Medication Management

Last updated 1 Jun 2026 · Palliative care

📋 Key Information Summary

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Medication management in palliative care aims to relieve symptoms, reduce distress, improve quality of life, and align with the patient's documented goals of care and advance care plan.
A structured medication review — ideally using the STOPPFrail or similar tool — should be performed at transition to palliative care, on each change in prognosis, and whenever new symptoms emerge.
Deprescribing is as important as prescribing; discontinue medications whose burden now outweighs benefit (e.g., statins, bisphosphonates, preventive agents in advanced illness with limited life expectancy).
Anticipatory prescribing of key symptom-relief medications (opioids, antiemetics, anxiolytics, anticholinergics) prevents crises and enables timely dose titration.
Access to medications can be challenging in rural and remote Australia; the Section 19A supply pathway, Remote Area Aboriginal Health Services, and community palliative care pharmacy services are critical enablers.
The Pharmaceutical Benefits Scheme (PBS) Palliative Care Benefits (palliative care items) provide streamlined authority access for many end-of-life medications; verify eligibility with Services Australia.
Patient and carer education must cover medication purpose, safe administration (including subcutaneous routes), side-effect recognition, and when to escalate to the palliative care team.
Parenteral opioids for breakthrough pain — subcutaneous morphine or fentanyl — should be prescribed with clear dose-conversion guidance and PRN parameters.
Delirium, dyspnoea, nausea, and existential distress are among the most common and challenging symptom clusters requiring multi-drug strategies.
Storage at home requires lockable containers; unused opioids and controlled drugs must be returned to a pharmacy for destruction under state/territory health regulations.
Aboriginal and Torres Strait Islander peoples experience higher palliative care needs with lower access; culturally safe medication counselling and Yarning-based education improve adherence and comfort.
Regular medication monitoring should include symptom-burden assessment (e.g., POS-S or IPOS), sedation scores, and renal function to guide dose adjustments.

Introduction & Australian Epidemiology

Medication management is a cornerstone of palliative care, encompassing the selection, dosing, monitoring, review, and — critically — the cessation of medications as illness progresses. The overarching goal is to maximise comfort and dignity while minimising treatment burden, in alignment with the patient's values and documented preferences.

In Australia, approximately 160,000 people die each year, and an estimated 200,000 could benefit from palliative care at any given time. Yet access remains inequitable: metropolitan residents are significantly more likely to receive specialist palliative care than those in outer regional, remote, or very remote areas. Aboriginal and Torres Strait Islander Australians experience a palliative care burden approximately 1.5 times greater than non-Indigenous Australians but access services at a lower rate (AIHW, 2023).

The National Palliative Care Strategy 2018 and the NSQHS Standards (Clinical Governance Standard, Comprehensive Care Standard) both mandate that medication safety processes — including medication reconciliation, high-risk medication management, and patient-centred prescribing — are embedded across all care settings, including the home, residential aged care, and acute hospital.

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Goals-of-care alignment: Every medication decision in palliative care must be interpreted through the lens of the patient's current goals of care. A medication that was appropriate six months ago may now represent unwanted burden. Reassess goals regularly — at minimum at each transition of care.

This topic provides practical guidance on four pillars of safe palliative medication management: systematic medication review, ensuring access and supply, empowering patients and carers through education, and safe storage and disposal. These pillars apply across all palliative care settings — inpatient palliative care units, hospital consultation services, community palliative care, residential aged care facilities (RACFs), and the patient's own home.

Medication Review

A comprehensive medication review is the foundation of safe palliative prescribing. It should be conducted by a suitably trained clinician — ideally with input from a palliative care pharmacist — at key transition points:

Diagnosis of a life-limiting illness or transition to a palliative approach
Change in prognosis (e.g., disease progression, new hospital admission)
Transition between care settings (hospital → home, home → RACF)
Emergence of new or worsening symptoms
At least every 4 weeks in stable patients; more frequently in the terminal phase

The Structured Medication Review Process

The review should address the following domains using a structured framework such as the STOPPFrail criteria, the Palliative Care Therapeutic Guidelines recommendations, or the RACGP's guide to deprescribing:

Review Domain	Key Questions	Common Actions
Continued indication	Is the original condition still active and clinically relevant?	Discontinue disease-modifying agents with no symptom benefit (e.g., statins, antihypertensives if symptomatic hypotension risk)
Burden vs benefit	Does the medication cause side effects that outweigh therapeutic gain?	Stop bisphosphonates (GI burden), oral iron (constipation), anticholinesterases if no measurable cognitive benefit
Duplication	Are multiple agents targeting the same symptom or pathway?	Consolidate to single preferred agent; e.g., choose one strong opioid, one antiemetic class
Symptom coverage	Are current symptoms adequately addressed?	Add anticipatory medications for pain, nausea, dyspnoea, anxiety, secretions
Dose appropriateness	Are doses adjusted for renal/hepatic function, age, and current clinical status?	Reduce renally cleared drugs (morphine → oxycodone or fentanyl); avoid NSAIDs in CKD
Route of administration	Can the patient still swallow? Is absorption reliable?	Switch to subcutaneous, transdermal, sublingual, rectal, or continuous infusion routes
Interactions	Are there clinically significant drug-drug or drug-disease interactions?	Avoid QT-prolonging combinations; manage serotonergic interactions with tramadol

Common Medications to Deprescribe in Palliative Care

Medication Class	Rationale for Cessation	Tapering Requirement
Statins (atorvastatin, rosuvastatin)	No meaningful cardiovascular benefit in last year of life; muscle/joint side effects	No taper needed; cease abruptly
Bisphosphonates (alendronate, zoledronic acid)	Bone protection benefits accrue over years; GI and renal burden	No taper needed
Antihypertensives (perindopril, amlodipine)	Risk of symptomatic hypotension, falls, fatigue; unless symptomatic hypertension or heart failure	Gradual taper over 1–2 weeks (beta-blockers, clonidine); others can cease
Oral hypoglycaemics / insulin (in Type 2 DM)	Hypoglycaemia risk; tight glycaemic control no longer beneficial; comfort feeding means erratic intake	Reduce insulin gradually; cease sulfonylureas and metformin; monitor BGLs
Proton pump inhibitors (unless active symptoms)	Often prescribed prophylactically; increased infection risk, hypomagnesaemia	Taper if long-term use; may cease if no active GI indication
Anticoagulants (warfarin, DOACs)	Bleeding risk may outweigh thrombotic risk; monitoring burden; consider goals of care	Discuss with patient/family; DOACs can cease abruptly; warfarin — consider gradual reduction
Supplements (calcium, vitamin D, multivitamins)	Minimal benefit in advanced illness; tablet burden	No taper needed

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Do not abruptly cease: Beta-blockers (risk of rebound tachycardia and angina), corticosteroids (risk of adrenal crisis if used >3 weeks), benzodiazepines (risk of seizures), anticonvulsants, and gabapentinoids (gabapentin, pregabalin). These require gradual dose reduction even in palliative care.

Role of the Palliative Care Pharmacist

The Society of Hospital Pharmacists of Australia (SHPA) recommends that all palliative care inpatient units and community teams have access to a credentialed palliative care pharmacist. Key roles include conducting Home Medicines Reviews (HMRs — MBS Item 900) and Residential Medication Management Reviews (RMMRs — MBS Item 903) under the MedsCheck and Dose Administration Aid programs, opioid conversion calculations, and liaison with community pharmacy regarding supply continuity.

Access & Supply

Ensuring timely and uninterrupted access to medications is a fundamental requirement of palliative care. Delays in obtaining analgesics or antiemetics — particularly opioids — can cause unnecessary suffering and crisis presentations to emergency departments. Understanding PBS listings, supply pathways, and contingency planning is essential.

PBS Palliative Care Provisions

The PBS provides specific provisions for palliative care through the Palliative Care Pharmaceutical Benefits program. Eligible patients (those with a life expectancy of ≤12 months, certified by a medical practitioner) can access a range of medications under streamlined or authority-required PBS items, often with streamlined authority telephone or online approvals.

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PBS Palliative Care Schedule: Many opioids and symptom-control medications can be prescribed under the PBS Palliative Care provisions without the usual quantity limits. The prescriber should write "Palliative Care" on the prescription and annotate the authority approval number. Contact the PBS Authority phone line (1800 888 333) or use HPOS/OnlinePBS for streamlined approvals.

Key Medications Available Under PBS Palliative Care

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Morphine Sulfate (Immediate-Release)

Sevredol®, Ordine® · Opioid analgesic

Adult dose 2.5–5 mg PO every 4 hours PRN; titrate every 24–48 hours. SC: 2.5–5 mg PRN (1/2 to 2/3 oral dose equivalent)

Paediatric dose 0.1–0.2 mg/kg PO/SC every 4 hours PRN; titrate cautiously

Renal adjustment Reduce dose or switch to fentanyl/oxycodone in eGFR <30 mL/min — active metabolites accumulate

PBS status ✔ PBS Palliative Care Benefit

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Fentanyl Transdermal Patch

Durogesic® · Opioid analgesic

Adult dose 12–25 mcg/hr patch every 72 hours (after opioid stabilisation). Titrate in 12–25 mcg/hr increments every 72 hours

Renal adjustment Safer than morphine in renal impairment — no active metabolites. Preferred in CKD/eGFR <30

PBS status ✔ PBS Palliative Care Benefit

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Oxycodone (Immediate-Release)

Endone®, OxyNorm® · Opioid analgesic

Adult dose 2.5–5 mg PO every 4 hours PRN; titrate. SC: 50–75% of oral dose

Renal adjustment Reduce dose by 50% in eGFR 10–30; avoid in eGFR <10 (use fentanyl instead)

PBS status ✔ PBS Palliative Care Benefit

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Haloperidol

Serenace® · Antipsychotic / Antiemetic

Adult dose Nausea: 0.5–1 mg PO/SC BD. Delirium/agitation: 0.5–2.5 mg SC/IM every 4–6 hours PRN

Renal adjustment No specific adjustment; start low in elderly/hepatic impairment

PBS status ✔ PBS General Benefit

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Midazolam

Hypnovel® · Benzodiazepine / Sedative

Adult dose Anxiety/agitation: 2.5–5 mg SC/IV PRN. Continuous infusion for refractory terminal restlessness: 10–30 mg/24 hours SC via CSCI. Status epilepticus: 5–10 mg SC/IV

Renal adjustment Use lower doses; active metabolite accumulation in hepatic impairment

PBS status ✔ PBS General Benefit

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Hyoscine Butylbromide

Buscopan® · Anticholinergic

Adult dose Secretions: 20 mg SC every 4–8 hours. Colicky pain: 20 mg SC/IV every 4–6 hours. Continuous: 40–80 mg/24 hours SC

Renal adjustment No specific adjustment; use with caution in elderly

PBS status ✔ PBS General Benefit

Supply Pathways & Contingency Planning

Standard Community Pharmacy

Most palliative care medications (including opioids) can be dispensed at community pharmacies with a valid PBS prescription. Ensure the stockist has the required formulations; telephone ahead for subcutaneous preparations and syringe drivers.

Hospital Pharmacy Discharge Packs

Many hospitals provide 3–7 day emergency supply packs of subcutaneous medications for patients transitioning home under community palliative care. Confirm this prior to discharge.

After-Hours Access

Establish after-hours contingency plans: 24-hour pharmacies, palliative care on-call services, or pre-positioned emergency medication kits at home. Provide patients and carers with the contact number for the palliative care after-hours advice line.

Rural & Remote Supply

In remote communities, Royal Flying Doctor Service (RFDS) can supply and deliver medications. Section 19A of the Therapeutic Goods Act permits supply of unregistered products in remote areas. Aboriginal Health Services can access medications through the PBS Section 100 Remote Area Aboriginal Health Service supply scheme.

Special Access Scheme (SAS)

For medications not registered on the ARTG, prescribers can apply via the TGA Special Access Scheme (Category A for terminally ill patients — streamlined notification pathway). This may include specific formulations not commercially available in Australia.

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Opioid supply continuity: Never allow a patient to run out of opioid medication during palliative care. Prescribe sufficient quantities with repeats, and ensure the patient or carer knows to request refills several days before supply is exhausted. A sudden opioid withdrawal is a medical emergency.

Continuous Subcutaneous Infusion (CSCI) via Syringe Driver

When oral intake becomes unreliable, a syringe driver (e.g., McKinley T34™ or BD Alaris™) enables continuous subcutaneous infusion of compatible medications over 24 hours. This is the most common parenteral route in community palliative care in Australia.

Medication	Compatible with CSCI?	Typical 24-hour Dose	Notes
Morphine	Yes	Individualised; convert from 24-hour oral dose (ratio 2:1 oral:SC)	Avoid in renal failure; switch to fentanyl
Fentanyl	Yes	Individualised; careful conversion required	Preferred in renal impairment
Haloperidol	Yes	2.5–10 mg/24 h	Nausea, delirium, agitation
Midazolam	Yes	10–60 mg/24 h	Anxiety, agitation, seizures
Hyoscine butylbromide	Yes	40–80 mg/24 h	Secretions, colic
Cyclizine	Yes (use high-flow cannula — irritant)	150 mg/24 h	Nausea/vomiting; site rotation essential
Metoclopramide	Yes	30–60 mg/24 h	Prokinetic antiemetic; avoid in bowel obstruction
Dexamethasone	Yes	4–16 mg/24 h	Cerebral oedema, nausea, appetite stimulation
Glycopyrrolate	Yes	0.6–1.2 mg/24 h	Preferred over hyoscine for secretions (less CNS sedation)

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Incompatible in CSCI: Diazepam (not water-soluble), diclofenac, prochlorperazine (precipitates), ketamine (use separate syringe driver or alternate route). Always check compatibility charts — SHPA Injectable Medicines Compatibility Guide is the Australian reference.

Patient & Carer Education

Effective patient and carer education is essential to safe medication management in the home and RACF setting. Many palliative care crises arise not from medication failure but from lack of understanding about how to use, store, and escalate medications. Education should be delivered in plain language, repeated at each visit, and tailored to health literacy levels.

Core Educational Domains

Medication Purpose & Timing

Explain why each medication has been prescribed, when to take it (regular vs PRN), and what to expect. Written medication lists with plain-language descriptions (e.g., "pain relief" not just "oxycodone") are strongly recommended. Provide a Medication Management Plan document.

Opioid Safety & PRN Use

Educate carers on: how to administer PRN breakthrough doses, when breakthrough doses are needed (before pain escalates), maximum frequency, signs of opioid toxicity (excessive drowsiness, pinpoint pupils, respiratory rate <8/min), and when to call the palliative care team. Emphasise that opioids for symptom relief do not hasten death when used appropriately.

Subcutaneous Administration

If a syringe driver is in use, carers should understand the purpose of the device, how to recognise alarms or site complications (redness, swelling, leakage), and when to contact the nurse. For intermittent SC injections, carers may be trained by the community palliative care nurse — document competency assessment.

Recognising & Managing Side Effects

Common side effects to discuss: constipation (prevent with regular laxatives from opioid commencement), nausea (transient — usually settles in 48–72 hours), drowsiness (dose-related; report persistent sedation), and dry mouth (symptomatic management with ice chips, saliva substitutes).

Escalation Pathways

Provide clear written instructions on who to call and when: community palliative care nurse (first contact for symptom concerns), after-hours palliative care phone line, GP, and 000 for emergencies. Ensure the carer has all contact numbers programmed into their phone.

Medication Changes & Discharge Reconciliation

At each transition of care, provide an updated medication list showing what has been started, stopped, or changed. Conduct a verbal read-back with the patient/carer to confirm understanding. Discrepancies at transition are a leading cause of medication errors in palliative care.

Communication Considerations

Use teach-back methodology: ask the patient or carer to explain the medication plan in their own words
Provide written information in the patient's preferred language — access Translating and Interpreting Service (TIS National 131 450) for CALD patients
For Aboriginal and Torres Strait Islander patients, use yarning-based education, visual medication charts, and involve Aboriginal Health Workers or Aboriginal Liaison Officers
Address fears about opioids explicitly — many patients equate opioids with "giving up" or fear addiction. Reassure that tolerance and dependence are expected physiological phenomena and distinct from addiction
Include family members and carers in all education sessions where the patient consents
Document education provided and the patient/carer's demonstrated understanding in the clinical record

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Useful Australian resources for patients and carers: Palliative Care Australia "Living with Dying" booklet, Carers Australia fact sheets, NPS MedicineWise consumer guides on opioid safety, and state-specific palliative care helplines (e.g., Palliative Care Victoria 1800 360 000).

Storage & Disposal

Safe storage and disposal of palliative care medications — particularly opioids, benzodiazepines, and other controlled substances — is a patient safety, public health, and regulatory requirement. Unsecured medications in the home pose risks of accidental ingestion (especially by children), diversion, and intentional self-harm by distressed family members.

Storage Requirements

Standard

Non-Controlled Medications

Anti-emetics, laxatives, corticosteroids, and adjuvant analgesics stored in a cool, dry place away from direct sunlight and out of reach of children.

Setting: Home — kitchen or bedroom cupboard

Heightened

Controlled Substances (Schedule 8)

Opioids (morphine, oxycodone, fentanyl) and benzodiazepines (midazolam, diazepam) stored in a lockable container or locked cupboard. The key should be kept by the patient or primary carer, not accessible to visitors or children.

Setting: Home — locked box, bedside drawer with lock

Maximum

Injectable Controlled Substances

Subcutaneous morphine, fentanyl, midazolam ampoules/syringes — locked storage, minimal stock held at any time, inventory log recommended by some state regulations. Syringe drivers should be positioned safely with tubing protected from disconnection.

Setting: Home — locked medical box; RACF — controlled drug cupboard with double-lock requirements

State & Territory Regulatory Framework

Schedule 8 (controlled drug) prescribing and storage requirements vary by state and territory. Key points include:

Requirement	Details
Prescribing	Schedule 8 drugs require authority from the relevant state/territory Health Department (or Health Practitioner Regulation Agency) for ongoing prescribing beyond initial supply. Palliative care exemptions apply in most jurisdictions — consult local regulations.
Storage (home)	Not legislated for private residences in most jurisdictions, but strongly recommended by police and health authorities. Some RACF accreditation standards (Standard 4 — Medication Safety) require locked storage.
Storage (RACF)	Schedule 8 medications must be stored in a locked, fixed container or safe. Two-person sign-in/sign-out register is required in most jurisdictions. Regular stock reconciliation (minimum weekly) is mandated.
Disposal	Unused Schedule 8 medications must be returned to a pharmacy for destruction. The pharmacist must witness the destruction and complete the relevant state/territory form (e.g., NSW Health Destruction of S8 Drugs form). Do NOT flush opioids or place in household waste.
Death of patient	Following death, remaining controlled drugs should be collected by the community palliative care nurse, returned to the prescribing pharmacy, or handed to police for destruction — jurisdiction-dependent. Advise families not to keep medications "just in case."

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Safe disposal at home: While awaiting pharmacy return, unused medications should remain in locked storage. For non-controlled medications, the Return Unwanted Medicines (RUM) Project provides free return via any community pharmacy — patients can place unwanted medicines (excluding Schedule 8) in a sealed bag and return to their local pharmacy at any time.

Dose Administration Aids (DAAs)

For patients on multiple regular medications, dose administration aids (blister packs / Webster-paks®) prepared by community pharmacy improve adherence and reduce dosing errors. The PBS provides supply under the Dose Administration Aid program for eligible patients. This service is particularly valuable for elderly patients living alone and those with cognitive impairment.

DAAs should be reviewed and re-packed at least monthly
PRN medications cannot be included in DAAs — they must be dispensed separately and clearly labelled
Controlled substances (Schedule 8) are generally excluded from DAAs in most jurisdictions
When medications change (dose adjustment, cessation), the DAA must be re-packed promptly to avoid dosing errors

Empirical Symptom Management — Anticipatory Prescribing

Anticipatory prescribing — the pre-prescribing of injectable medications for common end-of-life symptoms before they arise — is a cornerstone of proactive palliative care. It ensures that when symptoms occur (often suddenly and distressingly), treatment can begin within minutes rather than hours. The "just-in-case" syringe or box should be available in every home where a patient is receiving end-of-life care.

Standard Anticipatory Medication Set

Pain (nociceptive)

Morphine SC 2.5–10 mg 4-hourly PRN

Ongoing

Switch to fentanyl/oxycodone if renal impairment

Pain (neuropathic)

Gabapentin 100–300 mg TDS PO or pregabalin 25–75 mg BD PO

Titrate over days

Reduce in renal impairment; monitor for sedation with opioids

Nausea & vomiting

Haloperidol 0.5–1 mg SC/PO BD–TDS or metoclopramide 10 mg PO/SC TDS

Ongoing

Metoclopramide contraindicated in bowel obstruction — use haloperidol or cyclizine

Nausea (vestibular)

Cyclizine 25–50 mg PO/SC TDS

Ongoing

Sedating; may cause confusion in elderly

Agitation / delirium

Haloperidol 0.5–2.5 mg SC/IM PRN; midazolam 2.5–5 mg SC PRN

PRN / regular review

Escalate to midazolam CSCI 10–30 mg/24h for refractory terminal agitation

Respiratory secretions

Hyoscine butylbromide 20 mg SC 4–8 hourly OR glycopyrrolate 0.2 mg SC 6–8 hourly

Ongoing

Reposition patient; glycopyrrolate preferred (less sedation)

Dyspnoea

Morphine 2.5–5 mg SC PRN (low-dose opioid); midazolam 2.5 mg SC PRN for anxiety-related

PRN

Fan, position upright, oxygen only if hypoxaemic and symptomatic benefit

Seizures

Midazolam 5–10 mg SC/IV stat, then CSCI 10–30 mg/24h

Until controlled

Levetiracetam 500–1000 mg SC BD for ongoing seizure prophylaxis

Opioid Conversion Guide

Opioid switching is frequently required due to intolerable side effects, renal impairment, or route changes. Use equianalgesic tables as a guide only — reduce the calculated dose by 25–50% when switching due to incomplete cross-tolerance.

From	To	Approximate Conversion	Notes
Oral morphine 30 mg/24h	SC morphine	15 mg/24h (2:1 oral:SC)	Reduce by 25–50% if switching for toxicity
Oral morphine 30 mg/24h	Transdermal fentanyl	12 mcg/hr patch	Patch onset delayed 12–24 hours — bridge with PRN SC/PO opioid
Oral morphine 30 mg/24h	Oral oxycodone	20 mg/24h (1.5:1 morphine:oxycodone)	Equianalgesic; consider in morphine intolerance
Oral morphine 60 mg/24h	Transdermal fentanyl	25 mcg/hr patch	Preferred in renal impairment
Oral morphine 120 mg/24h	Transdermal fentanyl	50 mcg/hr patch	Max patch generally 100 mcg/hr in palliative care

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Tramadol and pethidine are generally avoided in palliative care. Tramadol has a complex mechanism with serotonergic interaction risk and unpredictable metabolism in renal impairment. Pethidine's active metabolite (norpethidine) accumulates and causes seizures. Use morphine, oxycodone, or fentanyl instead.

Monitoring

Monitoring in palliative care differs from curative treatment — the focus shifts from achieving biochemical targets to optimising symptom control and quality of life. Monitoring should be proportionate to the patient's goals and stage of illness, avoiding unnecessary blood tests and imaging that cause distress without benefit.

Symptom Monitoring Tools

Integrated Palliative care Outcome Scale (IPOS): Validated Australian tool; 17 items covering physical symptoms, emotional well-being, and communication. Administer weekly or at each visit. Freely available from the IPOS website.
Palliative care Outcome Scale — Symptoms (POS-S): Shorter symptom assessment suitable for each clinical contact.
Eastern Cooperative Oncology Group (ECOG) Performance Status: Functional assessment to guide treatment decisions and prognosis communication.
Abbey Pain Scale: For non-verbal patients unable to self-report pain. Widely used in Australian RACFs.
Confusion Assessment Method (CAM): To screen for and monitor delirium.
Richmond Agitation–Sedation Scale (RASS): To monitor sedation level, especially in patients receiving opioids and benzodiazepines.

Laboratory Monitoring — When Indicated

Investigation	When to Consider	Action Trigger
Serum creatinine / eGFR	On initiation of opioids; every 4–8 weeks; if clinical deterioration	eGFR <30: switch morphine → fentanyl; review all renally cleared medications
Serum electrolytes	If on diuretics, ACE inhibitors, or with dehydration risk	Hyperkalaemia, hyponatraemia — may affect drug safety
Hepatic function (LFTs)	Known hepatic metastases or liver disease; suspected drug-induced liver injury	Significantly elevated: reduce hepatically metabolised drugs; avoid paracetamol >2g/day
INR	If continuing warfarin	INR >3.5: review warfarin dose or consider cessation per goals of care
Blood glucose	Patients on insulin or oral hypoglycaemics; steroid-induced hyperglycaemia	BGL <4 mmol/L: reduce hypoglycaemic agents; BGL persistently >20: symptomatic management

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Avoid futile investigations: In the terminal phase (hours to days of life), routine blood tests, imaging, and therapeutic drug monitoring are almost always inappropriate. Clinical assessment — respiratory rate, sedation score, symptom response — is the primary monitoring modality.

Special Populations

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Pregnancy

Opioids: Morphine is the preferred opioid; fentanyl and oxycodone also acceptable. Avoid codeine (risk of neonatal respiratory depression and ultra-rapid metaboliser genotype). Monitor neonate for withdrawal if mother on opioids near delivery.

Antiemetics: Ondansetron (PBS-listed, avoid in first trimester if possible — small cardiac risk), metoclopramide, and promethazine are generally safe. Avoid haloperidol in first trimester.

Benzodiazepines: Avoid if possible — neonatal respiratory depression, floppy infant syndrome. If essential for refractory agitation, use lowest effective dose for shortest duration.

Palliative care in pregnancy is rare but may occur with advanced malignancy diagnosed antenatally. Involve the obstetric team and neonatology early.

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Paediatrics

Opioids: Paediatric palliative care opioid dosing is weight-based (morphine 0.1–0.2 mg/kg SC/PO every 4 hours). Start at the lower end and titrate. Syringe drivers (CSCI) are used in children with appropriate weight-based dosing.

Midazolam: 0.05–0.1 mg/kg SC/IV for anxiety and seizures in paediatric palliative care. Can be given intranasally (0.2 mg/kg) for acute seizure management.

Routes: Sublingual, buccal, and transdermal routes are often preferred in children to avoid needle distress. Oral solutions (e.g., Ordine® oral morphine) can be flavoured to improve palatability.

Paediatric palliative care requires specialist involvement (state paediatric palliative care service). The Sydney Children's Hospital Network and Royal Children's Hospital Melbourne provide comprehensive guidelines. Medication errors are more common in paediatrics due to weight-based dosing — always double-check calculations.

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Elderly (≥75 years)

Opioids: Start at 50% of standard adult dose and titrate slowly. Morphine accumulation is more likely due to reduced renal clearance. Fentanyl (transdermal) is often better tolerated.

Benzodiazepines: High fall risk; paradoxical agitation possible. Use midazolam 1–2 mg SC instead of standard 5 mg doses. Lorazepam is preferred oral benzodiazepine (no active metabolites).

Anticholinergics: Hyoscine and cyclizine may precipitate delirium. Prefer glycopyrrolate for secretions (minimal CNS penetration). Monitor cognitive status closely.

Polypharmacy is the norm — the average elderly palliative care patient is on 8–12 medications. Prioritise deprescribing and ensure the Medication Management Plan is reviewed at every contact. Falls risk assessment should accompany any sedating medication.

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Renal Impairment

Morphine: AVOID in eGFR <30 mL/min. Active metabolite morphine-6-glucuronide accumulates causing prolonged sedation, myoclonus, and respiratory depression. Switch to fentanyl (metabolised hepatically, no renal excretion of active metabolites).

Oxycodone: Reduce dose by 50% in eGFR 10–30; avoid if eGFR <10. Active metabolite (oxymorphone) accumulates.

Fentanyl: PREFERRED in renal impairment. No dose adjustment required for mild-moderate renal impairment. Transdermal provides stable delivery.

Gabapentin / pregabalin: Significant dose reduction required (gabapentin 100 mg after each dialysis session; pregabalin 25 mg daily in eGFR <30).

NSAIDs: Generally AVOID — risk of acute kidney injury, fluid retention, and GI bleeding. If needed for bone pain, use lowest dose for shortest duration with PPI cover.

Patients on dialysis receiving palliative care require individualised medication plans. Discuss with the renal and palliative care teams regarding dialysis withdrawal timing and medication adjustments.

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Hepatic Impairment

Opioids: All opioids undergo hepatic metabolism — reduce doses by 50% and extend dosing intervals. Morphine clearance is reduced; fentanyl clearance is also reduced but more predictable. Avoid codeine (prodrug, unpredictable metabolism).

Midazolam: Use with extreme caution — clearance is markedly reduced, leading to prolonged sedation. Reduce dose by 50–75%.

Paracetamol: Maximum 2 g/day (not 4 g/day) in chronic liver disease. Avoid in severe hepatic failure (Child-Pugh C).

Coagulopathy in liver disease increases bleeding risk — avoid intramuscular injections; use SC or oral routes. Monitor for hepatic encephalopathy, which may be exacerbated by sedating medications.

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Immunocompromised

Drug interactions: Patients on immunosuppressants (tacrolimus, cyclosporine, chemotherapy) may have significant drug interactions with palliative medications. Avoid azole antifungals with opioids if possible (CYP3A4 inhibition increases opioid levels).

Opioids: Standard dosing applies but be aware of reduced hepatic function post-transplant or with hepatic GVHD. Avoid codeine and tramadol.

Infection risk: Corticosteroids may increase infection risk in already immunosuppressed patients. Weigh infection risk against symptom benefit.

Patients with HIV receiving palliative care may be on antiretrovirals with significant drug interactions (e.g., ritonavir boosting increases opioid levels via CYP3A4 inhibition). Always check interaction databases (Australian Medicines Handbook or Clinical Pharmacology).

Aboriginal and Torres Strait Islander Health Considerations

Aboriginal and Torres Strait Islander Health

Aboriginal and Torres Strait Islander Australians experience a disproportionate burden of life-limiting illness and face unique barriers to medication access, understanding, and adherence in palliative care. The AIHW reports that Indigenous Australians die from chronic diseases at rates 2–3 times higher than non-Indigenous Australians, yet access palliative care at lower rates, later in the disease trajectory, and with less continuity of care.

Cultural Safety in Medication Counselling

Medication education must be delivered in a culturally safe manner, acknowledging the importance of Country, kinship networks, and the role of Elders in health decision-making. Use Yarning-based communication, avoid medical jargon, and allow time for family consultation. Involve Aboriginal Health Workers (AHWs) and Aboriginal Liaison Officers (ALOs) in every medication discussion where possible.

Language and Literacy

English may be a second, third, or fourth language for many Indigenous Australians, particularly in remote communities. Translated medication information is limited; verbal and pictorial education resources are preferred. Use TIS National (131 450) for interpreter services. Partner with local AHWs to develop community-specific medication guides.

Remote and Very Remote Access

Many Indigenous communities are in remote or very remote Australia where the nearest pharmacy may be hours away. Aboriginal Health Services under Section 100 of the National Health Act can maintain a limited PBS formulary. The RFDS provides emergency medication delivery. Community-controlled health services (e.g., Aboriginal Community Controlled Health Organisations — ACCHOs) are the preferred provider model.

Fear and Mistrust of Opioids

Opioid stigma may be heightened in communities affected by substance misuse. Education must explicitly distinguish between therapeutic opioid use for symptom relief in palliative care and recreational misuse. Involve trusted community members and Elders in these conversations. Reframe pain management as "comfort care" or "keeping them comfortable" if the term "opioid" causes distress.

Sorry Business and End-of-Life Care

During Sorry Business (mourning and funeral practices), medication schedules may be disrupted. Families may wish to take a patient home to Country for end-of-life care. Support this through advance medication supply, community-based syringe driver management via AHWs, and palliative care telehealth follow-up. Ensure anticipatory medications are available and that AHWs are trained in their administration.

Storage and Safety

In overcrowded or itinerant living situations, locked medication storage may be challenging. Provide lockable medication boxes through the community health service. Refrigeration (for temperature-sensitive medications like some insulin formulations) may be unreliable — specify room-temperature-stable formulations where possible.

Closing the Gap — PBS Co-Payments

Aboriginal and Torres Strait Islander Australians with, or at risk of, chronic disease and holding a Medicare card are eligible for PBS Closing the Gap (CTG) co-payment — medications at the concessional rate (.30 per item in 2024) without needing a concession card. This significantly reduces cost barriers to palliative medications. Ensure the CTG annotation is on every PBS prescription.

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Recommended approach: Engage with the local Aboriginal Community Controlled Health Organisation (ACCHO) early in the palliative care pathway. Co-design the medication management plan with the AHW and family. Use the Palliative Care Australia's "Roadmap for Aboriginal and Torres Strait Islander Palliative Care" and the RHDAustralia guidelines for culturally safe chronic disease management.

📚 References

1. Palliative Care Australia. National Palliative Care Strategy 2018. Canberra: Australian Government Department of Health; 2018.
2. Australian Institute of Health and Welfare (AIHW). Palliative care services in Australia. Cat. No. HWL 76. Canberra: AIHW; 2023.
3. Palliative Care Expert Group. Palliative Care: Therapeutic Guidelines. Melbourne: Therapeutic Guidelines Limited; 2023. [Information derived; not cited as primary source.]
4. Lavan AH, Gallagher P, Parsons C, O'Mahony D. STOPPFrail: Screening Tool of Older Persons' Prescriptions in Frail adults with limited life expectancy. J Am Geriatr Soc. 2017;65(6):1253–1261.
5. Society of Hospital Pharmacists of Australia (SHPA). SHPA Standards of Practice for the Provision of Palliative Care Pharmacy Services. 3rd ed. Melbourne: SHPA; 2022.
6. Royal Australian College of General Practitioners (RACGP). Prescribing drugs of dependence in general practice — Part B: Opioids. Melbourne: RACGP; 2022.
7. Murtagh FEM, Bausewein C, Verne J, et al. How many people need palliative care? A study developing and comparing methods for population-based estimates. Palliat Med. 2014;28(1):49–58.
8. National Safety and Quality Health Service (NSQHS) Standards. Australian Commission on Safety and Quality in Health Care (ACSQHC). Sydney: ACSQHC; 2021.
9. Abernethy AP, Currow DC, Frith P, et al. Randomised, double blind, placebo controlled crossover trial of sustained release morphine for the management of refractory dyspnoea. BMJ. 2003;327(7414):523–528.
10. Clark K, Lam L, Currow D. Reducing dehydration in hospice patients — time for evidence-based practice? J Pain Symptom Manage. 2011;42(2):e1–e3.
11. Return Unwanted Medicines (RUM) Project. National Return and Disposal of Unwanted Medicines Limited. Melbourne: RUM Ltd; 2024. Available at: www.returnmed.com.au.
12. Australian Government Department of Health and Aged Care. Palliative Care Pharmaceutical Benefits — Prescribing Information. Canberra: Services Australia; 2024.
13. Aboriginal and Torres Strait Islander Health. Royal Australian College of General Practitioners (RACGP). National guide to a preventive health assessment for Aboriginal and Torres Strait Islander people. 3rd ed. Melbourne: RACGP; 2018.
14. Mitchell GK, Senior HE, Johnson CE, et al. Systematic integrative review of advance care planning and palliative care in chronic illness. J Palliat Med. 2018;21(S1):S62–S75.
15. Therapeutic Goods Administration (TGA). Special Access Scheme — Guidance for Health Practitioners. Canberra: Australian Government Department of Health; 2023.

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

Preventive health

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

Quick Reference: Differential Diagnosis at a Glance

Costovertebral dysfunction

Paracetamol ± NSAID; manual therapy

2–6 weeks

Provocable on palpation; no red flags

Thoracic compression fracture

Paracetamol; ± calcitonin; DXA + osteoporosis Rx

6–12 weeks healing

Elderly; osteoporosis; acute onset

ACS (posterior MI)

Aspirin 300 mg, GTN, heparin; urgent PCI

Time-critical

ECG, troponin; CV risk factors

Aortic dissection

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

Time-critical

Tearing pain; BP differential >20 mmHg

Vertebral osteomyelitis

IV antibiotics (vancomycin + ceftriaxone initially); ID consult

6 weeks IV antibiotics

Fever, elevated CRP, IV drug use

Biliary colic / cholecystitis

Paracetamol ± morphine; lap cholecystectomy

Surgical within 72 h (cholecystitis)

RUQ/infrascapular; post-prandial; RUQ US

📚 References

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

for PBS-listed medicines at participating pharmacies.

Cultural safety

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

Medication adherence

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

Specific conditions

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

Referral pathways

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

📚 References

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

for PBS-listed medicines at participating pharmacies.

Cultural safety

Medication adherence

Specific conditions

Referral pathways

📚 References

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