Palliative care and advance care planning: the Australian GP approach

What palliative care actually is

Palliative care is active, holistic care for people living with life-limiting illness. It is not “giving up” — it is systematic, expert attention to the full range of physical, psychological, social, and spiritual needs of patients and their families. Palliative Care Australia defines it as care that improves quality of life when curative treatment is no longer the primary goal or cannot offer further benefit.

The Australian model integrates two tiers: generalist palliative care provided by GPs, RACF nursing staff, and community nurses (who manage the majority of palliative needs); and specialist palliative care services — community teams, hospital consult teams, and inpatient hospice or palliative care units — available for complex cases requiring expert input. Most Australians with palliative needs are cared for in the community, and the GP is often the clinical anchor of that care. Despite a stated preference for dying at home, most Australians currently die in hospital or residential aged care — a gap that community palliative care is designed to close.

The common misunderstanding — that palliative care is only for the final hours — delays referral and deprives patients of its benefits. Evidence from the oncology literature shows that early integration of palliative support alongside disease-directed treatment improves symptom control and, in some settings, prolongs life.

A. Core clinical — the AU general-practice framework

Recognising when a palliative approach is needed

The surprise question is the most clinically useful trigger: Would I be surprised if this patient died in the next 12 months? If the honest answer is no, it is time to initiate the palliative approach regardless of diagnosis. The SPICT-AU tool (Supportive and Palliative Care Indicators Tool) supplements this with structured indicators:

• Functional decline (ECOG performance status ≥ 3, increasingly dependent in ADLs)
• Disease-specific thresholds: NYHA IV heart failure, FEV₁ < 30% in COPD, eGFR < 15, FAST 7c advanced dementia (non-verbal, bedbound)
• Repeated unplanned admissions or progressive deterioration despite optimal treatment

Trajectories of dying differ across conditions and shape the approach. Cancer typically follows a relatively preserved functional course until the final months, then a sharp decline — the palliative trigger is often visible. Organ failure (heart failure, COPD, CKD, cirrhosis) follows an episodic trajectory of partial decline and partial recovery; prognostic uncertainty frequently delays palliative conversations. Frailty and dementia produce a gradual multi-year decline — palliative needs accumulate over years and are often poorly addressed.

Pain management

Pain management in palliative care follows the WHO analgesic ladder:

1. Non-opioid (paracetamol, NSAID where tolerated) ± adjuvant analgesic
2. Mild opioid (tramadol, used with caution) for moderate pain
3. Strong opioid for severe pain

Morphine is the first-line strong opioid for malignant pain in Australia, per eTG Palliative Care. For an opioid-naive adult, the starting dose is immediate-release morphine 2.5–5 mg orally every 4 hours, with the same dose available as a breakthrough PRN prescription up to once per hour. Once stable on regular immediate-release dosing, convert to a modified-release formulation (MS Contin or Kapanol) twice daily, with immediate-release morphine for breakthrough (1/6 of the total daily dose). The oral-to-subcutaneous conversion ratio is approximately 2:1 (i.e., 10 mg oral morphine = 5 mg subcutaneous morphine).

Renal impairment (eGFR < 30) changes opioid selection: morphine metabolites (M3G, M6G) accumulate and cause neurotoxicity. Per AMH, prefer fentanyl, hydromorphone, or buprenorphine in significant renal impairment.

Constipation is universal with opioids — it does not reduce with time. Always co-prescribe a stimulant laxative (senna or bisacodyl) combined with an osmotic agent (macrogol) from day one of opioid therapy.

Adjuvants for specific pain types:

• Neuropathic pain (burning, electric, allodynia): pregabalin, gabapentin, or amitriptyline — PBS Authority required for neuropathic indications
• Bone pain: NSAID, bisphosphonate (zoledronate IV), dexamethasone, single-fraction palliative radiotherapy
• Visceral or colicky pain: hyoscine butylbromide (Buscopan) 20 mg SC PRN

Schedule 8 and RTPM: All strong opioids are Schedule 8 in Australia. Real-Time Prescription Monitoring (RTPM) is mandatory in Victoria (SafeScript), Queensland (QScript), Tasmania, ACT, and SA; it is progressing in NSW and WA. State-specific authority requirements apply for Schedule 8 ongoing prescribing. TGA and state health departments publish current requirements.

Other common symptom domains

Nausea: Management is mechanism-directed per eTG. Gastric stasis or opioid-induced nausea: metoclopramide 10 mg PO/SC every 6–8 hours. Chemical or metabolic nausea (uraemia, hypercalcaemia, opioid): haloperidol 0.5–1.5 mg PO/SC every 8–12 hours. Refractory or multi-mechanism nausea: olanzapine 2.5–5 mg nocte (broad receptor activity; particularly useful in the last weeks). Bowel obstruction: hyoscine butylbromide ± dexamethasone; surgical review if appropriate.

Dyspnoea: Low-dose opioid — morphine 1–2.5 mg PO/SC every 4 hours PRN — reduces the sensation of dyspnoea via central mechanisms at doses that do not cause respiratory depression. A bedside fan directed at the face via trigeminal nerve stimulation provides equivalent or superior benefit to supplemental oxygen in patients who are not hypoxic. Reserve oxygen for patients with SpO₂ < 88%.

Terminal secretions (“death rattle”): More distressing for family than for the unconscious patient. Reposition to lateral or semi-prone. Hyoscine butylbromide (Buscopan) 20 mg SC every 4 hours PRN is the first-line antimuscarinic in Australia — minimal CNS penetration reduces sedation risk. Glycopyrrolate 0.2 mg SC is an alternative. Prescribe anticipatorily so doses are available without delay.

Terminal delirium and agitation: Seek and treat reversible causes (urinary retention, faecal impaction, drug toxicity, hypercalcaemia) where consistent with goals of care. Haloperidol 0.5–1.5 mg SC PRN for distressed delirium (avoid in Parkinson disease or Lewy body dementia); midazolam 2.5–5 mg SC PRN for severe refractory agitation. Avoid physical restraint.

Subcutaneous infusion

When the oral route fails — vomiting, dysphagia, reduced level of consciousness — a subcutaneous syringe driver provides continuous medication delivery. The Niki T34 McKinley pump is widely used in Australian community palliative care. Common end-of-life combinations include morphine + metoclopramide + hyoscine butylbromide, or morphine + haloperidol + midazolam. Compatibility must be confirmed; a palliative pharmacist at community palliative services or via palliAGED can advise.

Anticipatory prescribing (“just-in-case” medications) should be written in advance: morphine SC, midazolam SC, haloperidol SC, and hyoscine butylbromide SC — so they can be drawn up and administered by community nurses without delay when symptoms emerge in the last days.

B. Evidence for palliative care interventions

Intervention	Verdict	Key evidence
Early specialist palliative care in advanced cancer	🟢 Strong	Temel 2010 NEJM — early palliative care improved quality of life and, in a secondary analysis, overall survival in advanced lung cancer; integration from diagnosis recommended
Morphine for cancer pain	🟢 Strong	Cochrane (Wiffen) — strong evidence; first-line strong opioid in Australia; well-characterised dose titration and safety
Low-dose opioid for refractory dyspnoea	🟢 Strong	Multiple RCTs (Jennings; Barnes meta-analyses) — morphine 1–2.5 mg SC reduces dyspnoea sensation without respiratory depression at palliative doses; underused in practice
Fan / cool air to face for non-hypoxic dyspnoea	🟢 Strong	RCTs confirm trigeminal mechanism; equivalent or superior to oxygen when SpO₂ > 88%
Anticipatory antimuscarinic for terminal secretions	🟡 Moderate	Cochrane (Wee) — limited evidence of efficacy beyond placebo once secretions established; use early to prevent accumulation
Oxygen for non-hypoxic dyspnoea	🔴 Not recommended	Abernethy 2010 Lancet — oxygen no better than room air for non-hypoxic dyspnoea; unnecessary medicalisation
Artificial nutrition/hydration in advanced dementia	🔴 Not recommended	Cochrane (Sampson) — no survival, QoL, or pressure-injury benefit; Choosing Wisely Australia recommends against PEG in advanced dementia
Advance care planning (goal-concordant care)	🟢 Strong	Detering 2010 BMJ — Australian RCT; ACP improved family satisfaction and reduced PTSD in bereaved relatives; fewer unwanted interventions

C. Advance care planning and Voluntary Assisted Dying

Advance care planning

Advance Care Planning Australia defines advance care planning as the ongoing process by which a person, in consultation with their health team and family, considers and documents preferences for future healthcare. This is not a one-time form — it is a conversation that evolves with health status.

Three components:

1. Conversations: exploring values, what matters most to the person, and what medical interventions they would or would not want
2. Documentation: completing a state-specific Advance Care Directive (ACD) and/or a separate values statement
3. Substitute decision-maker (SDM): appointing a trusted person to make decisions if the patient loses capacity

State-by-state Advance Care Directive forms (per RACGP and Advance Care Planning Australia):

State / Territory	Directive	Substitute decision-maker
Victoria	Advance Care Directive	Medical Treatment Decision Maker
NSW	Advance Care Directive (common law)	Enduring Guardian
Queensland	Advance Health Directive	Enduring Power of Attorney (health)
WA	Advance Health Directive	Enduring Power of Guardianship
SA	Advance Care Directive	Substitute Decision-Maker
Tasmania	Advance Care Directive	Enduring Guardian
ACT	Health Direction	Enduring Power of Attorney (health)
NT	Advance Personal Plan	Decision-maker under APP

GP practice points:

• Raise ACP routinely in chronic disease management consultations, 75+ health assessments, and for any patient with a new life-limiting diagnosis
• Ensure copies are distributed to the patient, their family, your practice records, and uploaded to My Health Record
• Review annually and at any major health change

Voluntary Assisted Dying (VAD)

VAD is legal in all six Australian states as of 2026. The Australian Capital Territory has its own Voluntary Assisted Dying Act (2024) with specific eligibility criteria. The Northern Territory is progressing legislation. For current state-specific details, refer to the Australian Government Department of Health — Voluntary Assisted Dying pages.

General eligibility (state-specific variation applies):

• Adult (18+), Australian citizen or permanent resident, at least 12 months’ residency in the state
• Full decision-making capacity throughout the entire process; voluntary and free of coercion
• A disease, illness, or medical condition that is advanced, progressive, and will cause death — typically a prognosis of 6 months or less (12 months for neurodegenerative conditions in most states)
• Suffering intolerably from the condition in a way that cannot be relieved acceptably

The GP’s role:

• Conscientious objection is lawful, but the practitioner must inform the patient and provide information about accessing VAD via navigator services
• Participating practitioners must complete state-specific online training before acting as a coordinating or consulting practitioner
• VAD and palliative care are not mutually exclusive — many patients access both; the ANZSPM provides guidance on clinical integration

VAD navigator services (state-funded in Victoria, WA, Queensland, and NSW) support patients and families through the eligibility and administrative process.

D. Australian operations

MBS items relevant to palliative care in general practice:

• Standard attendance items (23, 36, 44) and prolonged attendance (91890/91891)
• Home visit items — after-hours (597–601); essential for community palliative care
• GP Management Plan (721) and Team Care Arrangement (723) — coordinate community nursing, occupational therapy, social work, and pastoral care
• Health assessments for older persons (701/703/705/707) — ACP discussion embedded
• Palliative care case conference items (92210–92218) — for complex multidisciplinary input
• My Aged Care — gateway to RACF admission, home care packages, respite care, and consumer-directed care

PBS medicines (Schedule 8 — state authority requirements apply):

• Morphine: immediate-release (Ordine, Sevredol) and modified-release (MS Contin, Kapanol) — PBS general for palliative cancer pain
• Oxycodone (OxyContin, Endone), hydromorphone (Dilaudid, Jurnista), fentanyl patches (Durogesic), buprenorphine patches (Norspan) — Authority Required for some formulations
• Pregabalin and gabapentin — PBS Authority for neuropathic pain indications
• Dexamethasone (appetite, bone pain, airway oedema, brain metastases) — PBS general
• Haloperidol, metoclopramide, midazolam, hyoscine butylbromide — accessible for symptom management

Community palliative care services (free, GP-referral):

• NSW: Sacred Heart Health Service, Calvary, LHD community palliative teams
• Vic: state palliative care consortia, Mercy Health, Calvary
• Qld: Hospital and Health Service community teams
• WA: Silver Chain Palliative Care
• SA and Tas: state services
• Specialist inpatient hospice or palliative care unit beds — limited in number; primarily metropolitan

ELDAC (End of Life Directions for Aged Care) provides structured support for GPs and RACF nursing staff with anticipatory prescribing templates, ACP resources, and training.

E. Special populations

Older adults in residential aged care: Advanced dementia is a life-limiting condition — it shortens life expectably and its late stages (non-verbal, bedbound, dysphagia) warrant a palliative approach. Goals-of-care documentation should precede any acute deterioration. Avoid futile hospital transfers when comfort-focused goals have been agreed. Anticipatory prescribing in the RACF reduces emergency calls and ambulance transfers. ELDAC supports nursing staff with comfort-care frameworks.

Aboriginal and Torres Strait Islander patients: Engage with respect for Sorry Business (cultural mourning and mourning period protocols), family and community involvement, and the significance of returning to Country. Partner with Aboriginal Community Controlled Health Organisations (ACCHOs) and Aboriginal Health Workers in care planning. TIS National (131 450) provides interpreter services across all languages including many First Nations languages.

Culturally and linguistically diverse (CALD) patients: Access interpreter services (TIS National 131 450). Explore cultural and religious frameworks around death, disclosure of prognosis, and whether the patient or family-centred decision-making is culturally appropriate. State-specific statutory ACD forms remain valid irrespective of cultural background.

Children: Paediatric palliative care requires specialist input from the outset — Sydney Children’s Hospitals, Royal Children’s Hospital Melbourne, Lady Cilento (Queensland Children’s), Perth Children’s, and Women’s and Children’s Adelaide provide statewide paediatric palliative services. Common conditions include cancer, neurodegenerative diseases, complex congenital conditions, and perinatal life-limiting diagnoses. Family-centred care and bereavement support for parents and siblings are integral.

When to escalate

Refer to or consult a specialist palliative care service when:

• Symptom complexity exceeds what can be managed in general practice — refractory pain despite appropriate opioid titration, refractory nausea, severe dyspnoea unresponsive to low-dose opioid and benzodiazepine, existential or spiritual distress requiring specialist input
• Subcutaneous syringe driver setup is needed for the first time and the general practice team and community nurse are unfamiliar with the device and drug combinations
• Family conflict about goals of care, or family distress beyond the capacity of the GP and community team
• Questions about opioid rotation, ketamine, or high-dose complex regimens
• VAD eligibility determination requires a second assessor who is VAD-trained
• Capacity assessment in a palliative context — medical or legal complexity
• Paediatric palliative care — specialist team required from the outset

What this article is and is not

This is general health information based on current Australian guidelines — eTG Palliative Care, RACGP resources, NHMRC end-of-life guidance, and Palliative Care Australia — and landmark palliative care research. It is not personal medical advice and does not create a doctor–patient relationship. Palliative care needs are individual and complex; decisions about symptom management, opioid prescribing, advance care planning, and VAD eligibility require assessment by your own GP and treating clinical team.

For Australian patient and family support: Palliative Care Australia, Advance Care Planning Australia, CareSearch, My Aged Care, ELDAC.

For grief and bereavement support: GriefLine 1300 845 745. For carer support: Carer Gateway 1800 422 737.

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Sources cited

1. Palliative Care Australia
2. CareSearch — palliative care evidence
3. palliAGED — aged care palliative care evidence
4. eTG complete — Palliative Care
5. Advance Care Planning Australia
6. RACGP — Palliative care resources
7. Voluntary Assisted Dying — Australian Government Department of Health
8. ANZSPM — Australia and New Zealand Society of Palliative Medicine
9. My Aged Care
10. TGA — Schedule 8 opioid prescribing
11. NHMRC — End of life care
12. End of Life Directions for Aged Care (ELDAC)
13. Australian Medicines Handbook