Palliative care patients missing out on pain relief due to RN shortage

Palliative patients no pain relief

Palliative care patients are suffering unnecessarily because there aren’t enough registered nurses (RN) on duty to administer the pain relief medication they need when they need it.

Sarah*, a specialist palliative care nurse practitioner, has told HelloCare she has seen a number of patients who have not been able to receive pain relief or have had long delays accessing breakthrough medications when needed because there is not an RN on duty.

Sarah, who requested we not use her real name, said, “In the past six weeks it has been very difficult for [aged care homes] to maintain adequate staffing levels.” 

Her team visits nearly 30 aged care homes in an eastern Australian state.

When friends and family see their loved one suffering because they can’t access pain relief, it can be devastating.

“The impact on families is huge,” Sarah explained. 

“They can see someone they love suffering, and … they are distressed by having to watch someone they love who is not dying comfortably.” 

At some of the facilities where Sarah works, there is regularly no RN rostered on overnight. 

“This means that I am unable to prescribe a dose range, and have to use fixed doses, which is not best practice at [the] end of life,” she said.

The royal commission recommended that from 1 July 2024, at least one RN should be on site in aged care at all times. However, the government has only mandated an RN be on site 16 hours per day.

RNs must administer S8 medication 

Palliative care patients are often given pain-relieving schedule 8 (S8) medications – such as morphine, oxycodone and fentanyl – through a syringe driver, which releases the medication gradually into their body over a 24-hour period.

The drugs are tightly restricted due to their highly addictive nature. An RN usually sets up the medication in a syringe driver and changes it regularly, usually every 24 hours.

Australian Nursing and Midwifery Federation (ANMF) federal secretary, Annie Butler, told HelloCare that enrolled nurses (ENs) can administer the medication if they have undertaken specialist training and if they are supervised by an RN.

Sometimes palliative care patients experience ‘breakthrough pain’, where their pain levels increase and the syringe driver dose is not strong enough. In this instance, the patient might need more medication – this is known as a ‘breakthrough dose’.

ENs are not permitted to administer breakthrough doses of S8 medication without an RN. 

“If there is no RN then the EN cannot practice, let alone administer S8 medicines,” Ms Butler said.

The Nursing and Midwifery Board of Australia (NMBA) has clearly stated that the need for ENs to have a named and accessible RN at all times and in all contexts of care for support and guidance is “critical to patient safety”.

Government must do more to attract workers to aged care

The Omicron surge has put unprecedented pressure on aged care staffing, but the workforce was already stretched thin, a fact that has been widely acknowledged for years. 

Though healthcare workers have been permitted since January to leave self-isolation to attend work if they have no symptoms of COVID-19, staff shortages have persisted.

The government has done little to attract workers to the sector, or provide meaningful reasons for them to stay. 

Bonus payments to frontline aged care workers were criticised as a band-aid fix. 

And while the government has launched a Productivity Commission inquiry into the structure of work in aged care and the Fair Work Commission is considering the value of aged care workers after the unions put forward the case for a 25% pay rise, few concrete steps have been taken. 

Ms Butler says aged care homes must have “at least one registered nurse on site at all times”, “minimum mandated care hours and the right skills mix” in the form of guaranteed staff ratios, and “improved wages and conditions”.

Sarah also believes the government must do more to ensure safe staffing levels in aged care, including introducing staff ratios.

“Increasing wages for registered nurses and carers would help to retain people with qualifications,” she said.

She believes the government’s callout to volunteers will only increase the number of “unskilled, unqualified and unregistered” people in aged care homes, increasing the risk of “neglect, abuse, harm and suffering”.


Staff concerned about ENs administering medication without the appropriate supervision should raise the issue with their management, contact the ANMF and notify the NMBA.

*Name has been changed.

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  1. The system is under stress, no one would argue with that but couldn’t the palliative residents be transferred to hospital in these scenarios?
    If a patient was receiving Home care and became palliative the staff shortages would affect the process as well wouldn’t it.

    Hospital is an easy option, in fact that’s what they do.

  2. I have been a nurse/ midwife for over 30 years
    It has been more than a vocation it’s been a passion, I love my work to the very core of who I am
    I would love to to return to work
    I still have so much to offer, my expertise, time and devotion to the work I love
    But it needs to be where I have control over my own health that is unconditional
    I would even change states is that was required

  3. Because the complaints of under staffing are not visible to the general public there is no commercial pressure on individual aged care providers to resolve the problem.

    In fact providers have an incentive to under staff. Less staff means less expenses and a better chance of meeting budget.

    We need public transparency of all complaints
    If the complaint is not justified that should be seen as well.

    An quicker death is probably a better option than a painful subsistence in under staffed aged care.

    1. Max.. there aren’t any complaints for understaffing because there are no ratios to demand X amount of staff on duty so there technically is no understaffing.

      Most facilities have sufficient staff and are proud of the level of care they provide. The biggest incentive to deliver excellent care is word of mouth advertising. In any town of any size of a facility is doing the wrong thing word will get around and that will affect the business. That’s why the overwhelming majority of homes do the right thing.

    2. That’s so untrue Max. I’ve worked in aged care for over 25 years as an RN and a manager and I can tell you that no one deliberately understaffs to save money. We are painted in such a negative light all the time. The workforce challenges have never been greater. Until we start attracting and retaining staff it will be hard to staff how we all want to see. There is a very disturbing and negative narrative in this country about aged care.At the moment we are competing with SA Health for staff and a chronic shortage of RN’s That single issue alone if properly addressed would go along way to solving some of the very real issues we work through every day. The simple fact is that the majority of us continue to work in the sector because we care. If you have a solution for the chronic shortage of staff
      please feel free to let us know.

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