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Palliative Care Emergencies

Last updated 1 Jun 2026 · Palliative care

📋 Key Information Summary

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  • Palliative care emergencies require rapid assessment framed by goals of care, prognosis, burdens and benefits of intervention, care setting, and available resources — not all emergencies warrant escalation to intensive care or hospital transfer.
  • A documented Advance Care Plan (ACP) and Resuscitation Plan (ReSPlan) should be reviewed at every acute deterioration to guide decision-making.
  • Catastrophic haemorrhage (e.g. carotid blowout, massive haematemesis) carries very high mortality; management prioritises patient dignity, family support, and symptom control rather than futile resuscitation.
  • Acute pain in palliative care is managed with rapid-onset opioids (IV/SC morphine or fentanyl) titrated to effect; opioid-naïve patients require lower starting doses with close monitoring.
  • Acute agitation and delirium are managed with haloperidol or midazolam first-line, while addressing reversible causes (urinary retention, constipation, medications, infection).
  • Seizures in palliative patients are managed with buccal midazolam or IV lorazepam as first-line, with levetiracetam or sodium valproate for maintenance; phenytoin is often avoided due to drug interactions.
  • Refractory breathlessness responds to low-dose opioids (oral morphine 2.5–5 mg 4-hourly or equivalent), low-dose benzodiazepines, fan therapy, and non-pharmacological strategies.
  • Malignant spinal cord compression (MSCC) is a clinical emergency — start dexamethasone 8–16 mg IV immediately if suspected, and arrange urgent MRI spine within 24 hours.
  • All palliative care emergency drug kits should include: morphine (oral concentrate and injectable), midazolam, haloperidol, hyoscine butylbromide, dexamethasone, and an antiemetic.
  • Aboriginal and Torres Strait Islander patients face unique barriers including remote access, cultural safety, language, and delayed diagnosis; early involvement of Indigenous liaison officers and community-controlled health services is essential.
  • The burden of palliative care emergencies is higher in rural and remote Australia; telehealth, specialist outreach, and anticipatory prescribing mitigate access inequities.
  • After managing any palliative emergency, conduct a structured debrief, update the care plan, and ensure psychosocial and bereavement support for the patient, family, and care team.

Introduction & Australian Epidemiology

Palliative care emergencies are acute, often life-threatening presentations that occur in people with serious, advanced, or terminal illness. Unlike conventional emergencies where the primary goal is survival and cure, the management of these events is fundamentally shaped by the individual's goals of care, prognosis, treatment preferences, the balance of burdens and benefits, the care setting, and the resources available. A cancer patient presenting with catastrophic haemorrhage at home with a preference for comfort care requires a radically different response to a similar event in a patient awaiting curative treatment.

These emergencies can occur across all care settings — inpatient hospices, hospital wards, emergency departments, residential aged care facilities (RACFs), and at home with community palliative care support. The ability to respond rapidly and appropriately demands anticipatory planning, ready access to emergency medications, and a workforce confident in palliative-specific interventions.

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Core principle: In palliative care emergencies, the question is not simply "What can we do?" but rather "What should we do, given this person's values, goals, and prognosis?" Every intervention must be weighed against potential burdens including loss of consciousness at end of life, prolongation of dying, and unwanted hospital transfers.

Australian Context

In Australia, approximately 160,000 people die each year, and an estimated 100,000–120,000 could benefit from palliative care at some point. The AIHW reports that palliative care-related hospitalisations number over 100,000 annually, with a significant proportion involving acute emergency presentations. Cancer accounts for approximately 30% of palliative care admissions, but the largest growth is in non-malignant conditions — end-stage heart failure, chronic obstructive pulmonary disease (COPD), end-stage kidney disease, motor neurone disease (MND), and dementia.

Key Australian statistics relevant to palliative emergencies:

  • Malignant spinal cord compression occurs in 5–10% of patients with metastatic cancer and requires rapid intervention to preserve neurological function.
  • Up to 70% of patients with advanced cancer experience significant pain, with breakthrough pain episodes constituting a common emergency presentation.
  • Delirium affects 28–83% of patients in the terminal phase of illness and is a leading reason for emergency hospital transfer from RACFs and home settings.
  • Dyspnoea is experienced by up to 70% of patients with advanced cancer and up to 90% of patients with end-stage COPD or heart failure.
  • Major haemorrhage occurs in 3–6% of advanced cancer patients and carries an in-hospital mortality rate exceeding 60%.
  • Aboriginal and Torres Strait Islander Australians have higher rates of advanced disease at diagnosis and greater barriers to accessing palliative care, particularly in remote and very remote areas.

The Australian Commission on Safety and Quality in Health Care (ACSQHC) National Consensus Statement: Essential Elements for Safe and High-Quality End-of-Life Care (2015) and the National Palliative Care Strategy 2018 provide frameworks for managing palliative emergencies safely and with dignity. CareSearch and the Palliative Care Outcomes Collaboration (PCOC) offer national benchmarks for outcomes measurement.

Goals of Care & Emergency Planning

Effective management of palliative emergencies begins before the emergency occurs, with proactive advance care planning and preparation. Without an understanding of the patient's wishes and trajectory, clinicians risk initiating interventions that are burdensome, unwanted, or contrary to the patient's values.

Advance Care Planning (ACP) in Australia

Advance care planning is a legal and ethical framework supported by state and territory legislation across Australia. Each jurisdiction has specific legislation governing Advance Health Directives (AHDs), Substitute Decision-Makers (SDMs), and resuscitation orders.

State / Territory Key Legislation ACP Document Substitute Decision-Maker
NSW NSW Health Advance Planning Framework Advance Care Directive / ReSPlan Person responsible (hierarchy)
VIC Medical Treatment Planning and Decisions Act 2016 Advance Care Directive Medical treatment decision maker
QLD Powers of Attorney Act 1998 Advance Health Directive Enduring power of attorney (health)
SA Advance Care Directives Act 2013 Advance Care Directive Substitute decision-maker
WA Advance Health Directive Act 1996 Advance Health Directive Enduring power of guardianship
TAS Guardianship and Administration Act 1995 Advance Care Directive Enduring power of guardianship
NT Advance Personal Planning Act 2013 Advance Personal Plan Decision-maker
ACT Medical Treatment (Health Directions) Act 2006 Health Direction Attorney under EPA

Anticipatory Prescribing

Anticipatory (or "just-in-case") prescribing of injectable medications is a cornerstone of palliative emergency preparedness. All patients in the terminal phase or at risk of predictable emergencies should have subcutaneous medications available in the home, RACF, or hospice:

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Morphine (SC)
Ordine® · Sevredol® · Opioid analgesic
Adult dose 2.5–5 mg SC 4-hourly PRN; titrate to effect; breakthrough: equivalent of 1/6th total daily dose
Renal adjustment eGFR <30: reduce dose 50%, extend interval; use hydromorphone or fentanyl preferentially
PBS status ✔ PBS General Benefit
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Midazolam (SC/IV)
Hypnovel® · Hypnotic / Anticonvulsant
Adult dose Agitation: 2.5–5 mg SC/IM stat, repeat Q1H PRN; Seizures: 5–10 mg SC/IM/IV; Infusion: 0.5–1 mg/hr SC continuous (titrate)
Paediatric dose Seizures: 0.1–0.2 mg/kg IM/IV; buccal: 0.5 mg/kg (max 10 mg)
PBS status ✔ PBS General Benefit
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Haloperidol (SC/IM/IV)
Serenace® · Antipsychotic / Antiemetic
Adult dose Agitation/delirium: 0.5–2.5 mg SC/IM stat, repeat Q4–6H PRN; Nausea: 0.5–1 mg SC BD–TDS
Renal adjustment No specific adjustment; use lower doses in elderly
PBS status ✔ PBS General Benefit
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Hyoscine Butylbromide
Buscopan® · Anticholinergic (secretions)
Adult dose 20 mg SC stat, repeat Q4–6H PRN; continuous infusion: 60–120 mg/24h SC
Renal adjustment No specific adjustment
PBS status ✔ PBS General Benefit
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Anticipatory prescribing checklist: Ensure all medications are available as subcutaneous formulations, prescriber authority is documented, carers/nurses are trained in administration (or district nursing arranged), and a 24-hour contact number for the palliative care team is provided.

Catastrophic Events

Catastrophic events in palliative care are sudden, dramatic, and often fatal clinical crises. They include massive haemorrhage, airway obstruction, acute superior vena cava (SVC) obstruction, pulmonary embolism, and cardiac tamponade. The critical question in all cases is: Is this event reversible within the patient's goals of care, and would treatment provide meaningful benefit?

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Dignity-preserving management: When catastrophic events occur in patients with comfort-care goals, the priority shifts immediately to ensuring the patient is free from pain, fear, and distress. Pre-prepared emergency syringes of morphine and midazolam should be at the bedside. Family presence and emotional support are paramount.

Types of Catastrophic Events

Event Typical Cause Presentation Palliative Approach
Carotid blowout Head/neck cancer eroding carotid artery Sudden, massive oral/cervical haemorrhage; rapid haemodynamic collapse Comfort care: morphine 5–10 mg IV/SC + midazolam 5–10 mg IV/SC; supportive care for family
Massive haematemesis Oesophageal/gastric tumour erosion; portal hypertension Copious bright red vomiting, melaena, shock If active treatment: IV fluids, octreotide, PPI, urgent endoscopy; if comfort: symptom control
Airway obstruction Tumour, lymphangitis, post-radiation oedema, bleeding into airway Stridor, dyspnoea, cyanosis, panic Dexamethasone 8–16 mg IV, nebulised adrenaline, stenting if goals align; otherwise anxiolysis
SVC obstruction Mediastinal tumour, lymphoma, central line thrombosis Facial/arm swelling, plethora, dyspnoea, headache Dexamethasone 8 mg BD; stenting/chemotherapy if appropriate to goals
Cardiac tamponade Pericardial effusion from malignancy Beck's triad: hypotension, muffled heart sounds, JVP elevation Pericardiocentesis if appropriate; otherwise comfort measures

Emergency Symptom Control for Catastrophic Events

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Morphine (IV/SC bolus)
Rapid symptom relief in catastrophic haemorrhage
Adult dose 5–10 mg IV/SC stat; repeat every 5–10 min until distress controlled
Key note Higher doses acceptable when goal is comfort; respiratory depression is not a concern at end of life
PBS status ✔ PBS General Benefit
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Midazolam (IV/SC bolus)
Anxiolysis and sedation in catastrophic events
Adult dose 5–10 mg IV/SC stat; repeat Q5–10 min PRN until calm; continuous infusion 1–5 mg/hr if refractory
Key note Provides rapid anxiolysis; onset IV <2 min, SC 5–10 min
PBS status ✔ PBS General Benefit
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Dexamethasone (IV)
Reduces tumour oedema (airway, SVC, cord compression)
Adult dose 8–16 mg IV stat, then 8 mg BD; taper over 1–2 weeks if responding
Key note Give with PPI for gastric protection; monitor BGL in diabetics
PBS status ✔ PBS General Benefit

Catastrophic Haemorrhage: Home Management Plan

1
Be Prepared
Dark-coloured towels/sheets, waterproof mattress cover, gloves, pre-drawn syringes of morphine and midazolam at bedside.
2
Keep Safe
Position patient comfortably; do not attempt to stop uncontrolled arterial haemorrhage unless aligns with goals; call ambulance only if desired by patient/family.
3
Relieve Distress
Administer morphine 5–10 mg SC + midazolam 5–10 mg SC immediately; repeat as needed. Speak calmly to patient.
4
Support Family
Stay with the family; explain what is happening; ensure they know death is not painful for the patient. Offer bereavement follow-up.

Acute Pain & Agitation

Acute Pain in Palliative Care

Acute pain in palliative care may arise from disease progression (bone metastases, nerve infiltration, visceral distension), treatment-related causes (post-surgical, mucositis, neuropathy), or concurrent conditions (fractures, constipation). Pain management requires rapid assessment using a structured approach, distinguishing between background pain, breakthrough pain, and incident pain.

WHO Analgesic Ladder (Modified for Palliative Emergencies)

Step 1 — Mild Pain (NRS 1–3)
Non-opioid ± Adjuvant
Paracetamol 1 g PO QID; ± NSAIDs (if no contraindication); adjuvant agents as indicated by pain mechanism.
Setting: Home / RACF / Hospice
Step 2 — Moderate Pain (NRS 4–6)
Weak Opioid + Non-opioid ± Adjuvant
Tramadol 50–100 mg PO QID or low-dose morphine; most palliative care guidelines now favour low-dose strong opioids over tramadol/paracetamol-codeine combinations.
Setting: Home / RACF / Hospice / ED
Step 3 — Severe Pain (NRS 7–10)
Strong Opioid + Non-opioid ± Adjuvant
Morphine 5–10 mg SC/IV stat (opioid-naïve) or 50–100% of current dose for tolerant patients; re-assess in 15–30 min.
Setting: ED / Inpatient / Palliative care unit

Acute Pain Crisis Management — Key Principles

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Opioid-naïve patients: Start with morphine 2.5–5 mg SC/IV or 5 mg PO (immediate-release). Re-assess in 30 minutes (PO) or 15 minutes (SC/IV). Do not start with transdermal patches or sustained-release formulations in an acute pain crisis.
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Morphine — Immediate Release (PO)
Sevredol® · MSIR® · Opioid analgesic
Adult dose 5–10 mg PO 4-hourly; breakthrough: 2.5–5 mg PO PRN Q2H
Renal adjustment eGFR 10–30: reduce dose by 50%, extend interval; eGFR <10: avoid; use fentanyl or hydromorphone
PBS status ✔ PBS General Benefit
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Fentanyl (SC/IV/Transmucosal)
Sublimaze® · Abstral® · Actiq® · Rapid-onset opioid
Adult dose SC/IV bolus: 25–50 µg Q5–10 min titrated; intranasal: 50–100 µg; buccal: 100–200 µg for breakthrough pain
Renal adjustment Preferred in renal impairment (no active metabolites)
PBS status ✔ PBS General Benefit (injectable); ⬤ Authority Required (transmucosal)
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Hydromorphone (PO/SC)
Jurnista® · Dilaudid® · Strong opioid alternative
Adult dose PO: 1–2 mg Q4H (opioid-naïve); SC: 0.5–1 mg Q4H; useful alternative in renal impairment
Renal adjustment Preferred over morphine in significant renal impairment (less accumulation)
PBS status ⬤ Authority Required
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Ketamine (SC/IV — specialist use)
Ketalar® · NMDA antagonist for refractory pain
Adult dose Sub-anaesthetic: 50–100 mg/24h SC continuous infusion; titrate to effect; specialist supervision
Key note For opioid-refractory pain; requires specialist palliative care involvement
PBS status ✔ PBS General Benefit

Acute Agitation & Delirium

Acute agitation in palliative care is most commonly due to delirium (hyperactive or mixed subtype), but may also result from uncontrolled pain, anxiety, psychosis, or medication effects (e.g. corticosteroid psychosis, opioid-induced neurotoxicity). A structured approach addresses both the underlying cause and the presenting symptoms.

Reversible Causes — Always Assess

  • Urinary retention — palpate bladder; perform bladder scan; catheterise if indicated
  • Constipation / faecal impaction — digital examination; disimpaction if required
  • Medications — opioids, benzodiazepines, anticholinergics, corticosteroids, antiemetics
  • Infection — UTI, pneumonia, skin infections (treatment decisions guided by goals)
  • Metabolic — hypercalcaemia, hyponatraemia, hepatic encephalopathy, uraemia
  • Hypoxia — consider if appropriate; may not be correctable in advanced disease
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Haloperidol
Serenace® · First-line for delirium-related agitation
Adult dose 0.5–2.5 mg PO/SC/IM stat; repeat Q4–6H PRN; max 10 mg/24h in community
Renal adjustment No specific adjustment; start low in elderly
PBS status ✔ PBS General Benefit
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Midazolam
Hypnovel® · For refractory agitation or anxiety
Adult dose 2.5–5 mg SC/IM stat, repeat Q1H PRN; continuous infusion: 0.5–1 mg/hr SC
Key note Second-line after haloperidol; first-line if agitation is primarily anxiety-driven
PBS status ✔ PBS General Benefit
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Levomepromazine (Methotrimeprazine)
Nozinan® · Sedating antipsychotic for refractory agitation
Adult dose 6.25–12.5 mg SC stat; repeat Q6–8H; potent sedation — reserve for refractory symptoms
Key note Combined antiemetic, anxiolytic, and sedative; significant hypotension risk
PBS status ✔ PBS General Benefit
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Refractory delirium in terminal phase: If haloperidol and midazolam are insufficient, a continuous subcutaneous infusion (CSCI) of midazolam (0.5–3 mg/hr) ± haloperidol (0.5–2 mg/hr) or levomepromazine may be required. This should be under specialist palliative care guidance and consistent with the goals of care.

Seizures & Breathlessness

Seizures in Palliative Care

Seizures in palliative care patients are most commonly due to primary or metastatic brain tumours, metabolic encephalopathy (hepatic, renal, hypoglycaemia), medication withdrawal (benzodiazepines, alcohol), or stroke. New-onset seizures in a palliative patient require urgent assessment but the investigation and treatment pathway is determined by the goals of care.

Acute Seizure Management

1
Immediate (0–5 min)
Protect patient from injury; position in recovery position; do not restrain; time the seizure. Ensure airway patency.
2
First-line medication (5–10 min)
Buccal midazolam 10 mg (adults >5 years) or rectal diazepam 10–20 mg; IV lorazepam 4 mg if IV access available.
3
Second-line (15–20 min)
Repeat buccal midazolam or IV lorazepam once; if seizure continues: IV levetiracetam 1500–3000 mg or IV sodium valproate 15–30 mg/kg; or IV phenobarbitone 10–15 mg/kg (specialist guidance).
4
Refractory status (30+ min)
Midazolam CSCI 0.5–2 mg/hr; consider goals of care — if comfort is the aim, deep sedation may be appropriate without further escalation.
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Midazolam (Buccal)
Buccolam® · First-line out-of-hospital anticonvulsant
Adult dose 10 mg buccal (2 × 5 mg prefilled syringes); repeat once after 10 min if seizure persists
Paediatric dose 1–5 years: 5 mg; 5–10 years: 7.5 mg; 10–18 years: 10 mg buccal
PBS status ✔ PBS General Benefit
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Levetiracetam (PO/IV)
Keppra® · Maintenance anticonvulsant (preferred in palliative care)
Adult dose 500 mg PO/IV BD, titrate to 1000–1500 mg BD; loading dose 1500–3000 mg IV for acute seizure
Key advantage Minimal drug interactions; no hepatic metabolism; IV and oral formulations available
PBS status ⬤ Authority Required
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Maintenance anticonvulsant choice: In palliative care, levetiracetam or sodium valproate are preferred over phenytoin due to fewer drug interactions, availability of IV formulations, and better side-effect profiles. Clonazepam is useful as an adjunct for myoclonic seizures. Phenytoin requires therapeutic drug monitoring and interacts with corticosteroids, antifungals, and many other medications used in palliative care.

Breathlessness (Dyspnoea)

Breathlessness is one of the most distressing symptoms in palliative care, experienced by 50–70% of patients with advanced cancer and up to 90% of those with end-stage cardiac or respiratory disease. In the palliative context, the management approach prioritises subjective symptom relief over correction of underlying physiological parameters.

Non-Pharmacological Strategies

  • Fan therapy — hand-held fan directed at the face; evidence-based and immediately accessible
  • Positioning — upright or semi-reclined; leaning forward with arms supported
  • Open windows / fresh air — perception of airflow is beneficial
  • Relaxation techniques — pursed-lip breathing, diaphragmatic breathing, guided imagery
  • Pacing and activity modification — energy conservation strategies
  • Anxiety management — breathlessness and anxiety are tightly coupled; addressing one improves the other

Pharmacological Management of Dyspnoea

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Morphine (Low-dose oral)
First-line for refractory breathlessness
Adult dose Opioid-naïve: 2.5–5 mg PO immediate-release 4-hourly; or 2.5–5 mg SC Q4H; titrate by 30% every 24–48h
Mechanism Reduces central respiratory drive; decreases perception of breathlessness; does not cause clinically significant respiratory depression at these doses
PBS status ✔ PBS General Benefit
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Midazolam (Low-dose)
Anxiolytic component for breathlessness with anxiety
Adult dose 2.5–5 mg SC/PO PRN; or 0.5–1 mg/hr SC continuous if refractory; use as adjunct to opioids
Key note Most effective when breathlessness is significantly anxiety-driven; use lowest effective dose
PBS status ✔ PBS General Benefit
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Key evidence: Systematic reviews confirm that low-dose opioids (oral or parenteral) are safe and effective for refractory breathlessness in palliative care. The 2017 Cochrane review found opioids reduced breathlessness intensity with no significant increase in adverse events at the doses used. Supplemental oxygen has no additional benefit over room air in non-hypoxic patients (Lancet 2010).

Malignant Spinal Cord Compression (MSCC)

Malignant spinal cord compression (MSCC) occurs when tumour or vertebral metastases compress the spinal cord or cauda equina, causing neurological deficit. It affects 5–10% of patients with metastatic cancer and constitutes a true oncological emergency. Early recognition and intervention are critical — the ambulatory status at the time of treatment is the strongest predictor of post-treatment mobility.

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Time-critical emergency: If MSCC is suspected, start dexamethasone immediately (do not wait for MRI). The goal is to preserve or restore ambulatory function. Every hour of delay reduces the probability of ambulation after treatment. Refer for urgent MRI within 24 hours.

Clinical Presentation

  • Back pain (90–95%) — often the first symptom; may be present for weeks to months before neurological signs; localised, worse lying down, worse with Valsalva manoeuvre
  • Motor weakness (70–85%) — progresses from difficulty walking to paraparesis to paraplegia; assess using MRC grading
  • Sensory changes (50–70%) — numbness, tingling, band-like sensation at the level of compression
  • Autonomic dysfunction (40–60%) — urinary retention, constipation, overflow incontinence; late and ominous signs
  • Common levels: thoracic (70%), lumbosacral (20%), cervical (10%); multiple levels in up to 30%

Initial Assessment — Frankel Scale

Grade A — Complete
Complete motor and sensory loss
No motor or sensory function below the level of the lesion. Prognosis for recovery very poor regardless of treatment.
Goals: comfort care; symptom management; prevention of complications
Grade B–D — Incomplete
Partial neurological deficit
Some motor or sensory function preserved below the lesion. Grade D: walks with assistance. Grade B: sensory only. Grade C: motor present but non-functional.
Goals: urgent treatment if aligns with care goals; dexamethasone + surgical/RT review
Grade E — Normal
No neurological deficit (imaging finding only)
Compression seen on MRI but no functional impairment. Highest chance of preserving function with treatment.
Goals: urgent treatment; best outcomes

Acute Management Algorithm

1
Immediate: Dexamethasone
16 mg IV stat (or 8 mg IV if contraindication), then 8 mg BD PO/IV. Concurrent PPI for gastric protection. Do not wait for imaging.
2
Urgent MRI Whole Spine
MRI should be performed within 24 hours (ideally same day). CT myelogram if MRI contraindicated. Image the entire spine (multiple levels in ~30%).
3
Multidisciplinary Review
Neurosurgery/orthopaedics + radiation oncology + palliative care. Assess for surgical candidacy (SCORING system) and radiotherapy planning.
4
Definitive Treatment
Surgery (decompression + stabilisation) + adjuvant RT, or palliative radiotherapy alone (typically 20 Gy/5# or 30 Gy/10#, or 8 Gy/1#). Single-fraction RT if poor prognosis.
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Dexamethasone
First-line corticosteroid for MSCC
Adult dose Loading: 8–16 mg IV stat; maintenance: 8 mg PO/IV BD; taper over 2–4 weeks after definitive treatment
Renal adjustment None required
Key precautions PPI cover (e.g. pantoprazole 40 mg daily); monitor BGL (particularly in diabetics); psychiatric side effects
PBS status ✔ PBS General Benefit
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When comfort care is the goal: For patients who are not candidates for surgery or radiotherapy, dexamethasone may still provide short-term symptom benefit. The focus shifts to pain management (opioids ± nerve blocks), bladder care (catheterisation), skin integrity (pressure area care), and psychosocial support. Discuss expected trajectory honestly and compassionately.

Prognostic Factors for Treatment Decisions

Factor Favourable for Treatment Unfavourable
Ambulatory status Walking independently Paraplegia >48 hours
Sphincter function Continence preserved Bladder/bowel incontinence
Tumour type Breast, prostate, myeloma (radiosensitive) Renal cell, melanoma, NSCLC (radioresistant)
Life expectancy >3 months <3 months
Number of metastases Solitary / oligometastatic Widespread diffuse metastases
Performance status ECOG 0–2 ECOG 3–4

Investigations

The scope of investigations in palliative emergencies is guided by the goals of care. Not every patient requires a full septic workup; however, targeted investigations may identify reversible causes and guide appropriate intervention. The principle of "what will we do with the result?" should be applied consistently.

Essential Full blood count Detects anaemia (haemorrhage), thrombocytopenia, neutropenia; MBS item 65060. Available in all settings.
Essential Urea, electrolytes, creatinine Renal function, hyperkalaemia, uraemia; MBS item 66500. Guides opioid choice and dose adjustment.
Essential Blood glucose (BGL) Hypoglycaemia as cause of agitation/seizures; especially important with corticosteroid use and insulin.
Essential Calcium (corrected) Hypercalcaemia of malignancy: cause of confusion, nausea, constipation, and coma. MBS item 66503.
Available Liver function tests Hepatic metastases, hepatic encephalopathy; guides medication clearance. MBS item 66512.
Available Arterial blood gas If assessing for hypoxia or hypercapnia; rarely changes management in comfort-focused care.
Available Midstream urine / urine dipstick UTI as reversible cause of delirium; MBS item 69310.
Specialist MRI Whole Spine Gold standard for MSCC; MBS item 63200 (MRI lumbar spine) / 63203 (MRI thoracic). Arrange within 24 hours if MSCC suspected.
Specialist CT Brain (with contrast) If seizures due to suspected brain metastases; MBS item 56001. Consider if results will change management.
Referral CT Pulmonary Angiography Suspected PE in palliative patients where anticoagulation is aligned with goals; MBS item 57300.
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When NOT to investigate: If a patient has a documented comfort-only care plan and is in the terminal phase, investigations such as blood cultures, CT scans, and arterial blood gases may cause unnecessary distress. Clinical assessment and empiric symptom management are usually appropriate. Always ask: "Will this result change my management?"

Monitoring

Monitoring in palliative emergencies is focused, goal-directed, and proportional to the intensity of treatment. The type and frequency of monitoring depend on the clinical setting, the treatments being administered, and the patient's care goals.

Monitoring by Emergency Type

Emergency Key Parameters Frequency Setting
Acute pain crisis Pain score (NRS 0–10); sedation score (RASS); respiratory rate; pupil size; nausea Q15 min after opioid bolus; Q1H when stable ED / Palliative ward / Home with nurse
Agitation/delirium Agitation scale (RASS / PAS); level of consciousness; vital signs; pain score; bladder scan Q30 min until settled; Q2–4H when stable ED / Palliative ward / RACF
Seizures Seizure duration; consciousness level; neurological observations; oxygen saturation Continuous during seizure; Q15 min post-ictal; Q1H once stable ED / ICU (if escalation aligned with goals)
Breathlessness Modified Borg scale; respiratory rate; SpO₂ (clinical context); anxiety score Q30 min after intervention; Q4H ongoing Any setting; home with nurse assessment
MSCC Motor function (MRC grading); sensory level; bladder function; pain score; BGL (steroids) Q4–6H neurological observations Inpatient (oncology/ neurosurgery)
Catastrophic haemorrhage Comfort assessment; sedation level; family distress Continuous until death or stable Any setting (home, hospice, hospital)

Sedation Monitoring

When sedating agents (midazolam, levomepromazine) are used for refractory symptoms, use the Richmond Agitation-Sedation Scale (RASS) or a simple clinical sedation score to titrate to the minimum effective level. The target is typically RASS −2 to −3 (light to moderate sedation) unless the patient is in the terminal phase and comfort-focused deep sedation is intended.

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Principle of proportionality: In comfort-focused care, continuous cardiac monitoring, frequent blood tests, and invasive lines are usually inappropriate. Monitoring should be limited to clinical assessment of symptom control. Conversely, if a patient is receiving disease-modifying treatment for an emergency (e.g. surgery for MSCC), appropriate peri-operative monitoring applies.

Special Populations

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Pregnancy

  • Cancer in pregnancy is rare (~1:1000 pregnancies) but palliative emergencies may occur with advanced disease.
  • Opioids: Morphine is Category C; use at lowest effective dose; avoid in labour (fetal respiratory depression). Fentanyl may be preferred.
  • Midazolam: Category D — avoid in first trimester; risk of neonatal respiratory depression; avoid near term.
  • Dexamethasone: May be used short-term; risk of fetal adrenal suppression with prolonged use.
  • Haloperidol: Category C — use if benefits outweigh risks; monitor neonate for extrapyramidal effects.
  • Multidisciplinary involvement: obstetrics, neonatology, oncology, palliative care, ethics committee if conflicts arise.
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Paediatrics

  • Paediatric palliative emergencies are rare but devastating; most involve CNS tumours, leukaemia, or rare genetic conditions.
  • Morphine: 0.1–0.2 mg/kg SC/IV Q2–4H; 0.2–0.4 mg/kg PO Q4H. Start low, titrate.
  • Midazolam: 0.05–0.1 mg/kg SC/IV; buccal 0.5 mg/kg (max 10 mg) for seizures.
  • Seizures: Buccal midazolam first-line (>5 years); rectal diazepam if <5 years or buccal not tolerated.
  • Weight-based dosing is essential; use validated paediatric charts (e.g. Palliative Care for Children in Australia).
  • Family-centred care with strong psychosocial support; involve paediatric palliative care teams early.
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Elderly

  • Elderly patients are at increased risk of delirium, opioid toxicity, falls, and polypharmacy-related adverse events.
  • Opioids: Start at 50% of standard adult dose; morphine clearance is reduced; increased sensitivity to benzodiazepines.
  • Haloperidol: Start 0.25–0.5 mg; QTc prolongation risk — check ECG if available; avoid in Lewy body dementia.
  • Corticosteroids: Higher risk of hyperglycaemia, delirium, myopathy, and fractures.
  • RACF-based management is preferable to hospital transfer where possible and aligned with goals; ensure after-hours medication access.
  • Always review the full medication list; deprescribe non-essential medications to reduce burden and interaction risk.
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Renal Impairment

  • Renal impairment is common in palliative care (up to 30% of advanced cancer patients); significantly affects drug clearance.
  • Morphine: Active metabolites (M6G, M3G) accumulate; avoid if eGFR <30. Use fentanyl or hydromorphone as first-line alternatives.
  • Fentanyl: No active metabolites; preferred in renal impairment; no dose adjustment required.
  • Hydromorphone: Less accumulation than morphine; use with caution and dose reduction in severe renal impairment.
  • Midazolam: Prolonged effect in renal failure; use lower doses and extend intervals.
  • Gabapentin and pregabalin require significant dose reduction (gabapentin: 200 mg post-dialysis if anuric).
🫁

Hepatic Impairment

  • Hepatic metastases or cirrhosis alter drug metabolism; reduced protein binding increases free drug levels.
  • Opioids: All opioids are hepatically metabolised; start at 50% dose; morphine is preferred (less affected by mild-moderate impairment than oxycodone). Avoid codeine (prodrug).
  • Haloperidol: Start at lowest dose; risk of extrapyramidal effects and QTc prolongation increases.
  • Dexamethasone: Use with caution; steroid psychosis risk higher; monitor closely.
  • Coagulopathy is common — check INR before any invasive procedures (e.g. lumbar puncture, nerve blocks).
🛡️

Immunocompromised

  • Includes patients on chemotherapy, corticosteroids, transplant recipients, and those with advanced HIV.
  • Fever in neutropenia (ANC <0.5 × 10⁹/L) should prompt empiric antibiotics even in palliative patients if treatment goals include maintaining quality of life.
  • Empiric antibiotics: Piperacillin-tazobactam 4.5 g IV Q6H or meropenem 1 g IV Q8H per eTG guidelines; adjust to goals.
  • Palliative sedation may be complicated by infection-driven delirium; treat infection if contributing to distress.
  • Discuss advance care plans proactively — patients on chemotherapy should have clear documentation of escalation limits.

Aboriginal and Torres Strait Islander Health Considerations

Aboriginal and Torres Strait Islander Health

Aboriginal and Torres Strait Islander Australians experience a disproportionate burden of palliative care emergencies due to later diagnosis of advanced disease, higher rates of chronic illness, and significant barriers to accessing palliative care services. The AIHW reports that Indigenous Australians are 1.4 times more likely to die from cancer than non-Indigenous Australians and are more likely to present with advanced, incurable disease. Closing the Gap Target 1 (life expectancy) and the National Agreement on Closing the Gap (2020) emphasize the importance of culturally safe, community-controlled health care.

Access to palliative care services
Remote and very remote communities often lack specialist palliative care. The majority of palliative care services are concentrated in major cities. Community-controlled health services (ACCHOs) are critical for delivering culturally safe end-of-life care but are under-resourced for acute emergencies.
Cultural safety
"Sorry business" protocols, kinship obligations, connection to Country, and spiritual beliefs about death and dying must be respected. Many patients wish to return to Country for end-of-life care. Health services must avoid imposing Western models of dying without cultural consultation.
Communication
Language barriers are significant — many patients in remote communities speak English as a second, third, or fourth language. Aboriginal Health Workers and Practitioners (AHW/Ps) and Indigenous liaison officers should be involved in all emergency consultations and discussions about prognosis and goals of care.
Advance care planning
ACP engagement rates are lower among Indigenous Australians. Conversations about death must be approached with cultural sensitivity. RHDAustralia and Palliative Care Australia have developed culturally appropriate ACP resources. Documentation should be accessible and stored in My Health Record where consented.
Medication access
Remote communities may lack 24-hour pharmacy access or cold-chain storage for some injectable medications. Remote Area Nurse (RAN) initiated medication schedules under CARPA Standard Treatment Manual are essential. Ensure anticipatory medications are prescribed and available well in advance of need.
Hospital transfer considerations
Aeromedical retrieval from remote communities involves prolonged transport times (often 4–12 hours). Transfer decisions must weigh the burden of transfer against potential benefit. Many patients prefer to die on Country rather than in a distant hospital. Document transfer preferences clearly in the ACP.
Social determinants of health
Overcrowded housing, food insecurity, limited transport, and poverty affect the ability to manage palliative emergencies at home. Ensure connections to social and emotional wellbeing services, housing support, and community networks. Link with local Land Councils and community Elders where appropriate.
Bereavement support
Aboriginal and Torres Strait Islander bereavement practices are communal and may involve large gatherings, mourning periods, and cultural restrictions (e.g. avoidance of the deceased's name). Ensure health services understand and support these practices. Yarning circles and on-Country grief support are evidence-based approaches.

📚 References

  1. 1. Palliative Care Australia. National Palliative Care Strategy 2018. Canberra: Australian Government Department of Health; 2018.
  2. 2. Australian Commission on Safety and Quality in Health Care (ACSQHC). National Consensus Statement: Essential Elements for Safe and High-Quality End-of-Life Care. Sydney: ACSQHC; 2015.
  3. 3. Australian Institute of Health and Welfare (AIHW). Palliative care services in Australia. AIHW Cat. No. HWI 331. Canberra: AIHW; 2023.
  4. 4. CareSearch. Palliative Care Evidence: Clinical Evidence for Palliative Care. Flinders University, Adelaide; 2024. Available at: caresearch.com.au.
  5. 5. Royal Australian College of General Practitioners (RACGP). Guide to providing palliative care in general practice. 2nd ed. Melbourne: RACGP; 2023.
  6. 6. Johnson MJ, Bland JM, Oxberry SG, et al. Opioids for breathlessness: a systematic review and meta-analysis. BMJ Supportive & Palliative Care. 2013;3(1):11–20.
  7. 7. 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.
  8. 8. Patchell RA, Tibbs PA, Regine WF, et al. Direct decompressive surgical resection in the treatment of spinal cord compression caused by metastatic cancer: a randomised trial. Lancet. 2005;366(9486):643–648.
  9. 9. National Institute for Health and Care Excellence (NICE). Metastatic spinal cord compression: diagnosis and management of adults at risk of and with metastatic spinal cord compression. NICE Clinical Guideline CG75. London: NICE; 2008 (updated 2024).
  10. 10. Bush SH, Lawlor PG, Ryan K, et al. Delirium in adult cancer patients: ESMO Clinical Practice Guidelines. Annals of Oncology. 2018;29(Suppl 4):iv143–iv165.
  11. 11. Royal Children's Hospital Melbourne. Paiatric Palliative Care Clinical Practice Guidelines. 2nd ed. Melbourne: RCH; 2022.
  12. 12. RHDAustralia (Remote Area Health Corps). Chronic Disease Management for Aboriginal and Torres Strait Islander Health: A Palliative Care Approach. Darwin: RHDAustralia; 2023.
  13. 13. Palliative Care Outcomes Collaboration (PCOC). National Benchmarking Report 2023. University of Wollongong; 2023.
  14. 14. Currow DC, McDonald C, Oaten S, et al. Once-daily opioids for chronic dyspnoea: a dose increment and pharmacovigilance study. Journal of Pain and Symptom Management. 2011;42(3):388–399.
  15. 15. Harris DG, Noble SIR. Management of terminal haemorrhage in patients with advanced cancer: a systematic literature review. Journal of Pain and Symptom Management. 2009;38(6):931–940.
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).