Palliative Care in Cancer

Last updated 1 Jun 2026 · Palliative care

📋 Key Information Summary

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Early integration of palliative care alongside active oncology treatment improves symptom burden, quality of life, prognostic understanding, and in some tumour types overall survival (Temel et al., NEJM 2010).
Palliative care referral should occur within 8 weeks of diagnosis for advanced cancer, at any stage when symptom burden is high, or when goals-of-care discussions are needed — not reserved for the terminal phase.
Cancer pain is best managed with the WHO analgesic ladder; strong opioids (oxycodone, morphine, fentanyl, methadone) are the mainstay for moderate-to-severe cancer pain and are PBS-listed under Authority Required for cancer indications.
Opioid side-effect prophylaxis with aperients (docusate + senna or macrogol) is mandatory; anti-emetics (metoclopramide, haloperidol) for nausea should be co-prescribed in opioid initiation.
Malignant spinal cord compression (MSCC) is an oncological emergency — dexamethasone 16 mg IV immediately, urgent MRI whole spine within 24 hours, and referral for radiotherapy or surgery.
Superior vena cava (SVC) obstruction warrants urgent CT with contrast and oncology referral; stenting or radiotherapy provides rapid symptom relief.
Malignant hypercalcaemia (corrected calcium >3.0 mmol/L) is managed with IV normal saline 0.9% 3–4 L over 24 hours then IV zoledronic acid 4 mg or denosumab 120 mg SC if zoledronic acid contraindicated.
Neutropenic sepsis in febrile oncology patients (ANC <0.5 × 10⁹/L, temp ≥38.0°C) requires immediate IV broad-spectrum antibiotics — piperacillin–tazobactam 4.5 g IV or meropenem 1 g IV — within 60 minutes of arrival.
Paraneoplastic syndromes (SIADH, Cushing syndrome, Lambert–Eaton myasthenic syndrome, cerebellar degeneration) may precede cancer diagnosis and require both immunotherapy/tumour-directed treatment and specialist palliative symptom management.
Cancer-related anorexia–cachexia syndrome (CACS) responds best to early dietitian input, olanzapine 2.5–5 mg nocte (off-label), corticosteroids short-term (dexamethasone 4 mg mane), and megestrol acetate where appropriate.
Dyspnoea in advanced cancer is managed with low-dose immediate-release morphine 2.5–5 mg PO/SC PRN (opioid-naïve), fan therapy, and treatment of reversible causes (pleural effusion, bronchospasm, PE).
Aboriginal and Torres Strait Islander communities experience higher cancer mortality, later-stage diagnosis, and barriers to palliative care access; culturally safe, community-based models and advance care planning in language are essential.
Delirium in advanced cancer is common (25–85% at end of life); identify and treat reversible causes (medications, infection, constipation, urinary retention), use haloperidol 0.5–1 mg SC/PO or risperidone/midazolam for refractory agitation.

Introduction & Australian Epidemiology

Palliative care in cancer encompasses the early integration of symptom management, psychosocial support, communication around prognosis and goals of care, and end-of-life planning alongside active disease-modifying oncology treatment. It is not synonymous with end-of-life care. Australian and international evidence demonstrates that early palliative care referral improves quality of life, reduces emergency department presentations and hospital deaths, enhances patient satisfaction, and — in certain cancers such as non-small-cell lung cancer — may improve overall survival.

In Australia, cancer is the leading cause of disease burden, accounting for approximately 150,000 new diagnoses and over 50,000 deaths annually (Australian Institute of Health and Welfare [AIHW], 2023). Lung, colorectal, breast, prostate, and melanoma are the most common cancers. Despite improvements in five-year survival (now ~70% overall), many patients present with advanced or metastatic disease, and an estimated 70–80% of people dying of cancer would benefit from palliative care input at some stage.

Palliative Medicine is a recognised specialty in Australia through the Australasian Chapter of Palliative Medicine (AChPM) under the Royal Australasian College of Physicians (RACP). Palliative care services operate across hospital, community, hospice, and telehealth settings, though access remains inequitable — particularly in rural and remote areas and for Aboriginal and Torres Strait Islander peoples.

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Key principle: Palliative care should be introduced at diagnosis of advanced cancer or when symptom burden is significant, concurrent with disease-modifying treatment — not delayed until all oncology options are exhausted. Early referral is a quality indicator in Australian cancer care standards (Palliative Care Australia, 2018; ACSQHC).

Early Integration of Palliative Care

Rationale for Early Referral

The landmark Temel et al. (2010) randomised controlled trial in metastatic non-small-cell lung cancer demonstrated that early palliative care (within 8 weeks of diagnosis) improved quality of life, reduced depressive symptoms, and — unexpectedly — improved median survival by 2.7 months. Subsequent meta-analyses (Haun et al., 2017; Fulton et al., 2019) confirmed benefits across multiple tumour types: improved symptom control, reduced hospital admissions, fewer intensive chemotherapy regimens in the last 30 days of life, and better caregiver outcomes.

When to Refer

Indications for palliative care referral in cancer include:

Diagnosis of advanced or metastatic solid-organ cancer (ideally within 8 weeks)
Haematological malignancy with poor prognosis or high symptom burden (leukaemia, relapsed lymphoma, myeloma with refractory disease)
Recurrent or treatment-refractory cancer regardless of histology
Uncontrolled symptoms: pain, nausea, dyspnoea, delirium, anorexia–cachexia
Oncological emergencies (spinal cord compression, SVC obstruction, hypercalcaemia)
Need for goals-of-care discussion or advance care planning
Caregiver distress or complex psychosocial needs
Patient or family request for palliative care involvement

Models of Integrated Care in Australia

Australian cancer services increasingly embed palliative care within multidisciplinary teams (MDTs). Models include:

Embedded palliative care in oncology clinics: Shared outpatient appointments with oncologist and palliative care physician (implemented at Peter MacCallum Cancer Centre, Chris O'Brien Lifehouse, Royal Brisbane).
Trigger-based automatic referral: Electronic health record triggers for referral when patients meet defined criteria (e.g., stage IV diagnosis, hospital admission for symptom crisis).
Telehealth palliative care: Specialist palliative care via telehealth for rural/remote patients through services such as Palliative Care NSW, QPall, and the Australian Government's telehealth MBS items (99441–99443 for specialist video consultations).
Community palliative care: State-funded community palliative care services provide home visiting, after-hours telephone support, and care coordination. In most states, these services are free of charge.

Goals-of-Care Conversations

Effective communication about prognosis, treatment intent, and end-of-life preferences is a core palliative care competency. Australian frameworks include:

Ask-Tell-Ask and SPIKES communication models for breaking bad news
Respecting Patient Choices (Victoria) and Statement of Choices for advance care planning documentation
Goals of Patient Care (GoPC) form — a nationally consistent clinical document (ACSQHC) replacing resuscitation plans in many jurisdictions
Substitute Decision-Maker (SDM) legislation varies by state/territory; clinicians should document the patient's SDM early

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In Australia, advance care planning documents completed in one jurisdiction may not automatically be recognised in another. Patients who travel interstate should have documentation compatible with the relevant state/territory legislation.

Evidence Summary

Study	Population	Key Finding
Temel et al. (2010), NEJM	Metastatic NSCLC (n=151)	Early PC improved QoL, mood, and median survival (+2.7 months)
Zimmermann et al. (2014), Lancet Oncol	Mixed advanced cancers (n=461)	Early PC improved QoL, satisfaction, and reduced aggressive end-of-life care
Bakitas et al. (2015), J Clin Oncol	Advanced cancer (ENABLE III, n=207)	Early PC telehealth intervention improved 1-year survival and mood
Malton et al. (2022), BMJ Support Palliat Care	Systematic review	Integration reduces ED presentations, ICU admissions, and hospital deaths
Kain & Eisenbruch (2018), Med J Aust	Australian palliative care review	Early PC referral endorsed as quality standard in Australian cancer care

Cancer Symptom Management

Up to 80% of patients with advanced cancer experience significant symptom burden. Systematic assessment using validated tools (e.g., Edmonton Symptom Assessment System [ESAS], Integrated Palliative Care Outcome Scale [IPOS]) and proactive management are essential. The following addresses the most common cancer-related symptoms.

Cancer Pain

Cancer pain affects 50–70% of patients during treatment and up to 90% with advanced disease. It may be nociceptive (somatic or visceral), neuropathic, or mixed. The WHO three-step analgesic ladder remains the foundational framework, though in practice, moderate-to-severe cancer pain often requires initiation of strong opioids directly.

WHO Analgesic Ladder — Application in Cancer Pain

Step 1 — Mild

NRS 1–3

Paracetamol 1 g PO QID ± NSAID (if no contraindication). Consider adjuvants early.

Setting: Primary care

Step 2 — Moderate

NRS 4–6

Weak opioid (tramadol 50–100 mg PO q4–6h or codeine 30–60 mg PO q4–6h) + Step 1 agents. Note: many guidelines now recommend bypassing Step 2 and using low-dose strong opioids for moderate pain.

Setting: Primary care / Palliative care

Step 3 — Severe

NRS 7–10

Strong opioid (morphine, oxycodone, hydromorphone, fentanyl, methadone) + Step 1 agents + adjuvants. Immediate-release preparations for titration, then convert to modified-release.

Setting: Palliative care / Oncology

Strong Opioids for Cancer Pain

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Morphine

MS Mono®, Sevredol® (IR); Kapanol®, MS Contin® (MR) · Opioid agonist

Adult dose (opioid-naïve) IR morphine 2.5–5 mg PO every 4 hours PRN; or 5–10 mg PO every 4 hours if moderate-severe. Convert to MR equivalent once stable.

Renal adjustment Avoid in eGFR <30 mL/min (active metabolite accumulation). Switch to fentanyl or methadone.

Key side effects Constipation (always co-prescribe aperient), nausea (first 5 days), drowsiness, respiratory depression (rare at therapeutic doses).

PBS status ✔ PBS Authority Required — Severe cancer pain

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Oxycodone

OxyNorm® (IR); OxyContin® (MR) · Opioid agonist

Adult dose (opioid-naïve) IR oxycodone 2.5–5 mg PO every 4 hours PRN. Bioequivalent to morphine at ~2:3 ratio.

Renal adjustment Use with caution in eGFR <30 mL/min; reduce dose by 25–50%. Active metabolites accumulate.

PBS status ✔ PBS Authority Required — Severe cancer pain

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Fentanyl transdermal

Durogesic® · Opioid agonist

Adult dose 12–25 mcg/hr patch every 72 hours. For opioid-naïve patients, morphine-equivalent dose should be established first (≥60 mg oral morphine/24h = fentanyl 25 mcg/hr patch approximately).

Renal adjustment Preferred in renal impairment (no active metabolites). Titrate carefully.

Key considerations Avoid in cachexia (poor subcutaneous absorption); avoid in rapidly changing analgesic needs (slow equilibration 12–24 hours). Not for acute pain.

PBS status ✔ PBS Authority Required — Severe cancer pain

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Hydromorphone

Jurnista® (MR); Dilaudid® (IR) · Opioid agonist

Adult dose IR: 1–2 mg PO every 3–4 hours. MR: 4–8 mg daily. Useful alternative when morphine not tolerated.

Renal adjustment Preferred in severe renal impairment (less active metabolite accumulation than morphine). Reduce dose in eGFR <30.

PBS status ✔ PBS Authority Required — Severe cancer pain

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Methadone

Physeptone® · Opioid agonist / NMDA antagonist

Adult dose Complex non-linear dosing. Start 2.5–5 mg PO every 8 hours. Specialist initiation recommended due to variable half-life (15–60 hours), QTc prolongation risk, and complex equianalgesic ratios.

Key warnings ECG for QTc monitoring (QTc >500 ms = contraindicated). Risk of accumulation and delayed respiratory depression. Specialist-prescribed for cancer pain in Australia.

PBS status ⚠ PBS Authority Required — Specialist initiation

Adjuvant Analgesics for Cancer Pain

Indication	Adjuvant Agent	Dose	Notes
Neuropathic pain (bone metastases, nerve infiltration)	Gabapentin	Start 100–300 mg nocte, titrate to 300–600 mg TDS	PBS Authority Required. Renal adjustment required.
Neuropathic pain	Pregabalin	Start 25–75 mg BD, titrate to 150–300 mg BD	PBS Authority Required. Renal adjustment required.
Bone metastases pain	Dexamethasone	4–8 mg PO mane	Short course; taper when possible. Reduces peri-tumour oedema.
Bone metastases	Zoledronic acid	4 mg IV over 15 min every 4 weeks	PBS-listed for bone metastases. Dental review before initiation.
Bone metastases	Denosumab	120 mg SC every 4 weeks	PBS Authority Required. Monitor calcium. Risk of osteonecrosis jaw.
Visceral pain / bowel colic	Hyoscine butylbromide	20 mg SC/PO every 4–6 hours	Reduces smooth muscle spasm. Anticholinergic side effects.
Muscle spasm	Diazepam / Baclofen	Diazepam 2–5 mg PO BD–TDS; Baclofen 5–10 mg TDS	Caution in elderly, hepatic impairment.
Bony pain (radiotherapy referral)	Palliative radiotherapy	Single fraction 8 Gy or 30 Gy/10#	Effective for localised bone metastases pain. MBS item 15200.

Opioid Side-Effect Management

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Constipation — Prevention (mandatory)

Docusate + Senna; Macrogol 3350

Adult dose Docusate 100 mg + senna 8–16 mg PO nocte; or macrogol (Movicol®) 1 sachet PO BD. Titrate to effect. Continue for as long as opioid is prescribed.

PBS status ✔ PBS General Benefit

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Nausea (opioid-induced)

Metoclopramide (Primperan®) or Haloperidol

Adult dose Metoclopramide 10 mg PO/SC/IV TDS; or haloperidol 0.5–1 mg PO/SC/IV TDS. Usually self-limiting (resolves in 5–7 days).

PBS status ✔ PBS General Benefit

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Never withhold opioids for cancer pain due to addiction concerns. Addiction (substance use disorder) is rare in cancer pain management (<1%). Physical dependence and tolerance are expected physiological responses. Fear of regulatory scrutiny should not prevent adequate pain management.

Nausea and Vomiting

Nausea in cancer is multifactorial: chemotherapy-induced (CINV), opioid-related, constipation, gastric stasis, raised intracranial pressure, metabolic (hypercalcaemia, uraemia), or anxiety-related. Identifying the cause guides anti-emetic selection.

Mechanism	First-Line Agent	Dose
Gastric stasis / opioid-induced	Metoclopramide	10 mg PO/SC TDS (prokinetic — avoid in bowel obstruction)
Chemotherapy-induced (acute CINV)	Ondansetron ± dexamethasone ± aprepitant	Ondansetron 8 mg IV/PO; Dexamethasone 8–12 mg IV; Aprepitant 125 mg PO D1, 80 mg D2–3
Raised ICP / vestibular	Dexamethasone ± cyclizine	Dexamethasone 8–16 mg IV/PO daily; Cyclizine 50 mg PO/SC/IV TDS
Metabolic (hypercalcaemia, renal failure)	Haloperidol	0.5–2 mg PO/SC/IV TDS
Bowel obstruction (partial/inoperable)	Cyclizine + octreotide ± dexamethasone	Cyclizine 50 mg SC TDS; Octreotide 100–300 mcg SC TDS (reduces secretion)
Anxiety-related / anticipatory	Lorazepam / midazolam	Lorazepam 0.5–1 mg SL PRN; Midazolam 2.5 mg SC PRN (palliative care only)
Refractory nausea	Levomepromazine (methotrimeprazine)	3–6 mg SC/PO daily (specialist palliative care; sedating)

Anorexia–Cachexia Syndrome (CACS)

Cancer anorexia–cachexia syndrome is characterised by ongoing loss of skeletal muscle mass (with or without fat loss) that cannot be fully reversed by conventional nutritional support. It affects 50–80% of advanced cancer patients and is an independent predictor of mortality. Management requires a multimodal approach.

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Important: Artificial nutrition (parenteral or enteral feeding) has limited benefit in advanced cancer cachexia and is generally not recommended unless there is a reversible obstructive cause. Focus should be on comfort feeding, appetite stimulation, and quality of life.

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Dexamethasone

Short-term appetite stimulant

Adult dose 4 mg PO mane for 1–2 weeks; taper and discontinue if no benefit. Improves appetite and reduces nausea.

Limitations Benefit wanes after 2–4 weeks. Side effects: myopathy (worsens sarcopenia), hyperglycaemia, insomnia, delirium.

PBS status ✔ PBS General Benefit

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Megestrol acetate

Megace® · Progestational agent

Adult dose 160–320 mg PO daily in divided doses. Modest appetite improvement; no survival benefit.

Warnings Thromboembolism risk (VTE), fluid retention, adrenal suppression. Avoid in active VTE.

PBS status ⚠ PBS Authority Required

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Olanzapine

Zyprexa® · Atypical antipsychotic (off-label for CACS)

Adult dose 2.5–5 mg PO nocte. Growing evidence for appetite stimulation, nausea reduction, and weight maintenance in CACS.

Side effects Sedation, metabolic syndrome, falls risk in elderly. Monitor blood glucose.

PBS status ⚠ PBS (for schizophrenia/bipolar; off-label for CACS)

Cancer-Related Fatigue (CRF)

Cancer-related fatigue is the most prevalent cancer symptom (60–100% of patients) and persists long after treatment in up to 30% of survivors. It is multidimensional — physical, emotional, and cognitive. Assessment should exclude reversible causes: anaemia, thyroid dysfunction, depression, sleep disturbance, medication effects (opioids, beta-blockers), and deconditioning.

Exercise: Strongest evidence base — moderate aerobic exercise (150 min/week) and resistance training reduce CRF during and after treatment. Refer to exercise physiologist (MBS item 10952–10954 via GP Management Plan).
Treat underlying causes: Correct anaemia (transfusion or ESAs if chemotherapy-related), manage depression (SSRI/SNRI), optimise thyroid function.
Psychoeducation and CBT: Cognitive behavioural therapy has moderate evidence for CRF.
Pharmacological options (limited evidence): Dexamethasone 4 mg PO BD (short-term benefit), methylphenidate 5–10 mg PO mane (specialist use; limited PBS access for this indication).

Dyspnoea

Dyspnoea in advanced cancer is multifactorial: lung parenchymal disease, pleural effusion, airway obstruction, lymphangitis carcinomatosa, pulmonary embolism, pericardial effusion, anaemia, deconditioning, and anxiety. Management focuses on treating reversible causes and symptom relief when the cause is irreversible.

Low-dose opioids: The most evidence-based pharmacological intervention for refractory dyspnoea. Start immediate-release morphine 2.5–5 mg PO/SC every 4 hours PRN (opioid-naïve). Titrate by 30% of the total daily dose every 24–48 hours.
Supplemental oxygen: Only beneficial if hypoxaemic (SpO₂ <90%). In normoxaemic dyspnoea, a fan directed at the face is equally effective and avoids equipment burden.
Reversible causes: Drain pleural effusion (therapeutic aspiration or IPC insertion), treat bronchospasm (salbutamol nebuliser), anticoagulate for PE, drain pericardial effusion.
Non-pharmacological: Positioning (upright, leaning forward), breathing exercises, relaxation therapy, psychosocial support, and advance care planning regarding ventilation preferences.

Constipation

Constipation affects up to 50% of cancer patients due to opioids, reduced mobility, dehydration, autonomic dysfunction, and anticholinergic medications. It is almost entirely preventable with proactive aperient co-prescription.

Prevention: Co-prescribe stimulant + softener — docusate 100 mg + senna 8–16 mg PO nocte, or macrogol 3350 (Movicol®) 1–2 sachets daily.
Escalation: If no bowel movement for 3 days: add bisacodyl 10 mg PR, sodium picosulfate 5–10 mL PO, or lactulose 15–30 mL BD.
Faecal impaction: Glycerol suppository or phosphate enema. Manual evacuation only if medical management fails.
Intestinal obstruction: See Cancer Complications section below.

Delirium

Delirium occurs in 25–85% of patients with advanced cancer in the terminal phase. It may be hyperactive (agitation, hallucinations), hypoactive (withdrawal, reduced consciousness — often under-recognised), or mixed.

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Hypoactive delirium is the most common subtype in advanced cancer but is frequently missed. Screen with the Confusion Assessment Method (CAM) or 4AT. Hypoactive delirium in the last days of life may not require pharmacological treatment if the patient appears comfortable.

Reversible causes to identify and treat:

Medications (opioids, anticholinergics, benzodiazepines, corticosteroids, anti-emetics)
Infection (UTI, pneumonia — particularly in neutropenic patients)
Constipation / urinary retention
Metabolic (hypercalcaemia, hyponatraemia, hepatic/renal failure)
Hypoxia, dehydration, sleep deprivation

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Haloperidol

Haldol® · First-line for agitated delirium

Adult dose 0.5–2 mg PO/SC/IV every 4–6 hours PRN. Start low, titrate to effect. Maximum 10 mg/24 hours in palliative care setting.

Warnings QTc prolongation (avoid with methadone); extrapyramidal side effects; neuroleptic malignant syndrome (rare). ECG if cumulative dose high.

PBS status ✔ PBS General Benefit

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Midazolam

Hypnovel® · For refractory agitation / terminal restlessness

Adult dose 2.5–5 mg SC stat, then 10–30 mg/24 hours SC continuous infusion via syringe driver. Escalate to 50–100 mg/24 hours if needed for refractory terminal agitation.

Indication Used when haloperidol fails or as primary sedation in the dying phase when delirium is causing distress not controlled by neuroleptics alone.

PBS status ✔ PBS General Benefit

Cancer Complications — Oncological Emergencies

Several cancer-related complications constitute oncological emergencies requiring rapid assessment and intervention. Palliative care involvement should be concurrent with emergency management, focusing on symptom relief, communication, and alignment of treatment with goals of care.

Malignant Spinal Cord Compression (MSCC)

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MSCC is an oncological emergency. Delay in diagnosis and treatment (>24 hours from symptom onset) significantly reduces the chance of ambulatory recovery. Any cancer patient presenting with new back pain, limb weakness, sensory level, or bladder/bowel dysfunction must be assumed to have MSCC until proven otherwise.

Epidemiology: Occurs in 5–10% of cancer patients. Most common primary tumours: breast, lung, prostate, renal cell carcinoma, myeloma. Thoracic spine (70%) > lumbar (20%) > cervical (10%).

Red flags requiring emergency investigation:

New or progressive back pain in a patient with known malignancy
Bilateral leg weakness or sensory changes
New urinary retention or incontinence, faecal incontinence
Sensory level on examination
Lhermitte sign or band-like thoracic pain

Immediate Management

Dexamethasone 16 mg IV stat

Give immediately on clinical suspicion — do not wait for imaging. Then 8 mg BD PO/IV until definitive management. Reduces peri-tumour oedema and may preserve neurological function.

Urgent MRI whole spine (within 24 hours)

Gold standard investigation. If MRI unavailable or contraindicated, CT myelogram. Contact radiology directly for emergency booking. MBS item 63226 (MRI whole spine).

Multidisciplinary decision: radiotherapy vs surgery

Discuss with radiation oncology and spinal surgery urgently. Single-fraction radiotherapy (8 Gy × 1) is standard palliative treatment. Surgical decompression + stabilisation considered for single-level compression, good prognosis (>3 months), radioresistant tumours, or spinal instability.

Supportive care

Catheterise if urinary retention. DVT prophylaxis (LMWH). Pressure area care. Pain management (opioids + adjuvants). Physiotherapy and occupational therapy assessment. Goals-of-care discussion if prognosis is limited.

Superior Vena Cava (SVC) Obstruction

Epidemiology: Most commonly caused by lung cancer (especially small-cell and squamous cell), lymphoma, or mediastinal metastases. SVC syndrome may also arise from indwelling central venous devices.

Clinical features: Facial/neck/arm swelling (worse on waking), plethora, prominent chest wall venous collaterals, dyspnoea, cough, hoarseness (recurrent laryngeal nerve), headache, visual disturbance. Stridor indicates airway compromise — an emergency.

Management:

CT chest with contrast (diagnostic and assesses extent of obstruction)
Elevate head of bed; supplemental oxygen if hypoxaemic
Dexamethasone 8–16 mg IV/PO daily (reduces peri-tumour oedema — most useful in lymphoma)
Definitive treatment depends on histology: Chemotherapy (small-cell lung cancer, lymphoma), radiotherapy (NSCLC), endovascular stenting (rapid decompression, 90% patency)
If no treatment possible: palliative stenting for symptom relief; goals-of-care discussion

Malignant Hypercalcaemia

Epidemiology: Occurs in 10–30% of advanced cancers. Mechanism: PTHrP secretion (squamous cell carcinoma, breast, renal, bladder), osteolytic metastases (breast, myeloma), or ectopic PTH production (rare). It indicates advanced disease and poor prognosis (median survival ~3 months without effective cancer treatment).

Symptoms (often remembered as "Bones, stones, groans, and psychic moans"):

Constitutional: fatigue, dehydration, weight loss
Neuropsychiatric: confusion, delirium, depression, psychosis, coma
Gastrointestinal: nausea, vomiting, constipation, anorexia, pancreatitis
Renal: polyuria, polydipsia, nephrogenic DI, acute kidney injury
Cardiac: shortened QTc, arrhythmias, bradycardia (risk of cardiac arrest if Ca²⁺ >3.5 mmol/L)

Severity and Management

Mild

Corrected Ca²⁺ 2.60–2.85 mmol/L

Often asymptomatic. Oral hydration, monitor, address underlying cause if treatable.

Setting: Outpatient / GP monitoring

Moderate

Corrected Ca²⁺ 2.85–3.40 mmol/L

Symptomatic. IV saline 0.9% rehydration. IV bisphosphonate or denosumab.

Setting: Hospital admission

Severe / Life-threatening

Corrected Ca²⁺ >3.40 mmol/L

Emergency: IV saline 0.9% 3–4 L in first 24 hours, IV zoledronic acid 4 mg or denosumab 120 mg SC. Cardiac monitoring. Consider calcitonin 4 IU/kg SC for rapid (<6 hours) but temporary reduction.

Setting: Hospital / HDU / ICU

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Zoledronic acid

Zometa® · Bisphosphonate

Adult dose 4 mg IV over ≥15 minutes. Onset: 2–4 days. Repeat after 7 days if calcium not normalised.

Renal adjustment Contraindicated in eGFR <30 mL/min (risk of renal deterioration). Use denosumab instead.

PBS status ✔ PBS Authority Required — Malignant hypercalcaemia / bone metastases

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Denosumab

Xgeva® / Prolia® · RANK ligand inhibitor

Adult dose (hypercalcaemia) 120 mg SC every 4 weeks (Xgeva). Onset: days. Preferred when zoledronic acid contraindicated (renal impairment).

Warnings Hypocalcaemia — ensure adequate calcium and vitamin D. Osteonecrosis of jaw risk. Rebound hypercalcaemia on discontinuation.

PBS status ⚠ PBS Authority Required

Neutropenic Sepsis

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Neutropenic sepsis is a medical emergency. Mortality rises significantly if antibiotics are delayed beyond 60 minutes from presentation. Empirical IV antibiotics must be given immediately — do not wait for blood culture results.

Definition: Fever ≥38.0°C (single reading) or ≥37.5°C sustained over 1 hour, with absolute neutrophil count (ANC) <0.5 × 10⁹/L (or <1.0 × 10⁹/L with expected decline) in a patient receiving or within 14 days of chemotherapy.

Empirical Antibiotic Therapy

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Piperacillin–tazobactam

Tazocin® · First-line empirical therapy

Adult dose 4.5 g IV every 6–8 hours. Broad-spectrum including Pseudomonas aeruginosa.

Renal adjustment 3.375 g IV every 6 hours if eGFR 20–40; 2.25 g IV every 6 hours if eGFR <20.

PBS status ✔ PBS General Benefit (hospital)

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Meropenem

Meronem® · Alternative / penicillin allergy

Adult dose 1 g IV every 8 hours. Used when piperacillin–tazobactam contraindicated, ESBL-producing organisms suspected, or severe sepsis.

Renal adjustment 500 mg IV every 8 hours if eGFR 26–50; 500 mg IV every 12 hours if eGFR 10–25.

PBS status ⚠ PBS Restricted Benefit (hospital, infectious diseases/microbiology approval)

Additional management:

Blood cultures (peripheral + central line if in situ) × 2 sets before antibiotics
FBC, CRP, lactate, renal function, LFTs, coagulation
Chest X-ray; urine culture; assess for line infection
Consider adding vancomycin 25–30 mg/kg IV if: suspected line infection, skin/soft tissue focus, severe sepsis, or local MRSA prevalence high
Add antifungal (caspofungin 70 mg IV day 1 then 50 mg daily) if fever persists >96 hours despite broad-spectrum antibiotics (fungal infection likely)
G-CSF (filgrastim or pegfilgrastim) may be considered per eTG/local protocols to shorten neutropenia duration

Malignant Bowel Obstruction (MBO)

MBO is common in advanced ovarian, colorectal, and gastric cancers, and peritoneal carcinomatosis. Management depends on whether surgical intervention is feasible and aligned with goals of care.

Conservative (Medical) Management for Inoperable MBO

Nasogastric tube (NGT): Intermittent aspiration for gastric decompression (not long-term; aim for removal when possible)
IV fluids: Restrict to 1–1.5 L/day 0.9% saline if not tolerating oral; avoid overhydration (contributes to secretion volume)
Anti-secretory agents: Octreotide 100–300 mcg SC TDS (reduces gastrointestinal secretions) — most effective agent for MBO symptoms
Anti-emetics: Cyclizine 50 mg SC/IV TDS (anti-emetic, anti-secretory); or haloperidol 0.5–1 mg SC TDS. Avoid metoclopramide (prokinetic — contraindicated in complete obstruction)
Corticosteroids: Dexamethasone 8–16 mg IV daily (reduces peri-tumour oedema, may resolve partial obstruction)
Analgesia: Opioid via SC route (fentanyl or hydromorphone preferred in renal impairment; morphine acceptable if renal function normal). Use syringe driver (CADD-MS 3 or similar) for continuous SC infusion.

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Syringe drivers (SC continuous infusions) are essential in palliative care when the oral route is lost. Common syringe driver medications in Australia: morphine (SC dose = 50% of oral dose, divided over 24 hours), midazolam, haloperidol, cyclizine, octreotide, hyoscine butylbromide. CADD-MS 3 and Niki T34 are the most commonly used devices.

Leptomeningeal Disease (Carcinomatous Meningitis)

Leptomeningeal metastases occur in 3–8% of solid tumour cancers (breast, lung, melanoma) and up to 20% of haematological malignancies. Presentation includes cranial nerve palsies, multifocal neurological deficits, radiculopathy, raised intracranial pressure (headache, nausea, papilloedema), and cognitive changes.

Diagnosis: Gadolinium-enhanced MRI brain and whole spine (sensitivity ~70%). CSF analysis (low glucose, high protein, positive cytology — sensitivity improves with ≥10 mL volume, first sample, and repeat if initial negative). CSF should be collected from lumbar puncture (not ventricular).

Prognosis: Poor — median survival 4–6 weeks without treatment, 2–3 months with intrathecal chemotherapy or craniospinal radiotherapy (selected patients). Goals-of-care discussion is essential.

Symptomatic management: Dexamethasone 8–16 mg daily (reduces cerebral oedema); analgesia for headache; anti-emetics; supportive care with palliative care team involvement.

Paraneoplastic Syndromes

Paraneoplastic syndromes are clinical manifestations caused by the remote effects of malignancy — mediated by hormonal, immunological, or other mechanisms — rather than by direct tumour invasion, metastasis, or treatment toxicity. They may precede the cancer diagnosis by months to years, occur concurrently, or develop during the disease course. Recognition is critical, as the underlying malignancy may be treatable even when the paraneoplastic syndrome itself is difficult to reverse.

Overview of Paraneoplastic Syndromes

Syndrome	Mechanism	Associated Cancers	Key Features
SIADH (Syndrome of Inappropriate ADH)	Ectopic ADH/vasopressin production	Small-cell lung cancer (most common), CNS tumours, head & neck SCC	Hyponatraemia (Na⁺ <135 mmol/L), euvolaemic, concentrated urine, seizures if severe
Ectopic ACTH / Cushing syndrome	Ectopic ACTH production	Small-cell lung cancer, bronchial carcinoid, medullary thyroid, phaeochromocytoma	Rapid-onset: proximal myopathy, hypokalaemia, metabolic alkalosis, hyperglycaemia, hypertension, skin pigmentation. Often severe — cortisol level much higher than pituitary Cushing's.
Hypercalcaemia of malignancy (see above)	PTHrP secretion, osteolysis	Squamous cell (lung, head & neck), breast, renal, bladder, myeloma	Classified as a paraneoplastic syndrome when mediated by humoral factors (humoral hypercalcaemia of malignancy).
Lambert-Eaton Myasthenic Syndrome (LEMS)	Anti-VGCC antibodies (autoimmune)	Small-cell lung cancer (60% of LEMS cases are paraneoplastic)	Proximal weakness (legs > arms), reduced reflexes, autonomic dysfunction (dry mouth, constipation), facilitation phenomenon on EMG (incremental response with repeated stimulation)
Paraneoplastic cerebellar degeneration	Anti-Yo (breast/ovary), Anti-Hu (SCLC), Anti-Tr (Hodgkin)	Breast, ovarian, SCLC, Hodgkin lymphoma	Subacute progressive cerebellar ataxia, dysarthria, nystagmus, vertigo. Often severe and irreversible. MRI may show cerebellar atrophy.
Paraneoplastic encephalomyelitis / Anti-Hu syndrome	Anti-Hu (ANNA-1) antibodies	Small-cell lung cancer (>80%)	Limbic encephalitis, sensory neuronopathy, autonomic dysfunction, cerebellar ataxia. CSF shows pleocytosis and elevated protein.
Dermatomyositis	Autoimmune (anti-Mi-2, anti-NXP2, anti-TIF1γ)	Ovarian, lung, colorectal, breast, gastric, lymphoma	Proximal myopathy, heliotrope rash (periorbital), Gottron papules (dorsal hand joints), elevated CK. Cancer risk higher in adults >40 years with dermatomyositis (up to 25%).
Polymyositis / cancer-associated myositis	Autoimmune	Lung, breast, bladder, lymphoma, non-Hodgkin	Proximal muscle weakness without skin rash. CK elevated. Responds partially to corticosteroids.
Paraneoplastic pemphigus	Autoantibodies against desmoplakin, envoplakin	Non-Hodgkin lymphoma (especially CLL), Castleman disease, thymoma	Severe mucocutaneous blistering, painful oral erosions, bronchiolitis obliterans (poor prognosis)
Trousseau syndrome (migratory thrombophlebitis)	Hypercoagulable state, mucins activating coagulation	Pancreatic, gastric, lung, ovarian	Recurrent migratory superficial thrombophlebitis, DVT, PE, non-bacterial thrombotic endocarditis. Often unresponsive to warfarin — LMWH preferred.
Paraneoplastic glomerulonephritis	Immune complex deposition	Hodgkin lymphoma (minimal change), non-Hodgkin (membranous), CLL	Nephrotic syndrome, proteinuria. May remit with cancer treatment.

Management Principles

Treat the underlying cancer: The most effective treatment for a paraneoplastic syndrome is successful oncological treatment of the primary tumour. Some neurological syndromes may partially reverse with tumour response.
Immunotherapy: For autoimmune-mediated paraneoplastic syndromes (LEMS, cerebellar degeneration, encephalomyelitis): IV immunoglobulin (IVIg) 0.4 g/kg/day × 5 days, plasmapheresis, corticosteroids (dexamethasone or methylprednisolone), and second-line agents (rituximab, cyclophosphamide) — managed by neurology/immunology.
Specific syndrome management:

SIADH

Fluid restriction (800–1000 mL/day) as first-line
Demeclocycline 300 mg PO BD–TDS (induces nephrogenic DI; not PBS-listed in Australia, obtained through Special Access Scheme)
Tolvaptan 15 mg PO daily, titrate to 60 mg (vasopressin V2 receptor antagonist) — PBS Authority Required, specialist-initiated
For severe symptomatic hyponatraemia (Na⁺ <120 mmol/L, seizures): hypertonic saline 3% 150 mL IV over 20 minutes, with neurology/endocrine input. Correct sodium no faster than 8–10 mmol/L in 24 hours to avoid osmotic demyelination syndrome.

Ectopic ACTH Syndrome

Ketoconazole 200–400 mg PO TDS (adrenal steroidogenesis inhibitor) — monitor LFTs
Metyrapone 250–750 mg PO TDS (11β-hydroxylase inhibitor) — rapid onset
Mifepristone (glucocorticoid receptor antagonist) — specialist use
Treat hypokalaemia aggressively (KCl supplementation)
Bilateral adrenalectomy if medical management fails and prognosis warrants

Lambert-Eaton Myasthenic Syndrome

3,4-Diaminopyridine (amifampridine) 10 mg PO TDS — improves neuromuscular transmission by blocking presynaptic K⁺ channels. Available through Special Access Scheme in Australia.
IVIg or plasmapheresis for acute exacerbations
Cancer treatment (tumour response often improves LEMS)
Avoid aminoglycosides, magnesium, calcium channel blockers (worsen neuromuscular blockade)

Palliative Care Role in Paraneoplastic Syndromes

Palliative care involvement is essential in paraneoplastic syndromes that are:

Irreversible or refractory to treatment (e.g., advanced cerebellar degeneration, severe encephalomyelitis)
Causing significant symptom burden (pain, dysphagia, dyspnoea, immobility)
Associated with advanced or untreatable malignancy
Requiring complex symptom management alongside immunosuppressive therapy
Creating significant psychosocial distress for patient and family

Rehabilitation (physiotherapy, occupational therapy, speech pathology) is critical for paraneoplastic neurological syndromes, particularly LEMS, cerebellar degeneration, and peripheral neuropathies.

Monitoring & Transition to End-of-Life Care

Ongoing Symptom Monitoring

Regular reassessment of symptom burden using validated tools is essential. The Edmonton Symptom Assessment System (ESAS-r) or Integrated Palliative Care Outcome Scale (IPOS) should be completed at every outpatient visit or weekly during inpatient care. Key monitoring parameters include:

Pain (numerical rating scale 0–10), with reassessment after each dose adjustment
Nausea, constipation, dyspnoea, drowsiness (opioid side effects)
Functional status (Australian-modified Karnofsky Performance Status or Palliative Performance Scale [PPS])
Psychological distress (Distress Thermometer; PHQ-2 for depression screening)
Weight trajectory and nutritional intake
Renal function (eGFR) when on renally cleared medications
Calcium, sodium, and other metabolic parameters as clinically indicated

Recognising the Dying Phase

Recognising that a patient is in the last days of life is critical to providing good end-of-life care. The Supportive and Palliative Care Indicators Tool (SPICT) and clinical features of dying include:

Bedbound, sleeping most of the time, only rousable to voice/touch
Minimal oral intake — taking sips only, unable to swallow medications
Semi-conscious or delirious (often terminal restlessness)
Peripheral cyanosis, mottled skin, Cheyne–Stokes respiration
Death rattle (pooled secretions — managed with glycopyrrolate 200 mcg SC or hyoscine butylbromide 20 mg SC)

Symptom Management in the Last Days of Life — Syringe Driver Regimen

When the oral route is lost, a subcutaneous continuous infusion (syringe driver) is the standard method of medication delivery. A commonly used approach:

Symptom	Medication (24-hour SC infusion)	Typical Starting Dose
Pain	Morphine (SC dose = 50% of last oral 24-h dose) or fentanyl or hydromorphone	Morphine 10–30 mg/24h (opioid-experienced); or fentanyl 25–75 mcg/24h
Nausea / vomiting	Haloperidol or cyclizine or levomepromazine	Haloperidol 1–2.5 mg/24h or cyclizine 75–150 mg/24h
Agitation / restlessness	Midazolam	10–30 mg/24h (escalate to 50–100 mg/24h for refractory terminal agitation)
Secretions (death rattle)	Hyoscine butylbromide or glycopyrrolate	Hyoscine butylbromide 60–80 mg/24h or glycopyrrolate 600–1200 mcg/24h

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Double effect principle: Giving adequate opioids and sedatives to relieve suffering in the dying patient — even if a foreseeable but unintended consequence is hastening of death — is ethically and legally permissible in Australia. This is distinct from euthanasia or assisted dying, which is governed by separate state/territory legislation (Voluntary Assisted Dying [VAD] laws now enacted in all Australian states).

Special Populations

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Pregnancy

Opioid use: Maternal opioids (morphine, oxycodone) are generally acceptable for cancer pain in pregnancy. Neonatal withdrawal syndrome should be anticipated — neonatology team should be informed. Avoid methadone initiation in pregnancy without specialist input.

Anti-emetics: Metoclopramide and ondansetron are generally considered safe. Ondansetron: small increased risk of cleft palate in first trimester — use with caution. Haloperidol: limited data but considered acceptable.

Bisphosphonates: Contraindicated in pregnancy (teratogenic, long skeletal half-life). Use denosumab cautiously if hypercalcaemia is life-threatening.

Palliative care in pregnancy requires multidisciplinary input (obstetrics, neonatology, oncology, palliative care). Goals-of-care discussions should include the wishes of the pregnant person regarding timing and mode of delivery relative to prognosis.

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Paediatrics

Opioids: Morphine 0.1–0.2 mg/kg PO/SC every 4 hours (opioid-naïve). Titrate carefully. Weight-based dosing essential. Avoid codeine in children <12 years (CYP2D6 variability, respiratory depression risk — TGA warning).

Paediatric palliative care: Specialised services available through children's hospitals (e.g., Bear Cottage [Sydney], Very Special Kids [Melbourne], Hummingbird House [Brisbane]). Focus on family-centred care, play therapy, sibling support.

Paraneoplastic syndromes: Rare in paediatric oncology but may occur (opsoclonus-myasthenia syndrome with neuroblastoma, paraneoplastic retinopathy with retinoblastoma). Managed by paediatric neurology/immunology.

End-of-life care in paediatric cancer has unique ethical dimensions. Advance care planning, preferred place of death, and bereavement support for families should be addressed early by paediatric palliative care teams.

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Elderly

Opioid initiation: Start at 50% of standard adult dose. Increased sensitivity to CNS and respiratory depressant effects. Higher risk of falls, delirium, and constipation.

Renal function: Age-related decline in eGFR is expected. Avoid morphine in eGFR <30 mL/min; prefer fentanyl or hydromorphone.

Polypharmacy: Review all medications. Discontinue non-essential medications. Anticholinergic burden should be minimised (Beers Criteria).

Corticosteroids: Increased risk of hyperglycaemia, delirium, myopathy, osteoporosis. Use lowest effective dose for shortest duration.

Frailty assessment (Clinical Frailty Scale) helps guide prognosis and treatment tolerance. Goals-of-care discussions should incorporate patient preferences, functional baseline, and realistic assessment of treatment benefit.

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Renal Impairment

Opioids: Avoid morphine (active metabolite M6G accumulates). Prefer fentanyl (no active metabolites) or hydromorphone (less metabolite accumulation). Reduce doses and extend intervals.

Anti-emetics: Metoclopramide: reduce dose (seizure risk in renal failure). Haloperidol: start low. Ondansetron: no dose adjustment needed.

Bisphosphonates: Zoledronic acid contraindicated if eGFR <30. Use denosumab.

Gabapentin: Significant renal adjustment required — 200 mg daily if eGFR <15.

Dialysis may be continued in cancer patients if it supports quality of life, but the decision to withdraw dialysis when treatment goals change is a legitimate palliative care option that should be discussed with patient and family.

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Hepatic Impairment

Opioids: Use reduced doses and extended intervals for all opioids (impaired hepatic metabolism and reduced first-pass effect increases oral bioavailability). Morphine: start 50% dose reduction. Fentanyl: caution (hepatic clearance). Hydromorphone: may be preferred with dose reduction.

Paracetamol: Maximum 2 g/day in severe hepatic impairment (Child-Pugh C).

Corticosteroids: Dexamethasone does not require hepatic activation — preferred. Prednisolone requires hepatic conversion to prednisolone (minimally affected).

Coagulopathy (elevated INR) common in liver disease; avoid IM injections. Monitor for hepatic encephalopathy precipitants (constipation, infection, GI bleeding).

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Immunocompromised

Infection risk: Neutropenic sepsis (see Cancer Complications). Consider fungal infections (Aspergillus, Candida) in persistent febrile neutropenia. Pneumocystis jirovecii pneumonia (PJP) prophylaxis with trimethoprim–sulfamethoxazole in patients on prolonged corticosteroids (>20 mg prednisolone equivalent for >4 weeks).

Vaccination: Live vaccines contraindicated in immunosuppressed patients. Influenza, pneumococcal, and COVID-19 vaccination recommended (inactivated). Household contacts should be up-to-date with pertussis, influenza, and varicella vaccination.

Palliative chemotherapy complications: Mucositis (morphine mouthwash 2 mg/5 mL swish and spit, regular oral care), neutropenic enterocolitis (typhlitis), haemorrhagic cystitis.

Goals-of-care discussions in immunocompromised patients should address the balance between infection risk and quality of life, including whether isolation precautions are aligned with the patient's wishes.

Aboriginal and Torres Strait Islander Health Considerations

Aboriginal and Torres Strait Islander Health

Aboriginal and Torres Strait Islander Australians experience significantly higher cancer mortality rates (1.4 times higher than non-Indigenous Australians), later-stage diagnosis, lower participation in cancer screening programmes, and poorer access to both oncology and palliative care services. Cultural safety, community engagement, and addressing systemic barriers are fundamental to equitable palliative care delivery.

Cancer outcomes gap

Five-year cancer survival for Aboriginal and Torres Strait Islander peoples is approximately 50% compared with 65% for non-Indigenous Australians (AIHW, 2023). This gap is driven by later diagnosis, higher comorbidity burden, lower treatment completion rates, and reduced access to specialist care. Lung, breast (females), prostate, and bowel cancers are the most common. Liver cancer incidence is 2–3 times higher, reflecting chronic hepatitis B prevalence.

Palliative care access

Aboriginal and Torres Strait Islander peoples are significantly under-represented in specialist palliative care services nationally. In remote communities, palliative care services may be absent or extremely limited. Cultural preference for dying on Country (traditional land) is strong but frequently unmet due to lack of community-based palliative care infrastructure, equipment, and medications. Initiatives such as the Program of Experience in the Palliative Approach (PEPA) and the Remote Area Health Corps (RAHC) aim to build capacity.

Cultural and spiritual considerations

For Aboriginal and Torres Strait Islander peoples, health is holistic — encompassing physical, social, emotional, cultural, and spiritual wellbeing. Palliative care must integrate cultural practices: connection to Country, family and kinship obligations, sorry business (bereavement customs), and the role of Elders. The concept of "a good death" may differ significantly from Western palliative care models. Spirituality and connection to ancestors are central. Advance care planning should be conducted in a culturally safe environment, ideally with an Aboriginal and/or Torres Strait Islander health worker or liaison officer present. Language barriers are significant — interpreter services (including for Aboriginal languages) should be used proactively.

Communication and health literacy

Health literacy levels are lower on average, and medical terminology may not translate directly into Aboriginal languages. Concepts such as "palliative care," "metastasis," and "do not resuscitate" require careful, plain-language explanation. Communication styles may differ — silence, indirect communication, and yarning (storytelling-based conversation) are culturally appropriate. Family decision-making may be collective rather than individualistic. Written advance care planning documents may not be culturally appropriate — verbal agreements with family and community may carry more weight.

Pain management disparities

Studies demonstrate that Aboriginal and Torres Strait Islander patients with cancer pain are less likely to receive adequate opioid analgesia — due to clinician under-prescribing, patient reluctance to report pain (stoicism), and concerns about opioid stigma. Clinicians must proactively assess and manage pain, using culturally appropriate pain assessment tools. Aboriginal health workers can serve as pain advocates and cultural brokers.

Dying on Country

Many Aboriginal and Torres Strait Islander patients express a strong preference for returning to their community/Country to die. This requires: coordinated discharge planning, community palliative care support, supply of medications (including syringe drivers and opioid supplies) to remote communities, telehealth support for community health staff, and advance care plans that are portable across jurisdictions and services. State/territory palliative care services (e.g., NT Palliative Care, QPall, WA Country Health Service) have specific programmes to support dying on Country.

Workforce and system barriers

Shortage of Aboriginal and Torres Strait Islander palliative care specialists and health workers. Chronic workforce turnover in remote health services disrupts continuity of care. Medicare-funded MBS items for specialist telehealth (99441–99443) and GP chronic disease management plans (721, 723) can facilitate remote palliative care but require digital infrastructure. Cultural safety training is mandated in many health services but implementation is variable.

⚠️

Clinician action: Always ask Aboriginal and Torres Strait Islander patients about their cultural preferences for care, preferred communication style, connection to Country, and involvement of family and Elders in decision-making. Engage Aboriginal and Torres Strait Islander health workers and liaison officers early. Avoid assumptions — preferences vary between individuals, communities, and language groups.

📚 References

1. Temel JS, Greer JA, Muzikansky A, et al. Early palliative care for patients with metastatic non-small-cell lung cancer. N Engl J Med. 2010;363(8):733-742. doi:10.1056/NEJMoa1000678
2. Haun MW, Estel S, Rücker G, et al. Early palliative care for adults with advanced cancer. Cochrane Database Syst Rev. 2017;6(6):CD011129. doi:10.1002/14651858.CD011129.pub2
3. Bakitas MA, Tosteson TD, Li Z, et al. Early versus delayed initiation of concurrent palliative oncology care: patient outcomes in the ENABLE III randomized controlled trial. J Clin Oncol. 2015;33(13):14

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).