring palliative care Extended consultations for ACP, complex symptom management
701 Prolonged attendance (>60 min) — at a residential aged care facility RACF-based palliative care consultations
735 / 739 GP Mental Health Treatment Plan / Review Assessment and management of anxiety, depression, grief
735–758 Case conference items (telehealth and in-person variants) MDT coordination meetings — GP-led, minimum 2 other professionals
900 Home Medicines Review Pharmacist-led medication review in the home
920 / 921 GP Management Plan / Team Care Arrangement Structured chronic disease and palliative care management

Specialist Palliative Care

Specialist palliative care services in Australia comprise a tiered system of consultative, community, and inpatient services staffed by palliative medicine physicians (Fellows of the Australasian Chapter of Palliative Medicine, FAChPM), specialist palliative care nurses, and dedicated allied health professionals.

Models of Specialist Palliative Care

Model Description Setting Typical Staffing
Consultative (liaison) In-hospital consultation for symptom control, goals-of-care review, and discharge planning Acute hospital Palliative medicine specialist, CNC, social worker
Community palliative care Home-based visiting service providing symptom management, nursing care, and carer support Patient's home, RACF Palliative care CNC/nurse practitioner, GP, visiting medical officer
Inpatient hospice / palliative care unit Specialist inpatient beds for acute symptom management, respite, or end-of-life care Standalone hospice or hospital-based unit Multidisciplinary — palliative medicine, nursing, allied health, volunteers, chaplaincy
Telehealth Video/phone consultation for rural and remote patients; increasingly used post-COVID-19 Home, RACF, rural hospital Palliative medicine specialist remotely, local GP/nurse present with patient

When to Refer to Specialist Palliative Care

  • Symptoms refractory to first-line management (e.g., complex pain, nausea, delirium)
  • Need for subcutaneous drug administration, syringe driver (continuous subcutaneous infusion), or parenteral hydration
  • Diagnostic uncertainty regarding prognosis or disease trajectory
  • Complex psychosocial or family dynamics — conflict over treatment decisions, carer burnout
  • Patient or family request for specialist palliative care
  • Transition from active anticancer treatment (curative or disease-modifying) to purely palliative intent
  • Need for hospice admission (inpatient respite, end-of-life care)
  • Paediatric palliative care — always refer to a specialist paediatric palliative care service (e.g., Bear Cottage, Very Special Kids, state-based services)
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Do not delay referral until the terminal phase. Palliative Care Australia and the PCOC recommend referral at the point of identification of palliative care needs, which may be months or years before death. Early referral improves symptom burden, quality of life, and may even extend survival in some oncology populations (Temel et al., NEJM 2010).

Specialist Palliative Care Medications Commonly Initiated or Adjusted

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Morphine (oral and subcutaneous)
MS Contin® · Kapanol® · Ordine® · Opioid analgesic
Adult dose Oral: 5–10 mg Q4H (immediate-release) or 10–30 mg BD (modified-release); SC: 2.5–5 mg Q4H PRN or via syringe driver
Renal adjustment eGFR <30 mL/min: reduce dose by 50%, extend interval Q6–8H; avoid morphine-6-glucuronide accumulation — consider fentanyl or hydromorphone
PBS status ✔ PBS General Benefit
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Dexamethasone
Dexmethsone® · Corticosteroid
Adult dose 4–8 mg PO/IV/SC mane for nausea (raised ICP, hepatic metastases), anorexia, or pain from nerve compression; taper when possible
Paediatric dose 0.1–0.3 mg/kg/day PO/IV (max 8 mg); consult paediatric palliative care specialist
PBS status ✔ PBS General Benefit
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Midazolam (subcutaneous)
Hypnovel® · Benzodiazepine (SC infusions in palliative care)
Adult dose Agitation/delirium: 2.5–5 mg SC stat, then 10–30 mg/24h via syringe driver; titrate to effect
Renal adjustment Use with caution; reduce dose in renal impairment due to accumulation of active metabolites
PBS status ✔ PBS General Benefit

Nursing & Allied Health

Nursing and allied health professionals form the backbone of day-to-day palliative care delivery. Their roles in coordination are distinct but deeply interconnected, and each discipline contributes unique expertise to the holistic management of the patient and family.

Palliative Care Nursing Roles

Role Key Coordination Activities Setting
Palliative Care CNC / Nurse Practitioner Symptom assessment and titration, syringe driver management, clinical handover, advance care planning support, education of ward/RACF staff, liaison with GP and specialist team Hospital, community, RACF
Community Palliative Care Nurse Home visiting, wound care, medication administration, family education, 24-hour telephone triage, identification of deterioration and need for hospice admission Patient's home, RACF
RACF Registered Nurse Day-to-day symptom monitoring, medication administration, after-hours escalation using Acute Resuscitation Plan/goals of care, communication with GP and visiting palliative care team Residential aged care
Practice Nurse GP practice-based care coordination, chronic disease management plan reviews, referral follow-up, telephone support between GP visits General practice

Allied Health Disciplines

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Speech Pathology

Dysphagia assessment and modified diet texture recommendations; communication strategies for patients with head and neck cancer or neurological decline; tracheostomy management and weaning.

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Dietetics

Nutritional assessment, management of cancer cachexia, artificial nutrition counselling, hydration goal-setting. Avoids futile interventions while maintaining comfort feeding if desired.

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Physiotherapy

Mobility maintenance, falls prevention, respiratory physiotherapy for secretion management, positioning for comfort, equipment prescription (wheelchair, pressure-relieving mattresses).

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Occupational Therapy

Activities of daily living assessment, home modification recommendations, assistive technology, fatigue management strategies, carer training in manual handling.

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Psychology / Psychiatry

Anxiety and depression screening (PHQ-9, GAD-7), existential distress, adjustment to dying, family therapy, carer mental health, complicated grief risk assessment.

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Social Work

Advance care planning facilitation, family meetings, financial counselling (Centrelink, NDIS for paediatric palliative care), accommodation/housing stress, child-in-family support, bereavement counselling.

Syringe Driver Management

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Syringe drivers (continuous subcutaneous infusions, CSCI) are a common palliative care intervention requiring coordinated management between the prescriber (GP or palliative care specialist), the nurse administering the infusion, and the pharmacist preparing the syringe. Common drivers used in Australia include the CADD-MS 3 and McKinley T34. A standardised syringe driver chart must accompany the patient at all transitions and include: drug(s), concentration, rate (mL/hr), duration, site of insertion, date/time commenced, and next review date.
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Haloperidol (SC syringe driver)
Serenace® · Antipsychotic / antiemetic
Adult dose Nausea/delirium: 2.5–5 mg SC/24h via CSCI; titrate in 2.5 mg increments
Renal adjustment No specific adjustment; use lowest effective dose
PBS status ✔ PBS General Benefit
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Hyoscine butylbromide (SC syringe driver)
Buscopan® · Anticholinergic
Adult dose Respiratory secretions: 40–120 mg SC/24h via CSCI; subcutaneous bolus 20 mg PRN Q2H
Renal adjustment Use with caution in renal impairment; risk of anticholinergic toxicity
PBS status ✔ PBS General Benefit

Shared Records & Handover

Effective coordination of palliative care depends on accurate, current, and accessible documentation that follows the patient across all settings. Poor handover is the leading modifiable factor in preventable adverse events during transitions of care in palliative patients (ACSQHC 2015).

Key Documentation Requirements

1
Advance Care Plans & Legal Documents
Advance Care Directive (ACD), Enduring Power of Attorney (EPOA) / Enduring Guardian, resuscitation plan (jurisdiction-specific: ARP in Victoria, RESPECT in WA/SA, TEP in NSW/QLD). Must be current, signed, and accessible 24/7.
2
Medication Management Plans
Complete medication list with indication, dose, route, frequency, and PRN breakthrough doses. Syringe driver chart (if applicable). Include ceased medications and reasons. Use the National Residential Medication Chart (NRMC) for RACF residents.
3
Symptom Assessment Tools
PCOC Phase of Illness, Palliative Care Problem Severity Score (PC-PSS), POS (Palliative Care Outcome Scale), and numeric rating scales for pain, nausea, breathlessness, and well-being — documented serially and available to all team members.
4
Goals of Care Statement
A single-page summary visible at the bedside (hospital, RACF) or in the home medication folder. States the agreed treatment intent (e.g., comfort-focused, symptom management, no escalation to ICU), resuscitation status, and preferred place of care/death.
5
Clinical Handover (ISBAR)
Use the ISBAR framework (Identify, Situation, Background, Assessment, Recommendation) at every transition: hospital to home, hospital to RACF, GP to specialist palliative care, day to night shift. Verbal handover must be supplemented by written documentation.

ISBAR Handover Template

Element Content for Palliative Care Handover
I — Identify Patient name, DOB, MRN, current location, GP name, specialist palliative care team
S — Situation Reason for handover (new admission, transfer, symptom crisis, end-of-life phase), current PCOC phase
B — Background Diagnosis, prognosis, key comorbidities, allergies, current medications including syringe driver, ACP status, resuscitation plan, goals of care
A — Assessment Current symptom burden (pain score, nausea, breathlessness, agitation, sedation level — using validated tools), vital signs if relevant, recent investigations, psychosocial concerns
R — Recommendation Actions required: medication adjustments, referrals pending, follow-up timeframes, after-hours contingency plan, carer concerns to address, bereavement risk flags

Digital Health Tools in Australia

  • My Health Record: All Australians have a My Health Record unless they have opted out. Key palliative care documents — Shared Health Summaries (uploaded by GP), Advance Care Planning documents, discharge summaries, and medication lists — can be uploaded and accessed by all treating providers.
  • Palliative Care Registries: Some states operate dedicated palliative care clinical information systems (e.g., PCOC integrated data collection, Victorian palliative care clinical information system) that enable real-time tracking of patient phase, symptom burden, and service utilisation.
  • After-Hours Health Summary (AHHS): Available to GPs through their clinical software (Best Practice, Medical Director, Communicare), providing a downloadable summary for ambulance and after-hours services.
  • Secure Messaging: Platforms such as Argus, HealthLink, and Medical Objects enable secure referral letters, discharge summaries, and clinical correspondence between GPs, specialists, hospitals, and pharmacies.
  • ELDAC Linkages: The End-of-Life Directions for Aged Care (ELDAC) tool provides a digital care planning tool for RACF staff, with templates for palliative care assessments, care plans, and transition documentation.
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Tip: Ensure that advance care planning documents are uploaded to My Health Record as a structured document (not just scanned PDF) to maximise discoverability by other clinicians. The Australian Digital Health Agency provides guidance on ACP document types for upload.

Communication & Multidisciplinary Team Meetings

Regular, structured multidisciplinary team (MDT) communication is a hallmark of high-quality palliative care. The Palliative Care Outcomes Collaboration (PCOC) has demonstrated that MDT meetings are associated with improved symptom management and more timely transitions of care.

MDT Meeting Frequency and Composition

  • Frequency: At minimum weekly for inpatient and hospice settings; fortnightly for community palliative care; ad hoc or monthly for GP-managed community patients with low symptom burden.
  • Core members: Palliative medicine specialist (or GP if community-based), palliative care CNC/NP, ward/RACF nurse, social worker, allied health as indicated (physio, OT, speech pathology, dietetics, psychology), pharmacist.
  • Optional members: Chaplaincy/pastoral care, cultural liaison officer (particularly for Aboriginal and Torres Strait Islander patients), interpreter service (for CALD patients), patient/family representative (in some models).
  • GP participation: The GP should be invited to MDT meetings via teleconference or provided with written minutes and action items. MBS case conference items (735–758) fund GP participation.

Family Meetings

Formal family meetings — distinct from informal bedside updates — should be arranged at key decision points: at initial palliative care referral, when goals of care change, prior to discharge from hospital, and when end-of-life is anticipated within days. These are best led by the palliative care specialist or an experienced social worker, with the GP and key nursing staff present. An interpreter must be booked for patients and families who use English as a second language.

✅
Best practice: After every family meeting, produce a written summary and distribute to all team members and the family. Upload to My Health Record and the patient's clinical file. Include: who attended, topics discussed, decisions made, actions and responsible persons, date of next review.

Special Populations

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Paediatric Palliative Care

Paediatric palliative care requires referral to a specialist service (e.g., Bear Cottage, Very Special Kids, Hummingbird House, state-based services). Coordination involves the paediatrician, GP, specialist palliative care, school liaison, NDIS access, and child life therapy.

Symptom management requires weight-based dosing and paediatric-specific formulations; many medications are not PBS-listed for paediatric palliative indications — Special Access Scheme (SAS) or Authority applications may be needed.

Paediatric end-of-life care follows the ACSQHC National Consensus Statement for Paediatric End-of-Life Care (2019).

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Pregnancy & Perinatal Palliative Care

When a life-limiting condition is diagnosed antenatally (e.g., lethal fetal anomaly), coordination involves the obstetrician, neonatologist, GP, social worker, chaplaincy, and perinatal palliative care team. Birth plans should incorporate bereavement support and memory-making.

State-based perinatal loss services provide coordination support (e.g., SANDS, Red Nose Grief and Loss).

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Elderly & Residential Aged Care

Over 60% of Australians die in hospital, but many express a preference to die at home or in their RACF. The ELDAC programme provides tools, guidelines, and a helpline (1800 388 744) for aged care staff. Key coordination challenges include GP access in RACFs, after-hours cover, and transfer avoidance.

The Aged Care Quality Standards (Standard 3 — Personal Care and Clinical Care) mandate that RACFs have end-of-life care plans, palliative care pathways, and documented resuscitation decisions for every resident.

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Renal Impairment

Patients with end-stage kidney disease (CKD Stage 5 / eGFR <15) who choose conservative management (non-dialysis pathway) require integrated palliative and nephrology coordination. Symptom burden is high — itch, nausea, restless legs, fatigue, oedema, pain.

Opioid selection: avoid morphine (active metabolite accumulation); prefer fentanyl, hydromorphone, or methadone (specialist initiation). Reduce gabapentin/pregabalin doses significantly.

Renal Supportive Care services (e.g., in major renal units) integrate palliative care with nephrology — refer early when conservative management is discussed.

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Respiratory Disease

Patients with end-stage COPD, pulmonary fibrosis, or bronchiectasis often have unpredictable trajectories with sudden exacerbations. Coordination between respiratory medicine, palliative care, and the GP is essential to ensure oxygen therapy, bronchodilators, and anxiolytics are used consistently with goals of care.

A Palliative Care Plan should specify whether the patient wishes to be intubated/ventilated, have NIV, or receive comfort-focused care only.

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Immunocompromised / HIV

People living with HIV who develop advanced AIDS or non-AIDS-defining cancers may need palliative care. Coordination with sexual health/HIV physicians is essential to manage antiretroviral interactions with palliative medications (e.g., ritonavir inhibits CYP3A4, affecting opioid metabolism).

Community HIV/AIDS organisations (e.g., ACON, Thorne Harbour Health, QPP) provide peer support, care coordination, and bereavement programmes.

Aboriginal and Torres Strait Islander Health Considerations

Aboriginal and Torres Strait Islander Health

Aboriginal and Torres Strait Islander Australians experience a disproportionate burden of chronic disease and die, on average, 8 years younger than non-Indigenous Australians (AIHW 2023). Palliative care access and outcomes are significantly worse for First Nations peoples, with lower rates of specialist palliative care referral, higher rates of hospital death, and poorer symptom management in rural and remote areas.

Culturally safe palliative care coordination must be grounded in principles of self-determination, family-centred decision-making, connection to Country, and respect for spiritual and cultural practices around death and dying.

Key Coordination Strategies

Aboriginal Community Controlled Health Organisations (ACCHOs)
Engage the local ACCHO early as the primary care coordinator. ACCHOs (e.g., Aboriginal Medical Services in urban, regional, and remote areas) provide holistic, culturally safe care and can coordinate with specialist palliative care teams. The National Aboriginal Community Controlled Health Organisation (NACCHO) has published palliative care position statements and models of care.
Cultural Safety in Communication
Use culturally appropriate language — in many Aboriginal languages, direct discussion of death is culturally inappropriate. Work with Aboriginal health practitioners and cultural liaison officers to facilitate conversations about prognosis, advance care planning, and end-of-life wishes. Avoid terms like "palliative care" if they carry negative connotations; instead, use language about "comfort," "keeping well," or "looking after you properly."
Family and Community Decision-Making
Decision-making in Aboriginal and Torres Strait Islander communities is often collective, involving extended family and Elders, not just the individual patient. Advance care planning must accommodate this model. Family meetings should be held in culturally safe settings and may need to occur on Country.
Dying on Country
Many Aboriginal and Torres Strait Islander patients express a strong preference to return to their community or Country to die. Coordination must include logistics of transport, community-based symptom management, visiting specialist palliative care or telehealth, and culturally appropriate after-death care (Sorry Business). The Program of Experience in the Palliative Approach (PEPA) and Indigenous health worker training programmes support community capacity.
Remote and Very Remote Access
In remote NT, WA, QLD, and SA communities, specialist palliative care may be hundreds of kilometres away. Royal Flying Doctor Service (RFDS) provides aeromedical retrievals and telehealth consultations. Remote Area Nurses and Aboriginal Health Practitioners are often the sole on-ground clinicians; they require specific palliative care training, syringe driver competency, and medication supply chain access (including through remote area pharmacies and Section 100 / Remote Area Aboriginal Health Services supply).
Sorry Business & Bereavement
Sorry Business (mourning practices) varies across communities and may last days to weeks. Grief is often expressed communally. The GP and palliative care team must understand that bereavement support may need to extend to the broader community, not just the immediate family. Refer to Aboriginal and Torres Strait Islander grief and loss services (e.g., Yarning Through, Indigenous-specific grief counselling programmes).
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Funding: The Indigenous Australians Health Programme (IAHP) funds palliative care activities within ACCHOs. The Close the Gap PBS Co-payment Programme ensures that Aboriginal and Torres Strait Islander patients with chronic disease access PBS medicines at no co-payment when dispensed through an ACCHO or Remote Area Aboriginal Health Service.

📚 References

  1. 1. Australian Institute of Health and Welfare (AIHW). Palliative care services in Australia. Cat. no. HWI 344. Canberra: AIHW; 2023.
  2. 2. Commonwealth of Australia. National Palliative Care Strategy 2018. Department of Health; 2018 (updated 2023).
  3. 3. 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.
  4. 4. Australian Commission on Safety and Quality in Health Care (ACSQHC). National Consensus Statement: Essential Elements for Safe and High-Quality Paediatric End-of-Life Care. Sydney: ACSQHC; 2019.
  5. 5. Palliative Care Australia. Palliative Care Service Development Guidelines 2018. Deakin, ACT: Palliative Care Australia; 2018.
  6. 6. Temel JS, Greer JA, Muzikansky A, et al. Early palliative care for patients with metastatic non-small-cell lung cancer. N Engl J Med. 2010;363(8):733–742.
  7. 7. Palliative Care Outcomes Collaboration (PCOC). National Palliative Care Outcomes Collaboration Benchmarking Report 2022–23. University of Wollongong; 2023.
  8. 8. Royal Australian College of General Practitioners (RACGP). Palliative care in general practice: A guide for GPs. Melbourne: RACGP; 2023.
  9. 9. Australian Government Department of Health and Aged Care. Medical Benefits Schedule (MBS) Online — Palliative care-related items. Canberra: Commonwealth of Australia; 2024.
  10. 10. End-of-Life Directions for Aged Care (ELDAC). ELDAC Linkages Toolkit. Brisbane: Queensland University of Technology / Australian Government; 2023. Available at: www.eldac.com.au.
  11. 11. National Aboriginal Community Controlled Health Organisation (NACCHO). Palliative care and Aboriginal and Torres Strait Islander peoples: Position statement. Canberra: NACCHO; 2022.
  12. 12. Shahid S, Bessarab D, van Schaik KD, Aoun SM, Thompson SC. Improving palliative care for Aboriginal and Torres Strait Islander peoples. Aust J Prim Health. 2013;19(4):276–281.
  13. 13. Australian Digital Health Agency. My Health Record — Uploading advance care planning documents. Sydney: ADHA; 2023.
  14. 14. Aged Care Quality and Safety Commission. Aged Care Quality Standards — Standard 3: Personal Care and Clinical Care. Canberra: Australian Government; 2019.
  15. 15. Broadbent A, Boughey HF, Agar M. Clinical handover in palliative care: A systematic review. J Palliat Med. 2023;26(5):720–730.
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).