Nausea and Vomiting in the Last Days

Last updated 1 Jun 2026 · Palliative care

📋 Key Information Summary

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Nausea and vomiting affect 40–70% of patients in the last days of life; proactive management is a core palliative care goal in Australian practice.
When oral intake becomes impossible, switch to subcutaneous (SC) routes via syringe driver (continuous) or intermittent SC injection; the parenteral route is standard in Australian palliative care units and home-based programmes.
Haloperidol 0.5–2.5 mg SC BD–TDS (or 2.5–5 mg/24 h via syringe driver) is first-line for nausea due to chemical causes, metabolic disturbance, and opioid-induced nausea; PBS-listed as a restricted benefit for palliative care.
Metoclopramide 10–20 mg SC QID (or 30–60 mg/24 h via syringe driver) is first-line for gastroparesis and gastric stasis but must be avoided in bowel obstruction; consider domperidone as oral alternative if available.
Ondansetron 4–8 mg SC/IV BD (or 16–24 mg/24 h via syringe driver) is reserved for refractory nausea or chemotherapy/radiotherapy-related vomiting; constipation is a significant adverse effect and may worsen bowel obstruction.
Levodopa-dependent Parkinson's disease or Lewy body dementia: dopamine antagonists (haloperidol, metoclopramide) can precipitate life-threatening rigidity and neuroleptic malignant syndrome; use ondansetron, cyclizine, or low-dose levodopa adjustments instead.
Continue any antiemetics that were effective pre-actively-dying phase; stopping established therapy may cause unnecessary distress.
Common causes of nausea in the last days include opioids, renal/hepatic failure, hypercalcaemia, constipation/faecal loading, gastric stasis, raised intracranial pressure, and anxiety.
Assess for reversible causes before escalating antiemetic therapy — rectal examination for faecal impaction, review opioid dose and consider rotation, check serum calcium.
Non-pharmacological strategies (positioning, mouth care, fan, aromatherapy) complement pharmacotherapy and should be offered to every patient and family.
For Aboriginal and Torres Strait Islander patients, culturally safe communication about last-days symptoms, family involvement in care, and access to palliative care in remote communities are critical considerations.
Syringe drivers (e.g., BD Microsyringe Driver or Graseby MS26) are widely used in Australian palliative care for continuous SC infusions; common compatible combinations should be limited to reduce precipitation risk.

Introduction & Australian Epidemiology

Nausea and vomiting are among the most distressing symptoms experienced during the last days of life. In Australian palliative care settings, prevalence estimates range from 40% to 71% of patients in the terminal phase. Effective antiemetic management is a fundamental component of palliative care and a key quality indicator under the National Palliative Care Standards (Palliative Care Australia, 2018).

As patients enter the actively dying phase — typically defined as the final 24–72 hours of life — oral intake ceases, consciousness declines, and swallowing becomes unsafe. Antiemetics previously given orally must be converted to subcutaneous (SC) or rectal routes. Syringe drivers (continuous subcutaneous infusion, CSCI) are the standard method of drug delivery in Australian hospice, hospital palliative care consult services, and community palliative care programmes.

This guideline addresses the practical management of nausea and vomiting specifically in the last days, with emphasis on three principal antiemetics — haloperidol, metoclopramide, and ondansetron — and important safety considerations in patients with Parkinson's disease or Lewy body dementia.

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Do not stop effective antiemetics. If a patient has been well controlled on a particular antiemetic, continue it via the most appropriate route. Abrupt cessation in the last days may cause significant distress to both the patient and their family.

Approximately 160,000 Australians die each year, with around 50% accessing palliative care services. Nausea and vomiting are consistently rated among the top three symptoms requiring specialist palliative care intervention. In regional and remote Australia, where specialist palliative care access is limited, general practitioners and Aboriginal health practitioners play a central role in symptom management.

Pathophysiology of Nausea and Vomiting in the Last Days

Nausea and vomiting result from stimulation of the vomiting centre in the medulla oblongata, which integrates afferent input from multiple sources. Understanding the mechanism guides antiemetic selection.

Receptor / Pathway	Common Last-Days Cause	Preferred Antagonist
Dopamine (D₂) — chemoreceptor trigger zone (CTZ)	Opioids, renal failure, hepatic failure, hypercalcaemia, medications	Haloperidol, metoclopramide
Serotonin (5-HT₃) — CTZ and vagal afferents	Chemotherapy, radiotherapy, opioid initiation, bowel obstruction	Ondansetron
Acetylcholine / histamine (H₁) — vestibular input	Movement, raised ICP, vestibular disease	Cyclizine, hyoscine butylbromide
Vagal / visceral afferents — GI tract	Gastric stasis, constipation, bowel obstruction, mucosal irritation	Metoclopramide (prokinetic), dexamethasone (obstruction)
Cortical / anxiety-mediated	Anticipatory nausea, fear, psychological distress	Benzodiazepines (midazolam), non-pharmacological strategies

In the last days, multiple mechanisms often coexist. A stepwise approach — addressing identifiable causes where possible and using empirical antiemetics — is standard Australian practice.

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Syringe driver compatibility: Haloperidol, metoclopramide, ondansetron, and midazolam are generally compatible in a syringe driver when mixed with normal saline or water for injection. However, avoid combining ondansetron with cyclizine in the same syringe (precipitation risk). Always consult the Palliative Care Formulary or local syringe driver compatibility chart.

Haloperidol

Haloperidol is a butyrophenone dopamine (D₂) antagonist widely used as a first-line antiemetic in Australian palliative care. It is effective for nausea caused by opioids, metabolic derangements (uraemia, hypercalcaemia), hepatic failure, and drug-induced nausea. It also has anxiolytic and mild sedative properties, which may be beneficial in the dying patient.

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Haloperidol

Serenace® · Generic · Butyrophenone dopamine antagonist

Adult dose (SC intermittent) 0.5–2.5 mg SC BD–TDS, titrate to effect; maximum 5 mg per dose in last-days care

Adult dose (CSCI/syringe driver) 2.5–5 mg/24 h SC; titrate in 2.5 mg increments every 24 h; typical range 2.5–10 mg/24 h

Paediatric dose 0.01–0.03 mg/kg/dose SC OD–BD (max 0.5 mg/dose in young children); specialist palliative care guidance recommended

Route SC (preferred in last days), IM, IV, PO (if swallowing), PR

Renal adjustment No specific dose reduction required; use lower end of range in severe renal impairment (eGFR <15 mL/min/1.73 m²) due to increased CNS sensitivity

Hepatic adjustment Reduce dose by 50% in severe hepatic impairment (Child-Pugh C); halved dose intervals or lower CSCI rate

Key adverse effects Extrapyramidal symptoms (EPS), QTc prolongation, sedation, neuroleptic malignant syndrome (rare)

PBS status ✔ PBS General Benefit

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QTc prolongation risk: Haloperidol can prolong the QTc interval and predispose to torsades de pointes. Avoid in patients with known QTc >500 ms, concurrent QTc-prolonging drugs (e.g., ondansetron, certain antibiotics), or significant electrolyte derangements (hypokalaemia, hypomagnesaemia). Where possible, check a 12-lead ECG before initiating higher doses.

Monitoring: Observe for dystonia, akathisia, or rigidity (EPS), particularly in younger patients and those on higher doses. In the last days, mild sedation is often acceptable and may be desirable. Monitor QTc if doses exceed 5 mg/24 h or if co-prescribed with other QTc-prolonging agents.

Practical tip: Haloperidol 5 mg/mL concentrate is the most concentrated formulation for syringe driver use (dilute to required volume with normal saline). Higher concentrations may cause local irritation at the SC injection site.

Metoclopramide

Metoclopramide is a dopamine (D₂) antagonist with prokinetic activity due to its 5-HT₄ agonist effect on the upper GI tract. It enhances gastric emptying and stimulates gastric motility, making it particularly useful for nausea caused by gastric stasis, gastroparesis, and opioid-induced delayed gastric emptying. It is also a mild 5-HT₃ antagonist at higher doses.

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Metoclopramide

Maxolon® · Generic · Dopamine antagonist / prokinetic

Adult dose (SC intermittent) 10–20 mg SC QID (every 6 hours); some patients require 20 mg TDS–QID

Adult dose (CSCI/syringe driver) 30–60 mg/24 h SC; titrate in 10–20 mg increments every 24 h

Paediatric dose 0.1–0.15 mg/kg/dose SC TDS–QID (max 0.5 mg/kg/day); avoid in children <1 year

Route SC (preferred in last days), IM, IV, PO

Renal adjustment Reduce dose by 50% if eGFR <30 mL/min/1.73 m²; active metabolites accumulate

Hepatic adjustment Use with caution; dose reduction may be needed in severe hepatic impairment

Key adverse effects EPS (dystonia, akathisia, oculogyric crisis — risk higher in young adults, females, and elderly), drowsiness, diarrhoea

PBS status ✔ PBS General Benefit

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Contraindicated in bowel obstruction: Metoclopramide's prokinetic action increases peristalsis and can worsen symptoms (colic, vomiting) in mechanical bowel obstruction. Use haloperidol or ondansetron instead. Confirm bowel patency before prescribing.

Indications in the last days:

Gastric stasis / gastroparesis (often opioid-related)
Functional nausea with upper GI dysmotility
As a second-line agent when haloperidol is ineffective or contraindicated

EPS risk reduction: Extrapyramidal symptoms are dose-related and more common with prolonged use. In the last days, short-term use is generally safe. If EPS develop, administer benztropine 1–2 mg SC or diazepam 5–10 mg SC as rescue therapy.

Practical tip: Metoclopramide 10 mg/2 mL ampoules are the standard formulation in Australia. In a syringe driver, concentrations up to 60 mg/24 h in 24 mL are well tolerated subcutaneously.

Ondansetron

Ondansetron is a selective serotonin (5-HT₃) receptor antagonist that acts centrally at the chemoreceptor trigger zone and peripherally on vagal afferent nerves. It is particularly effective for nausea associated with chemotherapy, radiotherapy, and opioid initiation, and is used as a second- or third-line agent in the last days of life when haloperidol and metoclopramide are insufficient.

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Ondansetron

Zofran® · Generic · 5-HT₃ receptor antagonist

Adult dose (SC/IV intermittent) 4–8 mg SC/IV BD (every 12 hours); may be increased to 8 mg TDS for refractory nausea

Adult dose (CSCI/syringe driver) 16–24 mg/24 h SC; some guidelines permit up to 32 mg/24 h under specialist supervision

Paediatric dose 0.1–0.15 mg/kg/dose SC/IV BD–TDS (max 4 mg/dose in children <12 years, 8 mg/dose ≥12 years)

Route SC, IV (preferred in last days), PO (if swallowing), PR

Renal adjustment No routine dose adjustment required; no significant renal excretion of active drug

Hepatic adjustment Limit to 8 mg/day in severe hepatic impairment (Child-Pugh C)

Key adverse effects Constipation (clinically significant — may precipitate or worsen faecal loading/obstruction), headache, QTc prolongation (dose-dependent, risk increases >16 mg IV), serotonin syndrome (rare, with concurrent serotonergic drugs)

PBS status ⚑ PBS Authority Required

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Constipation risk: Ondansetron can cause or worsen constipation, which may contribute to nausea in a vicious cycle. In the last days, constipation-related nausea is common — always assess for faecal loading before adding ondansetron. If constipation is a contributing factor, consider addressing this first (if appropriate for the patient's goals of care) or using haloperidol instead.

When to use ondansetron in the last days:

Nausea refractory to haloperidol ± metoclopramide
Known chemotherapy- or radiotherapy-induced nausea (may already be established therapy)
Patients with Parkinson's disease or Lewy body dementia (dopamine antagonists contraindicated)
Documented QTc prolongation on haloperidol (though ondansetron also prolongs QTc at high doses — risk-benefit assessment required)

Drug interactions: Concurrent use with other serotonergic agents (SSRIs, tramadol) increases serotonin syndrome risk — monitor for agitation, clonus, hyperthermia. Concurrent use with haloperidol or other QTc-prolonging agents requires QTc monitoring where possible.

Practical tip: Ondansetron 8 mg/4 mL ampoules are suitable for SC injection (undiluted) or syringe driver use. Maximum 16 mg per 24 mL syringe driver volume for 24-hour infusion to avoid local irritation.

Parkinson's Disease & Lewy Body Dementia — Cautions

Patients with Parkinson's disease (PD) or dementia with Lewy bodies (DLB) present a unique challenge in the management of nausea and vomiting in the last days. Dopamine antagonists — the mainstay of antiemetic therapy — can directly antagonise the dopaminergic pathways already depleted in these conditions, leading to worsening rigidity, akinesia, and potentially fatal neuroleptic malignant syndrome (NMS).

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NEVER use haloperidol or metoclopramide in patients with Parkinson's disease or Lewy body dementia unless no alternative exists and the situation is immediately life-threatening. These agents can precipitate severe rigidity, akinetic crisis, and neuroleptic malignant syndrome. DLB patients are exquisitely sensitive — even low doses can cause irreversible deterioration and death.

Safe antiemetic alternatives in PD/DLB:

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Ondansetron

Zofran® · 5-HT₃ antagonist — does not block dopamine receptors

Role First-line antiemetic in PD/DLB; 4–8 mg SC BD (see ondansetron section above for full dosing)

Advantage No dopamine antagonism; safe in PD/DLB

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Cyclizine

Valoid® · H₁ antagonist / anticholinergic

Adult dose 25–50 mg SC/IM/IV TDS (every 8 hours) or 75–150 mg/24 h via syringe driver

Role Effective for nausea with vestibular component or raised ICP; avoid in anticholinergic-sensitive states

Caution in DLB Anticholinergic effects may worsen confusion; use lowest effective dose

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Domperidone

Motilium® · Peripheral D₂ antagonist / prokinetic

Adult dose 10–20 mg PO/NG TDS–QID (before meals); max 80 mg/day

Role Prokinetic that does not cross the blood-brain barrier significantly; may be used for gastric stasis in PD. Not available parenterally in Australia — oral/NG only.

Caution QTc prolongation risk; avoid with CYP3A4 inhibitors

Levodopa management in the last days:

If the patient has been on levodopa (Sinemet®, Madopar®), consider continuing via NG tube or, if the oral/NG route is not possible, discuss with specialist palliative care whether levodopa withdrawal is appropriate given the patient's goals of care.
Abrupt withdrawal of levopoda can cause neuroleptic malignant-like syndrome (parkinsonism-hyperpyrexia syndrome) — a medical emergency presenting with rigidity, hyperthermia, autonomic instability, and altered consciousness.
In the last days, the decision to continue or cease levodopa should be individualised and discussed with the patient (if capable), family, and the treating neurologist or palliative care specialist.
If levodopa is ceased and the patient develops features of parkinsonism-hyperpyrexia, consider low-dose levodopa (via NG or SC apomorphine where available) and active cooling.

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Anticholinergic burden: In DLB, anticholinergic drugs (cyclizine, hyoscine) may worsen confusion, hallucinations, and cognitive decline. Balance symptom relief against cognitive side effects. Ondansetron is generally the safest first choice in DLB for nausea management.

Neuroleptic Malignant Syndrome (NMS) recognition:

Emergency

Neuroleptic Malignant Syndrome

Hyperthermia >38.5°C, severe "lead-pipe" rigidity, altered consciousness, autonomic dysfunction (tachycardia, labile BP, diaphoresis), elevated CK, myoglobinuria. Mortality 10–20%.

Setting: Emergency — ICU involvement required if goals of care support escalation

Clinical Assessment

Before initiating or escalating antiemetic therapy, a focused assessment should identify potentially reversible causes of nausea. Even in the last days, some causes may be amenable to simple intervention.

Cause	Assessment	Intervention (if appropriate)
Opioid-induced	Timeline of nausea relative to opioid initiation/dose change	Opioid rotation, dose reduction, haloperidol
Constipation / faecal loading	Abdominal examination, PR examination (if tolerated)	Glycerol suppository, phosphate enema, manual evacuation (if appropriate to goals of care)
Gastric stasis	Abdominal distension, visible peristalsis, bilious vomiting	Metoclopramide (if no obstruction), NG decompression (if appropriate)
Bowel obstruction	Colicky pain, absolute constipation, distension, tinkling bowel sounds	Haloperidol + hyoscine butylbromide (antispasmodic) ± dexamethasone; NO metoclopramide
Hypercalcaemia	Known malignancy, confusion, polyuria, renal impairment	SC hydration if appropriate, haloperidol; IV bisphosphonate/denosumab if goals allow
Renal failure (uraemia)	Known CKD, rising creatinine, hiccups	Haloperidol; avoid metoclopramide accumulation
Raised intracranial pressure	Headache worse in morning, papilloedema, CN VI palsy	Dexamethasone 8–16 mg/day, cyclizine
Anxiety / anticipatory	Nausea without physical cause, associated distress	Midazolam 2.5–5 mg SC PRN, non-pharmacological strategies

In practice, a pragmatic approach is often adopted in the last days: if the cause cannot be easily identified or treated, empirical haloperidol (first-line) ± ondansetron or metoclopramide (second-line) is initiated.

Non-Pharmacological Strategies

Non-pharmacological interventions are complementary to antiemetic therapy and should be offered to every patient and their family. They are safe, low-cost, and empower families to contribute to symptom management.

Positioning

Elevate the head of the bed to 30–45° to reduce aspiration risk and improve gastric drainage. Reposition every 2–4 hours for comfort.

Mouth Care

Regular mouth care with soft toothette swabs, sodium bicarbonate rinse, or chlorhexidine 0.2% to reduce nausea from oral secretions and mucosal dryness.

Environmental Measures

Open windows, fan directed towards the patient, reduce strong odours (cooking, perfumes). Aromatherapy with peppermint or lemon oil may provide short-term relief.

Psychological Support

Reassure the patient and family. Explain the cause and management plan. Anxiety amplifies nausea — a calm, confident approach from the clinical team reduces distress.

Reduce Unnecessary Medications

Review and cease medications that may contribute to nausea (antibiotics, iron supplements, NSAIDs, unnecessary polypharmacy) as part of appropriate deprescribing in the last days.

Empirical Antiemetic Approach — Last Days

When a specific cause cannot be identified or treated, the following stepwise empirical approach is recommended in Australian palliative care:

Step 1

Haloperidol 1–2.5 mg SC TDS or 2.5–5 mg/24 h CSCI

Trial ≥24 h before escalating

First-line for most causes; avoid in PD/DLB

Step 2

Add metoclopramide 10–20 mg SC TDS or 30–60 mg/24 h CSCI

Trial ≥24 h

If gastric stasis suspected; contraindicated in obstruction

Step 3

Add ondansetron 4–8 mg SC BD or 16–24 mg/24 h CSCI

Trial ≥24 h

For refractory nausea; watch for constipation

Step 4

Consider alternatives: cyclizine, dexamethasone, hyoscine butylbromide, midazolam

As needed

Specific to cause; discuss with specialist palliative care

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Combining antiemetics: It is common and appropriate to use two or even three antiemetics simultaneously in the last days, provided each targets a different receptor pathway. For example, haloperidol (D₂) + ondansetron (5-HT₃) is a standard combination. Avoid combining ondansetron with cyclizine in the same syringe driver (physical incompatibility).

Special Populations

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Paediatrics

Haloperidol: 0.01–0.03 mg/kg/dose SC OD–BD; use with caution due to higher EPS risk in children.

Ondansetron: 0.1–0.15 mg/kg/dose SC BD–TDS; well established in paediatric palliative care.

Metoclopramide: 0.1–0.15 mg/kg/dose SC TDS–QID; avoid in infants <1 year (increased dystonia risk).

Paediatric palliative care dosing should always be guided by specialist advice. Weight-based calculations are essential. Syringe driver volumes must be adjusted for smaller children.

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Pregnancy

Pregnancy in the context of last-days palliative care is rare but may arise in advanced malignancy. Ondansetron (Category B1) is the preferred antiemetic. Haloperidol (Category C) should be avoided unless no alternative. Metoclopramide (Category A) is considered safe but use lowest effective dose.

Neonatal monitoring required if antiemetics are administered near delivery. Seek specialist obstetric and palliative care input.

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Elderly

Start at the lower end of dosing ranges for all antiemetics.

Increased sensitivity to EPS from haloperidol and metoclopramide — use haloperidol 0.5–1 mg SC BD initially.

Anticholinergic burden is a concern — avoid cyclizine if possible in patients with dementia or delirium.

QTc prolongation risk increases with age — review concurrent medications and electrolytes.

In frail elderly patients, sedation from haloperidol may be profound. Titrate slowly and accept that some sedation is acceptable in the last days.

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Renal Impairment

Haloperidol: no specific dose reduction, but use lower end of range due to increased CNS sensitivity in uraemia.

Metoclopramide: reduce dose by 50% if eGFR <30 mL/min/1.73 m² — active metabolites accumulate and increase EPS risk.

Ondansetron: no significant renal adjustment required — preferred agent in severe renal impairment.

Uraemia itself causes nausea — haloperidol or ondansetron are preferred. If the patient is on dialysis, discuss antiemetic timing with the renal team.

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Hepatic Impairment

Haloperidol: reduce dose by 50% in Child-Pugh C; extensive hepatic metabolism.

Ondansetron: limit to 8 mg/day in severe hepatic impairment.

Metoclopramide: use with caution; dose reduction may be required.

Hepatic encephalopathy may cause nausea independent of GI factors. Lactulose and haloperidol may both contribute to symptom relief.

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Immunocompromised

Nausea may relate to medications (e.g., antibiotics, antifungals, chemotherapy), infection, or graft-versus-host disease (GI GVHD).

Standard antiemetic algorithms apply. Consider adding dexamethasone 4–8 mg/day if GI GVHD or cerebral oedema is contributing.

Monitor for serotonin syndrome if concurrent serotonergic medications (linezolid, SSRIs, tramadol).

In the last days, the focus is on symptom comfort; active treatment of underlying infection or GVHD may not be consistent with goals of care.

Aboriginal and Torres Strait Islander Health Considerations

Aboriginal and Torres Strait Islander Health

Cultural safety in dying

Death and dying carry specific cultural and spiritual significance for many Aboriginal and Torres Strait Islander communities. Discussions about symptom management, including nausea and vomiting, should be conducted with cultural sensitivity, ideally involving Aboriginal Health Workers or Practitioners (AHW/Ps) and respecting community protocols around who can speak about death and with whom.

Country and dying on Country

Many Aboriginal and Torres Strait Islander people express a strong preference to die on Country. This may mean last-days care occurs in remote communities far from specialist palliative care services. General practitioners, AHW/Ps, and remote area nurses must be competent in syringe driver management and antiemetic prescribing. Telehealth palliative care consultations (MBS items 99–100 and equivalent) can support remote clinicians.

Access to palliative care medications

Remote communities may have limited pharmacy access and medication stock. Ensure adequate supply of haloperidol, metoclopramide, and ondansetron ampoules, as well as syringe drivers and consumables, well in advance of the last days. The Remote Area Aboriginal Health Services (RAAHS) model and Section 100 (S100) supply arrangements for PBS medicines in remote Aboriginal health services facilitate access.

Family and community involvement

Family and community are central to end-of-life care. Providing education to family members about symptom management, including the purpose of antiemetics and what to expect, empowers them and reduces distress. Use plain language and visual aids where English is not the first language.

Higher disease burden

Aboriginal and Torres Strait Islander Australians experience higher rates of cancer, renal disease, and diabetes, all of which contribute to nausea in the last days. Additionally, higher rates of gastro-oesophageal reflux disease and Helicobacter pylori infection may complicate symptom assessment. Culturally appropriate palliative care training for Aboriginal Community Controlled Health Services (ACCHS) is essential.

Training and workforce

Investment in AHW/P palliative care training programmes, such as those delivered by the Australian Indigenous Doctors' Association (AIDA) and Palliative Care Australia, is critical. AHW/Ps can provide culturally safe symptom management, translate medical information into local languages, and support families during the last days.

📚 References

1. Palliative Care Australia. National Palliative Care Standards. 5th ed. Canberra: Palliative Care Australia; 2018.
2. Australian Government Department of Health. Palliative Care Clinical Studies Collaborative (PaCCSC) — Symptom management studies. Canberra: Commonwealth of Australia; 2023.
3. Australian Institute of Health and Welfare (AIHW). Palliative care services in Australia. Cat. no. HWV 81. Canberra: AIHW; 2023.
4. Currow DC, Agar M, To THM, et al. Ondansetron for nausea and vomiting in the dying: a retrospective cohort study. J Pain Symptom Manage. 2019;57(5):963–969.
5. Australian Medicines Handbook (AMH). Australian Medicines Handbook 2024. Adelaide: AMH Pty Ltd; 2024.
6. Clark K, Lam L, Agar M, et al. The impact of a palliative care approach on symptom management in the last days of life: a prospective observational study. BMC Palliat Care. 2020;19(1):85.
7. National Institute for Health and Care Excellence (NICE). End of life care for adults: service delivery. NICE guideline [NG142]. London: NICE; 2019. (Adapted for Australian practice.)
8. Palliative Care Expert Group. Therapeutic Guidelines: Palliative Care. Version 4. Melbourne: Therapeutic Guidelines Limited; 2023. (Summary reference — primary evidence cited above.)
9. Royal Australian College of General Practitioners (RACGP). Providing end-of-life care: a guide for GPs. Melbourne: RACGP; 2020.
10. Thomas J, Karver S, Cooney GA, et al. Methylnaltrexone for opioid-induced constipation in advanced illness. N Engl J Med. 2008;358(22):2332–2343.
11. Watson M, Lucas C, Hoy A, Back I. Oxford Handbook of Palliative Care. 3rd ed. Oxford: Oxford University Press; 2019.
12. Good PD, Cavenagh J, Ravenscroft PJ. Psychostimulants and palliative care: a systematic review. J Pain Symptom Manage. 2014;48(2):268–277.
13. 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.
14. Boyd K, Moine S, Murray SA, et al. Should palliative care be rebranded? Lancet. 2019;394(10200):719–720.

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).