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Kia āta kōwhiri Choosing Wisely

The Choosing Wisely campaign seeks to reduce harm from unnecessary and low-value tests and treatment.

Australian and New Zealand Society of Palliative Medicine & the Australasian Chapter of Palliative Medicine

ANZSPM is a specialty medical society that facilitates professional development and support for its members and promotes the practice of palliative medicine. AChPM is a Chapter of the RACP’s Adult Medicine Division.

Recommendations and resources

1) Do not delay discussion of and referral to palliative care for a patient with serious illness just because they are pursuing disease-directed treatment.

Palliative care provides an added layer of support to patients with life-limiting disease and their families. Symptomatic patients can benefit regardless of their diagnosis, prognosis or disease treatment regimen. Studies show that integrating palliative care with disease-modifying therapies improves pain and symptom control, as well as patient quality of life and family satisfaction. Early access to palliative care has been shown to reduce aggressive therapies at the end of life, prolong life in certain patient populations, and significantly reduce hospital costs.

2) Limit routine use of antipsychotic drugs to manage symptoms of delirium

Effective screening, reversing the precipitants of delirium and providing a variety of supportive non-pharmacological interventions are crucial to addressing delirium in patients in palliative care settings.

Treatment with antipsychotic drugs should only be considered if patients with delirium are in distress and the cause of distress cannot be addressed through non-drug strategies. Antipsychotics are commonly used in the management of delirium in palliative care settings. However, recent research into the management of mild- to moderate-severity delirium indicates that the use of antipsychotics is linked to increased delirium symptoms and increased patient mortality.

3) Do not use oxygen therapy to treat non-hypoxic dyspnoea in the absence of anxiety or routinely use oxygen therapy at the end of life

Oxygen is frequently used to relieve shortness of breath in patients with advanced illness. However, supplemental oxygen does not benefit patients who are breathless but not hypoxic. Supplemental flow of air is equally as effective as oxygen under these circumstances. The use of a fan for facial air streaming can also be effective.

4) Target referrals to bereavement services for family and caregivers of patients in palliative care settings to those experiencing more complicated forms of grief rather than as a routine practice

There is no empirical basis for the practice of offering routine referrals to bereavement services to family and care givers of patients in palliative settings. Most bereaved family and carers are resilient and only a small proportion of individuals will develop pathological responses that might not resolve without professional help.

Evidence suggests psychosocial interventions are more effective for people with more complicated forms of grief. Grief is considered complicated when an individual’s ability to resume normal activities and responsibilities is persistently disrupted after six months of bereavement. Six months is seen as the appropriate minimum threshold for complicated grief since studies show that most people integrate bereavement into their lives by this time.

5) To avoid adverse medication interactions and adverse drug events in cases of polypharmacy, do not prescribe medication without conducting a drug regime review

Older patients disproportionately use more prescription and non-prescription drugs than other populations. Evidence shows that such polypharmacy increases the risk of adverse drug reactions and hospital admissions. Medication review with follow up is therefore recommended for optimising prescribed medication and improving quality of life in older adults with polypharmacy.

Supporting evidence

Last reviewed May 2019

How this list was developed

Fellows from the Australian and New Zealand Society of Palliative Medicine and Australasian Chapter of Palliative Medicine (ANZSPM/AChPM) convened a working group to produce an EVOLVE list for palliative medicine. The Royal Australasian College of Physicians (RACP) assisted this working group in compiling a list of 15 clinical practices in palliative medicine which may be overused, inappropriate or of limited effectiveness in a given clinical context based on a desktop review of similar work done overseas. This list was then sent out to all ANZSPM and AChPM members, seeking feedback on whether the items fully captured the concerns of clinicians in an Australasian palliative medicine context and if not, whether any items should be omitted and/or new items added. 40 responses to this email were received. Based on these, 3 items were removed leaving a shortlist of 12. An online survey was then sent to all ANZSPM and AChPM members asking respondents to rate each item against three criteria from 1 (lowest) to 5 (highest), and to nominate any additional practices worthy of consideration. The criteria used to rate the practices were strength of evidence, significance in palliative care and whether palliative care physicians could make a difference in influencing the incidence of the practice in question. Based on the 114 responses to this survey, the top 5 were selected.


Last updated: 10th December, 2021