Prescribing for Malignant Bowel Obstruction in Palliative Care: A Cross-Sectional Australia and New Zealand Survey of Palliative Medicine Practitioners

Prescribing for Malignant Bowel Obstruction in Palliative Care: A Cross-Sectional Australia and New Zealand Survey of Palliative Medicine Practitioners | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Prescribing for Malignant Bowel Obstruction in Palliative Care: A Cross-Sectional Australia and New Zealand Survey of Palliative Medicine Practitioners Joshua Sandy, Joanne Patel, Lindy Turner, Bridgette Johnson, Riona Pais This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-8363554/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Purpose: Pharmacological management of malignant bowel obstruction can be complex with a variety of treatment options available, many of which are used off-label for this condition. The current prescribing practices of Palliative Care Clinicians in Australia and New Zealand remain unclear. To capture current prescribing preferences among palliative care clinicians, assess the presence of variability in prescribing practices, and explore the rationale behind their choices as well as any potential barriers to pharmacological management. Methods: A cross-sectional online survey of palliative medicine clinicians in 2024 used a clinical vignette to elicit prescribing preferences for first, second, and third-line agents, including the number of agents used and factors influencing decisions. Results: 117 responses were collected. For initial therapy, clinicians chose to prescribe Dexamethasone (78%) and Haloperidol (69%). For second and third line therapy Cyclizine (42%) and Levomepromazine (42%) were the most common responses. The number of agents prescribed was diverse, with results showing 24% initiating one agent, 33% two agents and 43% initiating three or more agents. Only 28% of respondents agreed or strongly agreed that there was a standard approach to prescribing in Australia and New Zealand. Conclusion: Responses revealed variation in prescribing practices despite a dominant first-line strategy. No clear consensus was found for second and third-line choices. The comparison to the 2021 MASCC guidelines revealed a disconnect between reported prescribing patterns and the level of supporting evidence. These findings highlight the need for further research and the need for localised guidelines to reduce variability. malignant bowel obstruction palliative care pharmacotherapy prescribing Australia and New Zealand Figures Figure 1 Figure 2 Introduction There are currently gaps in both the literature and expert-based guidelines regarding the pharmacological management of malignant bowel obstruction (MBO). The most comprehensive and internationally recognised guidelines the 2021 MASCC guidelines [1] made best practice recommendations, but the strength of conclusions were limited by the current levels of evidence for pharmacotherapies. The overall lack of consensus in the literature may have contributed to a potential diversity in prescribing choices, which carries potential implications for patient safety, healthcare costs, drug accessibility, routes of administration, risk of drug interactions, and challenges associated with transitions between care settings. MBO have been previously defined in the literature as meeting the following criteria: 1. Clinical evidence of bowel obstruction 2. Obstruction distal to the Treitz ligament 3. The presence of primary intra-abdominal or extra-abdominal cancer with peritoneal involvement 4. the absence of reasonable possibilities for a cure.[2] MBO affects 3- 15% of cancer cases and may appear at any time during the evolution of the disease, but is more frequent in cases of advanced cancer. Obstruction may be complete or partial and may appear as a subocclusive crisis or may involve one or multiple intestinal levels. In advanced and inoperable patients, multiple occlusive levels are presented in 80% of cases and peritoneal carcinomatosis is previously diagnosed in more than 65% of cases. [3] A summary of the 2021 MASCC guidelines is as follows: Octreotide has the strongest evidence base for managing vomiting, based on multiple randomised controlled trials and recommended it as first line therapy[4]. The anticholinergic antisecretory drug hysocine butylbromide is inferior to octreotide in the doses used in one randomised controlled study[5] but may be useful for breakthrough nausea and vomiting or colic in patients on octreotide[6]. Parenteral ranitidine[7] and dexamethasone[8] may be effective in reducing nausea and vomiting from MBO but the guideline authors conclude the evidence is too low to recommend its routine use. Olanzapine or metoclopramide are effective in reducing nausea and vomiting secondary to partial bowel obstructions in a small, randomized pilot trial[9] however, the guidelines conclude that additional studies are needed to clarify benefits. Haloperidol by convention[10] has been used to treat breakthrough nausea and vomiting from MBO in randomised trials but has not been compared with other antiemetics. Aim To capture current prescribing preferences among palliative care clinicians, explore the rationale behind clinicians’ choices, and identify potential barriers to pharmacological management that may be influencing practice. Methods Study Design A cross-sectional study utilising an online survey through REDCAP[ 11 , 12 ] of palliative medicine clinicians to examine prescribing preferences and attitudes for the treatment of nausea and vomiting using a clinical vignette. Recruitment and consent The Inclusion Criteria for the study was as follows: Specialist Palliative Medicine Doctors or Nurse Practitioners (Including Advanced Trainees, Unaccredited Training Position Registrars or Career Medical Officers in Palliative Medicine) Working currently or have worked in the past 5 years in Specialist Palliative Medicine Work in Australia or New Zealand Recruitment Participant recruitment was conducted through two primary methods. Firstly, an email to the online survey was distributed to members of the Australia and New Zealand Society of Palliative Medicine (ANZSPM) by the secretariat. Secondly, direct outreach was conducted to specialist palliative care organisations. Between May 27 and May 30, 2024, the Palliative Care Australia website[ 13 ] was accessed to identify organisations listed as providers of specialist palliative care services. A total of 181 emails were sent, requesting distribution of the survey among eligible clinicians. Forwarding the invite to eligible colleagues was encouraged. Consent information was provided and implied upon voluntary participation. Respondents working across multiple settings were asked to pick one to answer from the perspective of. Clinical Vignette The following vignette was provided to participants to base their responses: Mr JS is a 68-year-old man with advanced colorectal cancer with peritoneal metastases. He is not a candidate for further surgical intervention. You meet with him in your current primary place of practice setting and he describes a history of 3 days of severe continuous nausea with associated vomiting and is no longer passing stool or flatulence. While working in your primary place of practice in palliative medicine, you diagnose him with a malignant bowel obstruction. Results A total of 117 responses were obtained between June 4 and September 9, 2024. In 2023 there was a total of 435 palliative medicine doctors employed in Australia[ 14 ] and New Zealand[ 15 ] representing a 27% response rate. Respondent characterises were collected (Table 1). Choice of medication The survey presented a total of 12 commonly used medications with an additional ‘other’ text box. Clinicians were permitted to select multiple options and were asked to specify their choices for first-line, second-line, and third-line therapies. For initial therapy, clinicians predominantly chose to prescribe Dexamethasone (78%) and Haloperidol (69%) with other options less frequently selected (Table 2). For second round therapy options, the most common selected response was cyclizine (42%). For third line therapy options, the most commonly selected option was levomepromazine (42%). 76% of respondents chose to initiate more than 1 agent for initial therapy (Fig. 1 ). Non-Pharmacological Treatment Based on the clinical vignette 69% of respondents said they would recommend a non-pharmacological treatment option. (Table 3) Data Analysis Data was collated and graphics produced using IBM SPSS Statistics Version 30. Categorical variables from the demographic data were compared against responses using the chi square test. There was a statistically significant link between inital of pantoprazole based on years of practice (2% vs 16% for clinicians with greater than 10 years’ experience compared to those with less respectively p = 0.021). First round cyclizine, pantoprazole and ranitidine use was also more associated with clinicians within NSW compared to those practising in other jurisdictions (Cyclizine 30% vs 12% p = 0.019) (Pantoprazole 18% vs 4% p = 0.011) (ranitidine 22% vs 2% p = < 0.001). No statically significant differences were identified in later prescribing rounds or for choice of nasogastric insertion or surgical referral. No statistically significant difference in responses was identified when comparing metropolitan and regional clinicians, age or primary place of practice. Factor Ranking Clinicians were asked to rank five factors with 1 being the most important and 5 being the least to explain their choices. Effectiveness was the most influential factor in clinicians' prescribing decisions, followed by guidelines/supporting evidence. The rankings for tolerability and accessibility were similar, with both ranked as less influential than evidence. Cost was the least influential factor in decision-making (Fig. 2 ). Clinician Attitudes Clinicians were asked to respond to a five point Likert scale on topics featured below. 81% of respondents reporting they either Agreed or Strongly Agreed that there is ease of access to their preferred agents. 77% reported they either Agree or Strongly Agreed reported following a standard approach to their prescribing. Only 44% reporting they Agree or Strongly Agree that there is a standard approach at the level of their primary practice. Only 28% of respondents agreed or strongly agreed that there is a standard approach at the national level across Australia and New Zealand (Table 4) Discussion This is to the authors' knowledge, the first bi-national survey conducted in Australia and New Zealand aimed at capturing data on the prescribing choices of clinicians for malignant bowel obstruction. The Multinational Association of Supportive Care in Cancer (MASCC) 2021 guidelines, currently represent the most evidence-based and internationally recognised guidance for the pharmacological management of malignant bowel obstruction. Comparing the most common responses in this survey to the evidence levels of these agents as outlined in the MASCC guidelines reveals that clinicians frequently use a mixture of agents supported by both stronger and weaker levels of evidence. For initial prescribing, haloperidol and dexamethasone were the most commonly selected agents. According to MASCC, these are supported by evidence levels of III and IV, respectively—indicating limited or lower-quality evidence. For cyclizine and levomepromazine with the highest response for second and third line agents these hold also are supported by level IV evidence. The use of agents with lower levels of evidence may seem counterintuitive, but several plausible explanations may be that clinicians may prioritise agents with which they have the most experience and have observed clinical benefit, even in the absence of high-level evidence. In palliative care, treatment decisions are often nuanced and guided by individual patient response, leading to a reliance on practical, experiential knowledge over formal guideline recommendations. The MASCC guidelines themselves acknowledge a key limitation: the lack of high-quality evidence for many commonly used agents. The ability to draw strong conclusions was often hampered by small sample sizes, heterogeneity in study populations, and inconsistent outcome measures across trials. As a result, several agents in widespread clinical use—such as haloperidol, cyclizine, and levomepromazine—are given low evidence ratings not because they are necessarily ineffective, but because robust clinical trials are lacking. Another limitation of the MASCC guidelines is the absence of recommendations for combination or stepwise (sequential) therapy, which is a common clinical approach in managing complex symptoms such as malignant bowel obstruction. In the absence of such guidance, clinicians may adopt their own stepwise regimens based on practice norms, mentor influence, and anecdotal outcomes. Agents like haloperidol and cyclizine are often readily available and familiar to clinicians, making them more accessible choices even when supported by weaker evidence. Notably missing was responses reporting the use of octreotide which has level I evidence. This discrepancy may be attributed to the difficulty in accessing octreotide in community pharmacies, as well as the additional paperwork required for its use in public hospitals, which could act as barriers to its prescription. These practical challenges may contribute to clinicians opting for alternative treatments, despite the higher level of evidence supporting octreotide’s efficacy in managing malignant bowel obstruction. Hyoscine butylbromide, ranitidine, metoclopramide and ondansetron all received a rating of level III evidence in MASCC Guidelines but received lower levels of reported use in the survey. This discrepancy suggests a potential gap between evidence-based recommendations and actual clinical practice. The use of non-pharmacological management varied among respondents. 69% of clinicians recommended nasogastric tube insertion, while 25% suggested a surgical referral for a venting gastrostomy. According to the MASCC guidelines, these therapies are supported by level V and level IV evidence, respectively. The variability in the adoption of these non-pharmacological approaches may reflect clinical judgment, patient factors, or institutional practices. There was not an identified statically link between lower surgical referral rates and regional location. Data analysis did not reveal any statistically significant differences in prescribing patterns based on clinician age, primary palliative care setting, or whether they practiced in a regional versus metropolitan location. Some therapies showed statistically significant associations with years of clinical experience and jurisdiction of practice, suggesting that these factors may be influential. This highlights how institutional culture, local practice norms, and clinical experience may play a greater role in influencing therapeutic choices. In the responses ranking factors influencing prescribing choices, supporting evidence in the literature was ranked lower than clinician-perceived effectiveness. This raises the possibility that the gap between reported practice and available evidence may be driven by clinicians prioritising personal experiential practice over the existing evidence base. Several factors could explain this, including mentor-based training systems in palliative medicine, clinical inertia, scepticism about the quality of evidence guiding treatment, or a lack of promotion or awareness of current evidence. Only 28% of respondents agreed or strongly agreed that there is a standardised approach to prescribing across Australia and New Zealand, suggesting that diversity in prescribing practices at the national level is a widely observed among palliative care clinicians. Limitations The study relies on self-reported outcomes, not observed clinical practice. Use of a clinical vignette provides a limited view of a clinical situation as this does not account for individual circumstances, including for example individual pathology or partial versus complete bowel obstruction. Information on de-prescribing and dosing was not explored. A large proportion of respondents were located in New South Wales which may reduce generalisability. Conclusion This study provides novel cross-sectional data on current prescribing practices for the management of nausea and vomiting in malignant bowel obstruction among palliative care clinicians in Australia and New Zealand. Findings indicate the emergence of a dominant prescribing strategy—dexamethasone and haloperidol for initial therapy, cyclizine as a second-line option, and levomepromazine as a third-line agent without majority consensus in second- and third-line prescribing. A notable observation is the discrepancy between reported popular prescribing choices and the strength of supporting evidence as outlined in the MASCC 2021 guidelines. Statistically significant associations were found between prescribing patterns and clinician years of experience as well as jurisdiction of practice, indicating that both individual and systemic factors may influence therapeutic decision-making. These findings underscore the need for further primary drug trials, investigation into the drivers of prescribing behaviour, particularly the role of experiential learning, local systems, and perceived effectiveness. The development of localised, context-sensitive guidelines may aid in reducing practice variability and promoting more consistent, evidence-aligned care across the region. Declarations Acknowledgements The Australia and New Zealand Society of Palliative Medicine aided in distribution of the survey to members. Funding: This research has not received any specific funding Competing Interests: The authors declare there is no competing interest present Ethics Approval: Ethical approval for this study was granted by the Royal Prince Alfred Hospital Ethics Committee (HREC Reference Number: 2024/ETH00286, SSA 2024/STE00610). All procedures performed in this study were in accordance with the ethical standards of the institutional research committee and with the 1964 Helsinki Declaration and its later amendments. Consent to Participate: Informed consent was obtained from all individual participants included in the study. Consent for Publication: Not applicable Availability of Data and Material: The datasets generated during and/or analysed during the current study are available from the corresponding author on reasonable request. Code Availability: Not applicable Author Contributions: All authors contributed to the study conception and design and provided feedback of the final manuscript. Manuscript preparation, data collection and analysis were performed by Joshua Sandy. The project was overseen by Riona Pais. References Davis M, Hui D, Davies A, Ripamonti C, Capela A, DeFeo G, et al. Medical management of malignant bowel obstruction in patients with advanced cancer: 2021 MASCC guideline update. Support Care Cancer. 2021;29(12):8089–96. Anthony T, Baron T, Mercadante S, Green S, Chi D, Cunningham J, et al. Report of the Clinical Protocol Committee: Development of Randomized Trials for Malignant Bowel Obstruction. J Pain Symptom Manage. 2007 July;34(1):S49–59. Tuca A, Guell E, Martinez-Losada E, Codorniu N. Malignant bowel obstruction in advanced cancer patients: epidemiology, management, and factors influencing spontaneous resolution. Cancer Manag Res. 2012 June;159. Obita GP, Boland EG, Currow DC, Johnson MJ, Boland JW. Somatostatin Analogues Compared With Placebo and Other Pharmacologic Agents in the Management of Symptoms of Inoperable Malignant Bowel Obstruction: A Systematic Review. J Pain Symptom Manage. 2016;52(6):901–919.e1. Peng X, Wang P, Li S, Zhang G, Hu S. Randomized clinical trial comparing octreotide and scopolamine butylbromide in symptom control of patients with inoperable bowel obstruction due to advanced ovarian cancer. World J Surg Oncol. 2015;13:50. Mercadante S. Scopolamine butylbromide plus octreotide in unresponsive bowel obstruction. J Pain Symptom Manage. 1998;16(5):278–80. Clark K, Lam L, Currow D. Reducing gastric secretions–a role for histamine 2 antagonists or proton pump inhibitors in malignant bowel obstruction? Support Care Cancer. 2009;17(12):1463–8. Feuer DJ, Broadley KE. Systematic review and meta-analysis of corticosteroids for the resolution of malignant bowel obstruction in advanced gynaecological and gastrointestinal cancers. Systematic Review Steering Committee. Ann Oncol. 1999 Sept;10(9):1035–41. Kaneishi K, Imai K, Nishimura K, Sakurai N, Kohara H, Ishiki H, et al. Olanzapine versus Metoclopramide for Treatment of Nausea and Vomiting in Advanced Cancer Patients with Incomplete Malignant Bowel Obstruction. J Palliat Med. 2020 July;23(7):880–1. Ripamonti C, Twycross R, Baines M, Bozzetti F, Capri S, De Conno F, et al. Clinical-practice recommendations for the management of bowel obstruction in patients with end-stage cancer. Support Care Cancer. 2001 June;9(4):223–33. Harris PA, Taylor R, Thielke R, Payne J, Gonzalez N, Conde JG. Research electronic data capture (REDCap)--a metadata-driven methodology and workflow process for providing translational research informatics support. J Biomed Inform. 2009;42(2):377–81. Harris PA, Taylor R, Minor BL, Elliott V, Fernandez M, O’Neal L, et al. The REDCap consortium: Building an international community of software platform partners. J Biomed Inform. 2019 July;95:103208. PCA Staff. Palliative Care Australia [Internet]. 2024 [cited 2024 May 27]. Available from: https://nsd.palliativecare.org.au/s/search-service Australia Institute of Health and Welfare. Palliative care services in Australia. 2025 [cited 2025 Dec 15]. Palliative care services in Australia. Available from: https://www.aihw.gov.au/reports/palliative-care-services/palliative-care-services-in-australia/contents/palliative-care-workforce/characteristics Medical Council of New Zealand. The New Zealand Medical Workforce 2024 Report [Internet]. Medical Council of New Zealand; 2024 [cited 2025 Dec 15]. Available from: https://www.mcnz.org.nz/about-us/what-we-do/workforce-survey/ Tables Table 1. Respondent Characteristics (N=117) Number Percentage Location New South Wales 60 51.3% New Zealand 14 12.0% Queensland 17 14.5% South Australia 2 1.7% Tasmania 5 4.3% Victoria 12 10.3% Western Australia 7 6.0 % Setting Metropolitan 81 69.2% Regional 36 30.8% Age 20-30 2 1.7% 31-40 45 38.5% 41-50 37 31.6% 51-60 20 17.1% >60 13 11.1% Years of Practice 0-5 49 41.9% 5-10 16 21.4% 10-15 16 13.7% 15-20 11 13.7% >20 25 9.4% Primary Place of Practice Palliative Care Unit - Private 4 3.4% Palliative Care Unit - Public 37 31.6% Private Hospital: Inpatients (Consultative Liaison and admitted patients outside a dedicated palliative care unit) 5 4.3% Public Hospital: Inpatients (Consultative Liaison and admitted patients outside a dedicated palliative care unit) 37 31.6% Private Hospital: Outpatients (Clinic and Community Patients) 3 2.6% Public Hospital: Outpatients (Clinic and Community Patients) 31 26.5% Table 2. Prescribing Choices Initial Prescribing Choices Agent N=117 Percentage of Respondents Cyclizine 25 21.4% Dexamethasone 91 77.8% Esomeprazole 5 4.3% Famotidine 8 6.8% Haloperidol 81 69.2% Hyoscine butylbromide 7 6.0% Levomepromazine 0 0% Metoclopramide 13 11.1% Octreotide 12 10.3% Olanzapine 1 0.9% Pantoprazole 13 11.1% Ranitidine 14 12.0% Other 1 0.9% 2 nd line Prescribing Choices Agent Percentage of Respondents Cyclizine 49 41.9% Dexamethasone 7 6.0% Esomeprazole 3 2.6% Famotidine 14 12.0% Haloperidol 22 18.8% Hyoscine butylbromide 12 10.3% Levomepromazine 16 13.7% Metoclopramide 0 0% Octreotide 24 20.5% Olanzapine 13 11.1% Pantoprazole 3 2.6% Ranitidine 11 9.4% Other 3 2.6% 3 rd line Prescribing Choices Agent Percentage of Respondents Cyclizine 24 20.5% Dexamethasone 3 2.6% Esomeprazole 0 0% Famotidine 6 5.1% Haloperidol 8 6.8% Hyoscine butylbromide 20 17.1% Levomepromazine 49 41.9% Metoclopramide 0 0% Octreotide 28 23.9% Olanzapine 10 8.5% Pantoprazole 2 1.7% Ranitidine 3 2.6% Other 4 3.4% Table 3. Non-Pharmacological Measures (N=117) Count Percentage Nasogastric tube Insertion 80 68.6% Surgical referral for consideration of a venting gastrostomy 29 24.8% I would not recommend these options 36 30.8% Table 4. Clinician Attitudes Count (N=117) Percentage I can easily access my preferred pharmacotherapies for the treatment of nausea and vomiting for malignant bowel obstruction at my primary place of practice in palliative medicine Strongly Agree 41 35.0% Agree 54 46.2% Neutral 13 12.0% Disagree 6 5.1% Strongly Disagree 2 1.7% I follow a standard approach to prescribing pharmacotherapy for nausea and vomiting in malignant bowel obstruction: Strongly Agree 20 17.1% Agree 70 59.8% Neutral 21 17.9% Disagree 6 5.1% Strongly Disagree 0 0% At my primary place of practice, there is a standard approach to prescribing pharmacotherapy for nausea and vomiting in malignant bowel obstruction. Strongly Agree 4 3.4% Agree 48 41.0% Neutral 37 31.6% Disagree 25 21.4% Strongly Disagree 3 2.6% I believe there is a standard approach in Australia and New Zealand regarding prescribing pharmacotherapy for the management of nausea and vomiting in malignant bowel obstruction. Strongly Agree 3 2.6% Agree 30 25.6% Neutral 41 35.0% Disagree 39 33.4% Strongly Disagree 4 3.4% Additional Declarations No competing interests reported. Supplementary Files Appendix1ParticipantQuestionnaire.docx Cite Share Download PDF Status: Posted Version 1 posted You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-8363554","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":578406713,"identity":"6e316da6-2f44-44dd-9033-8f69c56915b9","order_by":0,"name":"Joshua 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1","display":"","copyAsset":false,"role":"figure","size":113234,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eAgent Prescribing Number for Initial Prescribing\u003c/strong\u003e\u003c/p\u003e","description":"","filename":"1.png","url":"https://assets-eu.researchsquare.com/files/rs-8363554/v1/4f2df53321291b16fd341c9b.png"},{"id":101203464,"identity":"50074194-4b5f-4190-9cd1-f41f3745683b","added_by":"auto","created_at":"2026-01-27 09:39:48","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":28919,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eRespondent Ranking of Prescribing Influences\u003c/strong\u003e\u003c/p\u003e","description":"","filename":"2.png","url":"https://assets-eu.researchsquare.com/files/rs-8363554/v1/c4c417742da070db7153b05b.png"},{"id":101297125,"identity":"d1764217-5bd1-4327-8124-9ee4f7f7f1a6","added_by":"auto","created_at":"2026-01-28 09:25:28","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":882888,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-8363554/v1/3c38a4a0-8854-400a-9aa0-69704af7a188.pdf"},{"id":100992703,"identity":"0676d46f-c378-4ec7-9be7-2a8a504d7633","added_by":"auto","created_at":"2026-01-23 14:50:32","extension":"docx","order_by":0,"title":"","display":"","copyAsset":false,"role":"supplement","size":30393,"visible":true,"origin":"","legend":"","description":"","filename":"Appendix1ParticipantQuestionnaire.docx","url":"https://assets-eu.researchsquare.com/files/rs-8363554/v1/8b4acf7eff05e10e40745870.docx"}],"financialInterests":"No competing interests reported.","formattedTitle":"Prescribing for Malignant Bowel Obstruction in Palliative Care: A Cross-Sectional Australia and New Zealand Survey of Palliative Medicine Practitioners","fulltext":[{"header":"Introduction","content":"\u003cp\u003eThere are currently gaps in both the literature and expert-based guidelines regarding the pharmacological management of malignant bowel obstruction (MBO). The most comprehensive and internationally recognised guidelines the 2021 MASCC guidelines [1] made best practice recommendations, but the strength of conclusions were limited by the current levels of evidence for pharmacotherapies. The overall lack of consensus in the literature may have contributed to a potential diversity in prescribing choices, which carries potential implications for patient safety, healthcare costs, drug accessibility, routes of administration, risk of drug interactions, and challenges associated with transitions between care settings.\u003c/p\u003e\n\u003cp\u003eMBO have been previously defined in the literature as meeting the following criteria:\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e1. Clinical evidence of bowel obstruction\u003c/p\u003e\n\u003cp\u003e2. Obstruction distal to the Treitz ligament\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e3. The presence of primary intra-abdominal or extra-abdominal cancer with peritoneal involvement\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e4. the absence of reasonable possibilities for a cure.[2]\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eMBO affects 3- 15% of cancer cases and may appear at any time during the evolution of the disease, but is more frequent in cases of advanced cancer. Obstruction may be complete or partial and may appear as a subocclusive crisis or may involve one or multiple intestinal levels. In advanced and inoperable patients, multiple occlusive levels are presented in 80% of cases and peritoneal carcinomatosis is previously diagnosed in more than 65% of cases.\u0026nbsp;[3]\u003c/p\u003e\n\u003cp\u003eA summary of the 2021 MASCC guidelines is as follows: Octreotide has the strongest evidence base for managing vomiting, based on multiple randomised controlled trials and recommended it as first line therapy[4]. The anticholinergic antisecretory drug hysocine butylbromide is inferior to octreotide in the doses used in one randomised controlled study[5] but may be useful for breakthrough nausea and vomiting or colic in patients on octreotide[6]. Parenteral ranitidine[7] and dexamethasone[8] may be effective in reducing nausea and vomiting from MBO but the guideline authors conclude the evidence is too low to recommend its routine use. Olanzapine or metoclopramide are effective in reducing nausea and vomiting secondary to partial bowel obstructions in a small, randomized pilot trial[9] however, the guidelines conclude that additional studies are needed to clarify benefits. Haloperidol by convention[10] has been used to treat breakthrough nausea and vomiting from MBO in randomised trials but has not been compared with other antiemetics.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAim\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eTo capture current prescribing preferences among palliative care clinicians, explore the rationale behind clinicians’ choices, and identify potential barriers to pharmacological management that may be influencing practice.\u003c/p\u003e"},{"header":"Methods","content":"\n\u003ch3\u003eStudy Design\u003c/h3\u003e\n\u003cp\u003eA cross-sectional study utilising an online survey through REDCAP[\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e, \u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e] of palliative medicine clinicians to examine prescribing preferences and attitudes for the treatment of nausea and vomiting using a clinical vignette.\u003c/p\u003e\n\u003ch3\u003eRecruitment and consent\u003c/h3\u003e\n\u003cp\u003eThe Inclusion Criteria for the study was as follows:\u003c/p\u003e \u003cp\u003e \u003cul\u003e \u003cli\u003e \u003cp\u003eSpecialist Palliative Medicine Doctors or Nurse Practitioners (Including Advanced Trainees, Unaccredited Training Position Registrars or Career Medical Officers in Palliative Medicine)\u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003eWorking currently or have worked in the past 5 years in Specialist Palliative Medicine\u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003eWork in Australia or New Zealand\u003c/p\u003e \u003c/li\u003e \u003c/ul\u003e \u003c/p\u003e\n\u003ch3\u003eRecruitment\u003c/h3\u003e\n\u003cp\u003eParticipant recruitment was conducted through two primary methods. Firstly, an email to the online survey was distributed to members of the Australia and New Zealand Society of Palliative Medicine (ANZSPM) by the secretariat.\u003c/p\u003e \u003cp\u003eSecondly, direct outreach was conducted to specialist palliative care organisations. Between May 27 and May 30, 2024, the Palliative Care Australia website[\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e] was accessed to identify organisations listed as providers of specialist palliative care services. A total of 181 emails were sent, requesting distribution of the survey among eligible clinicians. Forwarding the invite to eligible colleagues was encouraged.\u003c/p\u003e \u003cp\u003e Consent information was provided and implied upon voluntary participation. Respondents working across multiple settings were asked to pick one to answer from the perspective of.\u003c/p\u003e \u003cdiv id=\"Sec8\" class=\"Section2\"\u003e \u003ch2\u003eClinical Vignette\u003c/h2\u003e \u003cp\u003eThe following vignette was provided to participants to base their responses: Mr JS is a 68-year-old man with advanced colorectal cancer with peritoneal metastases. He is not a candidate for further surgical intervention. You meet with him in your current primary place of practice setting and he describes a history of 3 days of severe continuous nausea with associated vomiting and is no longer passing stool or flatulence. While working in your primary place of practice in palliative medicine, you diagnose him with a malignant bowel obstruction.\u003c/p\u003e \u003c/div\u003e"},{"header":"Results","content":"\u003cp\u003eA total of 117 responses were obtained between June 4 and September 9, 2024. In 2023 there was a total of 435 palliative medicine doctors employed in Australia[\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e] and New Zealand[\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e] representing a 27% response rate. Respondent characterises were collected (Table\u0026nbsp;1).\u003c/p\u003e\n\u003ch3\u003eChoice of medication\u003c/h3\u003e\n\u003cp\u003eThe survey presented a total of 12 commonly used medications with an additional \u0026lsquo;other\u0026rsquo; text box. Clinicians were permitted to select multiple options and were asked to specify their choices for first-line, second-line, and third-line therapies.\u003c/p\u003e \u003cp\u003eFor initial therapy, clinicians predominantly chose to prescribe Dexamethasone (78%) and Haloperidol (69%) with other options less frequently selected (Table\u0026nbsp;2). For second round therapy options, the most common selected response was cyclizine (42%). For third line therapy options, the most commonly selected option was levomepromazine (42%). 76% of respondents chose to initiate more than 1 agent for initial therapy (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cdiv id=\"Sec11\" class=\"Section2\"\u003e \u003ch2\u003eNon-Pharmacological Treatment\u003c/h2\u003e \u003cp\u003eBased on the clinical vignette 69% of respondents said they would recommend a non-pharmacological treatment option. (Table\u0026nbsp;3)\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec12\" class=\"Section2\"\u003e \u003ch2\u003eData Analysis\u003c/h2\u003e \u003cp\u003eData was collated and graphics produced using IBM SPSS Statistics Version 30.\u003c/p\u003e \u003cp\u003eCategorical variables from the demographic data were compared against responses using the chi square test.\u003c/p\u003e \u003cp\u003eThere was a statistically significant link between inital of pantoprazole based on years of practice (2% vs 16% for clinicians with greater than 10 years\u0026rsquo; experience compared to those with less respectively p\u0026thinsp;=\u0026thinsp;0.021). First round cyclizine, pantoprazole and ranitidine use was also more associated with clinicians within NSW compared to those practising in other jurisdictions (Cyclizine 30% vs 12% p\u0026thinsp;=\u0026thinsp;0.019) (Pantoprazole 18% vs 4% p\u0026thinsp;=\u0026thinsp;0.011) (ranitidine 22% vs 2% p\u0026thinsp;=\u0026thinsp;\u0026lt;\u0026thinsp;0.001).\u003c/p\u003e \u003cp\u003eNo statically significant differences were identified in later prescribing rounds or for choice of nasogastric insertion or surgical referral.\u003c/p\u003e \u003cp\u003eNo statistically significant difference in responses was identified when comparing metropolitan and regional clinicians, age or primary place of practice.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec13\" class=\"Section2\"\u003e \u003ch2\u003eFactor Ranking\u003c/h2\u003e \u003cp\u003eClinicians were asked to rank five factors with 1 being the most important and 5 being the least to explain their choices.\u003c/p\u003e \u003cp\u003e Effectiveness was the most influential factor in clinicians' prescribing decisions, followed by guidelines/supporting evidence. The rankings for tolerability and accessibility were similar, with both ranked as less influential than evidence. Cost was the least influential factor in decision-making (Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec14\" class=\"Section2\"\u003e \u003ch2\u003eClinician Attitudes\u003c/h2\u003e \u003cp\u003eClinicians were asked to respond to a five point Likert scale on topics featured below. 81% of respondents reporting they either Agreed or Strongly Agreed that there is ease of access to their preferred agents.\u003c/p\u003e \u003cp\u003e77% reported they either Agree or Strongly Agreed reported following a standard approach to their prescribing. Only 44% reporting they Agree or Strongly Agree that there is a standard approach at the level of their primary practice. Only 28% of respondents agreed or strongly agreed that there is a standard approach at the national level across Australia and New Zealand (Table\u0026nbsp;4)\u003c/p\u003e \u003c/div\u003e"},{"header":"Discussion","content":"\u003cp\u003eThis is to the authors' knowledge, the first bi-national survey conducted in Australia and New Zealand aimed at capturing data on the prescribing choices of clinicians for malignant bowel obstruction.\u003c/p\u003e \u003cp\u003e The Multinational Association of Supportive Care in Cancer (MASCC) 2021 guidelines, currently represent the most evidence-based and internationally recognised guidance for the pharmacological management of malignant bowel obstruction.\u003c/p\u003e \u003cp\u003e Comparing the most common responses in this survey to the evidence levels of these agents as outlined in the MASCC guidelines reveals that clinicians frequently use a mixture of agents supported by both stronger and weaker levels of evidence. For initial prescribing, haloperidol and dexamethasone were the most commonly selected agents. According to MASCC, these are supported by evidence levels of III and IV, respectively\u0026mdash;indicating limited or lower-quality evidence. For cyclizine and levomepromazine with the highest response for second and third line agents these hold also are supported by level IV evidence.\u003c/p\u003e \u003cp\u003eThe use of agents with lower levels of evidence may seem counterintuitive, but several plausible explanations may be that clinicians may prioritise agents with which they have the most experience and have observed clinical benefit, even in the absence of high-level evidence. In palliative care, treatment decisions are often nuanced and guided by individual patient response, leading to a reliance on practical, experiential knowledge over formal guideline recommendations. The MASCC guidelines themselves acknowledge a key limitation: the lack of high-quality evidence for many commonly used agents. The ability to draw strong conclusions was often hampered by small sample sizes, heterogeneity in study populations, and inconsistent outcome measures across trials. As a result, several agents in widespread clinical use\u0026mdash;such as haloperidol, cyclizine, and levomepromazine\u0026mdash;are given low evidence ratings not because they are necessarily ineffective, but because robust clinical trials are lacking.\u003c/p\u003e \u003cp\u003e Another limitation of the MASCC guidelines is the absence of recommendations for combination or stepwise (sequential) therapy, which is a common clinical approach in managing complex symptoms such as malignant bowel obstruction. In the absence of such guidance, clinicians may adopt their own stepwise regimens based on practice norms, mentor influence, and anecdotal outcomes. Agents like haloperidol and cyclizine are often readily available and familiar to clinicians, making them more accessible choices even when supported by weaker evidence.\u003c/p\u003e \u003cp\u003eNotably missing was responses reporting the use of octreotide which has level I evidence. This discrepancy may be attributed to the difficulty in accessing octreotide in community pharmacies, as well as the additional paperwork required for its use in public hospitals, which could act as barriers to its prescription. These practical challenges may contribute to clinicians opting for alternative treatments, despite the higher level of evidence supporting octreotide\u0026rsquo;s efficacy in managing malignant bowel obstruction. Hyoscine butylbromide, ranitidine, metoclopramide and ondansetron all received a rating of level III evidence in MASCC Guidelines but received lower levels of reported use in the survey. This discrepancy suggests a potential gap between evidence-based recommendations and actual clinical practice.\u003c/p\u003e \u003cp\u003eThe use of non-pharmacological management varied among respondents. 69% of clinicians recommended nasogastric tube insertion, while 25% suggested a surgical referral for a venting gastrostomy. According to the MASCC guidelines, these therapies are supported by level V and level IV evidence, respectively. The variability in the adoption of these non-pharmacological approaches may reflect clinical judgment, patient factors, or institutional practices. There was not an identified statically link between lower surgical referral rates and regional location.\u003c/p\u003e \u003cp\u003eData analysis did not reveal any statistically significant differences in prescribing patterns based on clinician age, primary palliative care setting, or whether they practiced in a regional versus metropolitan location. Some therapies showed statistically significant associations with years of clinical experience and jurisdiction of practice, suggesting that these factors may be influential. This highlights how institutional culture, local practice norms, and clinical experience may play a greater role in influencing therapeutic choices.\u003c/p\u003e \u003cp\u003eIn the responses ranking factors influencing prescribing choices, supporting evidence in the literature was ranked lower than clinician-perceived effectiveness. This raises the possibility that the gap between reported practice and available evidence may be driven by clinicians prioritising personal experiential practice over the existing evidence base. Several factors could explain this, including mentor-based training systems in palliative medicine, clinical inertia, scepticism about the quality of evidence guiding treatment, or a lack of promotion or awareness of current evidence.\u003c/p\u003e \u003cp\u003eOnly 28% of respondents agreed or strongly agreed that there is a standardised approach to prescribing across Australia and New Zealand, suggesting that diversity in prescribing practices at the national level is a widely observed among palliative care clinicians.\u003c/p\u003e \u003cdiv id=\"Sec16\" class=\"Section2\"\u003e \u003ch2\u003eLimitations\u003c/h2\u003e \u003cp\u003eThe study relies on self-reported outcomes, not observed clinical practice. Use of a clinical vignette provides a limited view of a clinical situation as this does not account for individual circumstances, including for example individual pathology or partial versus complete bowel obstruction.\u003c/p\u003e \u003cp\u003eInformation on de-prescribing and dosing was not explored. A large proportion of respondents were located in New South Wales which may reduce generalisability.\u003c/p\u003e \u003c/div\u003e"},{"header":"Conclusion","content":"\u003cp\u003eThis study provides novel cross-sectional data on current prescribing practices for the management of nausea and vomiting in malignant bowel obstruction among palliative care clinicians in Australia and New Zealand. Findings indicate the emergence of a dominant prescribing strategy\u0026mdash;dexamethasone and haloperidol for initial therapy, cyclizine as a second-line option, and levomepromazine as a third-line agent without majority consensus in second- and third-line prescribing.\u003c/p\u003e \u003cp\u003e A notable observation is the discrepancy between reported popular prescribing choices and the strength of supporting evidence as outlined in the MASCC 2021 guidelines.\u003c/p\u003e \u003cp\u003eStatistically significant associations were found between prescribing patterns and clinician years of experience as well as jurisdiction of practice, indicating that both individual and systemic factors may influence therapeutic decision-making.\u003c/p\u003e \u003cp\u003eThese findings underscore the need for further primary drug trials, investigation into the drivers of prescribing behaviour, particularly the role of experiential learning, local systems, and perceived effectiveness. The development of localised, context-sensitive guidelines may aid in reducing practice variability and promoting more consistent, evidence-aligned care across the region.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eAcknowledgements\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe Australia and New Zealand Society of Palliative Medicine aided in distribution of the survey to members.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding: \u003c/strong\u003eThis research has not received any specific funding\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting Interests:\u003c/strong\u003e The authors declare there is no competing interest present\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eEthics Approval: \u003c/strong\u003eEthical approval for this study was granted by the Royal Prince Alfred Hospital Ethics Committee (HREC Reference Number: 2024/ETH00286, SSA 2024/STE00610). All procedures performed in this study were in accordance with the ethical standards of the institutional research committee and with the 1964 Helsinki Declaration and its later amendments.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent to Participate:\u003c/strong\u003e Informed consent was obtained from all individual participants included in the study.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for Publication: \u003c/strong\u003eNot applicable\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of Data and Material:\u003c/strong\u003e The datasets generated during and/or analysed during the current study are available from the corresponding author on reasonable request.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCode Availability:\u003c/strong\u003e Not applicable\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthor Contributions: \u003c/strong\u003eAll authors contributed to the study conception and design and provided feedback of the final manuscript. Manuscript preparation, data collection and analysis were performed by Joshua Sandy. The project was overseen by Riona Pais.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eDavis M, Hui D, Davies A, Ripamonti C, Capela A, DeFeo G, et al. Medical management of malignant bowel obstruction in patients with advanced cancer: 2021 MASCC guideline update. Support Care Cancer. 2021;29(12):8089\u0026ndash;96.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eAnthony T, Baron T, Mercadante S, Green S, Chi D, Cunningham J, et al. Report of the Clinical Protocol Committee: Development of Randomized Trials for Malignant Bowel Obstruction. J Pain Symptom Manage. 2007 July;34(1):S49\u0026ndash;59.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eTuca A, Guell E, Martinez-Losada E, Codorniu N. Malignant bowel obstruction in advanced cancer patients: epidemiology, management, and factors influencing spontaneous resolution. 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Reducing gastric secretions\u0026ndash;a role for histamine 2 antagonists or proton pump inhibitors in malignant bowel obstruction? Support Care Cancer. 2009;17(12):1463\u0026ndash;8.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eFeuer DJ, Broadley KE. Systematic review and meta-analysis of corticosteroids for the resolution of malignant bowel obstruction in advanced gynaecological and gastrointestinal cancers. Systematic Review Steering Committee. Ann Oncol. 1999 Sept;10(9):1035\u0026ndash;41.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eKaneishi K, Imai K, Nishimura K, Sakurai N, Kohara H, Ishiki H, et al. Olanzapine versus Metoclopramide for Treatment of Nausea and Vomiting in Advanced Cancer Patients with Incomplete Malignant Bowel Obstruction. J Palliat Med. 2020 July;23(7):880\u0026ndash;1.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eRipamonti C, Twycross R, Baines M, Bozzetti F, Capri S, De Conno F, et al. Clinical-practice recommendations for the management of bowel obstruction in patients with end-stage cancer. Support Care Cancer. 2001 June;9(4):223\u0026ndash;33.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eHarris PA, Taylor R, Thielke R, Payne J, Gonzalez N, Conde JG. Research electronic data capture (REDCap)--a metadata-driven methodology and workflow process for providing translational research informatics support. J Biomed Inform. 2009;42(2):377\u0026ndash;81.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eHarris PA, Taylor R, Minor BL, Elliott V, Fernandez M, O\u0026rsquo;Neal L, et al. The REDCap consortium: Building an international community of software platform partners. J Biomed Inform. 2019 July;95:103208.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003ePCA Staff. Palliative Care Australia [Internet]. 2024 [cited 2024 May 27]. Available from: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://nsd.palliativecare.org.au/s/search-service\u003c/span\u003e\u003cspan address=\"https://nsd.palliativecare.org.au/s/search-service\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eAustralia Institute of Health and Welfare. Palliative care services in Australia. 2025 [cited 2025 Dec 15]. Palliative care services in Australia. Available from: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://www.aihw.gov.au/reports/palliative-care-services/palliative-care-services-in-australia/contents/palliative-care-workforce/characteristics\u003c/span\u003e\u003cspan address=\"https://www.aihw.gov.au/reports/palliative-care-services/palliative-care-services-in-australia/contents/palliative-care-workforce/characteristics\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMedical Council of New Zealand. The New Zealand Medical Workforce 2024 Report [Internet]. Medical Council of New Zealand; 2024 [cited 2025 Dec 15]. Available from: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://www.mcnz.org.nz/about-us/what-we-do/workforce-survey/\u003c/span\u003e\u003cspan address=\"https://www.mcnz.org.nz/about-us/what-we-do/workforce-survey/\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"},{"header":"Tables","content":"\u003ctable border=\"0\" cellspacing=\"0\" cellpadding=\"0\" width=\"555\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"2\" valign=\"bottom\" style=\"width: 377px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eTable 1. Respondent Characteristics (N=117)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 79px;\"\u003e\n \u003cp\u003eNumber\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 98px;\"\u003e\n \u003cp\u003ePercentage\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"7\" valign=\"top\" style=\"width: 186px;\"\u003e\n \u003cp\u003eLocation\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 192px;\"\u003e\n \u003cp\u003eNew South Wales\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 79px;\"\u003e\n \u003cp\u003e60\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 98px;\"\u003e\n \u003cp\u003e51.3%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 192px;\"\u003e\n \u003cp\u003eNew Zealand\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 79px;\"\u003e\n \u003cp\u003e14\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 98px;\"\u003e\n \u003cp\u003e12.0%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 192px;\"\u003e\n \u003cp\u003eQueensland\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 79px;\"\u003e\n \u003cp\u003e17\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 98px;\"\u003e\n \u003cp\u003e14.5%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 192px;\"\u003e\n \u003cp\u003eSouth Australia\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 79px;\"\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 98px;\"\u003e\n \u003cp\u003e1.7%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 192px;\"\u003e\n \u003cp\u003eTasmania\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 79px;\"\u003e\n \u003cp\u003e5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 98px;\"\u003e\n \u003cp\u003e4.3%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 192px;\"\u003e\n \u003cp\u003eVictoria\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 79px;\"\u003e\n \u003cp\u003e12\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 98px;\"\u003e\n \u003cp\u003e10.3%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 192px;\"\u003e\n \u003cp\u003eWestern Australia\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 79px;\"\u003e\n \u003cp\u003e7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 98px;\"\u003e\n \u003cp\u003e6.0 %\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 186px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 192px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 79px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 98px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"2\" valign=\"top\" style=\"width: 186px;\"\u003e\n \u003cp\u003eSetting\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 192px;\"\u003e\n \u003cp\u003eMetropolitan\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 79px;\"\u003e\n \u003cp\u003e81\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 98px;\"\u003e\n \u003cp\u003e69.2%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 192px;\"\u003e\n \u003cp\u003eRegional\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 79px;\"\u003e\n \u003cp\u003e36\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 98px;\"\u003e\n \u003cp\u003e30.8%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 186px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 192px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 79px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 98px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"5\" valign=\"top\" style=\"width: 186px;\"\u003e\n \u003cp\u003eAge\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 192px;\"\u003e\n \u003cp\u003e20-30\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 79px;\"\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 98px;\"\u003e\n \u003cp\u003e1.7%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 192px;\"\u003e\n \u003cp\u003e31-40\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 79px;\"\u003e\n \u003cp\u003e45\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 98px;\"\u003e\n \u003cp\u003e38.5%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 192px;\"\u003e\n \u003cp\u003e41-50\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 79px;\"\u003e\n \u003cp\u003e37\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 98px;\"\u003e\n \u003cp\u003e31.6%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 192px;\"\u003e\n \u003cp\u003e51-60\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 79px;\"\u003e\n \u003cp\u003e20\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 98px;\"\u003e\n \u003cp\u003e17.1%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 192px;\"\u003e\n \u003cp\u003e\u0026gt;60\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 79px;\"\u003e\n \u003cp\u003e13\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 98px;\"\u003e\n \u003cp\u003e11.1%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 186px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 192px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 79px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 98px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"5\" valign=\"top\" style=\"width: 186px;\"\u003e\n \u003cp\u003eYears of Practice\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 192px;\"\u003e\n \u003cp\u003e0-5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 79px;\"\u003e\n \u003cp\u003e49\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 98px;\"\u003e\n \u003cp\u003e41.9%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 192px;\"\u003e\n \u003cp\u003e5-10\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 79px;\"\u003e\n \u003cp\u003e16\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 98px;\"\u003e\n \u003cp\u003e21.4%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 192px;\"\u003e\n \u003cp\u003e10-15\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 79px;\"\u003e\n \u003cp\u003e16\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 98px;\"\u003e\n \u003cp\u003e13.7%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 192px;\"\u003e\n \u003cp\u003e15-20\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 79px;\"\u003e\n \u003cp\u003e11\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 98px;\"\u003e\n \u003cp\u003e13.7%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 192px;\"\u003e\n \u003cp\u003e\u0026gt;20\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 79px;\"\u003e\n \u003cp\u003e25\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 98px;\"\u003e\n \u003cp\u003e9.4%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 186px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 192px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 79px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 98px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"6\" valign=\"top\" style=\"width: 186px;\"\u003e\n \u003cp\u003ePrimary Place of Practice\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 192px;\"\u003e\n \u003cp\u003ePalliative Care Unit - Private\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 79px;\"\u003e\n \u003cp\u003e4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 98px;\"\u003e\n \u003cp\u003e3.4%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 192px;\"\u003e\n \u003cp\u003ePalliative Care Unit - Public\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 79px;\"\u003e\n \u003cp\u003e37\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 98px;\"\u003e\n \u003cp\u003e31.6%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 192px;\"\u003e\n \u003cp\u003ePrivate Hospital: Inpatients (Consultative Liaison and admitted patients outside a dedicated palliative care unit)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 79px;\"\u003e\n \u003cp\u003e5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 98px;\"\u003e\n \u003cp\u003e4.3%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 192px;\"\u003e\n \u003cp\u003ePublic Hospital: Inpatients (Consultative Liaison and admitted patients outside a dedicated palliative care unit)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 79px;\"\u003e\n \u003cp\u003e37\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 98px;\"\u003e\n \u003cp\u003e31.6%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 192px;\"\u003e\n \u003cp\u003ePrivate Hospital: Outpatients (Clinic and Community Patients)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 79px;\"\u003e\n \u003cp\u003e3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 98px;\"\u003e\n \u003cp\u003e2.6%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 192px;\"\u003e\n \u003cp\u003ePublic Hospital: Outpatients (Clinic and Community Patients)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 79px;\"\u003e\n \u003cp\u003e31\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 98px;\"\u003e\n \u003cp\u003e26.5%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u003cbr\u003e\u003c/p\u003e\n\u003ctable border=\"0\" cellspacing=\"0\" cellpadding=\"0\" width=\"546\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 217px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eTable 2. Prescribing Choices\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 263px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 217px;\"\u003e\n \u003cp\u003eInitial Prescribing Choices\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 263px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 217px;\"\u003e\n \u003cp\u003eAgent\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003eN=117\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 263px;\"\u003e\n \u003cp\u003ePercentage of Respondents\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 217px;\"\u003e\n \u003cp\u003eCyclizine\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003e25\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 263px;\"\u003e\n \u003cp\u003e21.4%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 217px;\"\u003e\n \u003cp\u003eDexamethasone\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003e91\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 263px;\"\u003e\n \u003cp\u003e77.8%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 217px;\"\u003e\n \u003cp\u003eEsomeprazole\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003e5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 263px;\"\u003e\n \u003cp\u003e4.3%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 217px;\"\u003e\n \u003cp\u003eFamotidine\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003e8\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 263px;\"\u003e\n \u003cp\u003e6.8%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 217px;\"\u003e\n \u003cp\u003eHaloperidol\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003e81\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 263px;\"\u003e\n \u003cp\u003e69.2%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 217px;\"\u003e\n \u003cp\u003eHyoscine butylbromide\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003e7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 263px;\"\u003e\n \u003cp\u003e6.0%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 217px;\"\u003e\n \u003cp\u003eLevomepromazine\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 263px;\"\u003e\n \u003cp\u003e0%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 217px;\"\u003e\n \u003cp\u003eMetoclopramide\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003e13\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 263px;\"\u003e\n \u003cp\u003e11.1%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 217px;\"\u003e\n \u003cp\u003eOctreotide\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003e12\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 263px;\"\u003e\n \u003cp\u003e10.3%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 217px;\"\u003e\n \u003cp\u003eOlanzapine\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 263px;\"\u003e\n \u003cp\u003e0.9%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 217px;\"\u003e\n \u003cp\u003ePantoprazole\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003e13\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 263px;\"\u003e\n \u003cp\u003e11.1%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 217px;\"\u003e\n \u003cp\u003eRanitidine\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003e14\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 263px;\"\u003e\n \u003cp\u003e12.0%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 217px;\"\u003e\n \u003cp\u003eOther\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 263px;\"\u003e\n \u003cp\u003e0.9%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 217px;\"\u003e\n \u003cp\u003e2\u003csup\u003end\u003c/sup\u003e line Prescribing Choices\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 263px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 217px;\"\u003e\n \u003cp\u003eAgent\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 263px;\"\u003e\n \u003cp\u003ePercentage of Respondents\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 217px;\"\u003e\n \u003cp\u003eCyclizine\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003e49\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 263px;\"\u003e\n \u003cp\u003e41.9%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 217px;\"\u003e\n \u003cp\u003eDexamethasone\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003e7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 263px;\"\u003e\n \u003cp\u003e6.0%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 217px;\"\u003e\n \u003cp\u003eEsomeprazole\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003e3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 263px;\"\u003e\n \u003cp\u003e2.6%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 217px;\"\u003e\n \u003cp\u003eFamotidine\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003e14\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 263px;\"\u003e\n \u003cp\u003e12.0%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 217px;\"\u003e\n \u003cp\u003eHaloperidol\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003e22\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 263px;\"\u003e\n \u003cp\u003e18.8%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 217px;\"\u003e\n \u003cp\u003eHyoscine butylbromide\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003e12\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 263px;\"\u003e\n \u003cp\u003e10.3%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 217px;\"\u003e\n \u003cp\u003eLevomepromazine\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003e16\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 263px;\"\u003e\n \u003cp\u003e13.7%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 217px;\"\u003e\n \u003cp\u003eMetoclopramide\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 263px;\"\u003e\n \u003cp\u003e0%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 217px;\"\u003e\n \u003cp\u003eOctreotide\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003e24\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 263px;\"\u003e\n \u003cp\u003e20.5%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 217px;\"\u003e\n \u003cp\u003eOlanzapine\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003e13\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 263px;\"\u003e\n \u003cp\u003e11.1%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 217px;\"\u003e\n \u003cp\u003ePantoprazole\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003e3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 263px;\"\u003e\n \u003cp\u003e2.6%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 217px;\"\u003e\n \u003cp\u003eRanitidine\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003e11\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 263px;\"\u003e\n \u003cp\u003e9.4%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 217px;\"\u003e\n \u003cp\u003eOther\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003e3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 263px;\"\u003e\n \u003cp\u003e2.6%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 217px;\"\u003e\n \u003cp\u003e3\u003csup\u003erd\u003c/sup\u003e line Prescribing Choices\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 263px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 217px;\"\u003e\n \u003cp\u003eAgent\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 263px;\"\u003e\n \u003cp\u003ePercentage of Respondents\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 217px;\"\u003e\n \u003cp\u003eCyclizine\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003e24\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 263px;\"\u003e\n \u003cp\u003e20.5%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 217px;\"\u003e\n \u003cp\u003eDexamethasone\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003e3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 263px;\"\u003e\n \u003cp\u003e2.6%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 217px;\"\u003e\n \u003cp\u003eEsomeprazole\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 263px;\"\u003e\n \u003cp\u003e0%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 217px;\"\u003e\n \u003cp\u003eFamotidine\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003e6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 263px;\"\u003e\n \u003cp\u003e5.1%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 217px;\"\u003e\n \u003cp\u003eHaloperidol\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003e8\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 263px;\"\u003e\n \u003cp\u003e6.8%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 217px;\"\u003e\n \u003cp\u003eHyoscine butylbromide\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003e20\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 263px;\"\u003e\n \u003cp\u003e17.1%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 217px;\"\u003e\n \u003cp\u003eLevomepromazine\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003e49\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 263px;\"\u003e\n \u003cp\u003e41.9%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 217px;\"\u003e\n \u003cp\u003eMetoclopramide\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 263px;\"\u003e\n \u003cp\u003e0%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 217px;\"\u003e\n \u003cp\u003eOctreotide\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003e28\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 263px;\"\u003e\n \u003cp\u003e23.9%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 217px;\"\u003e\n \u003cp\u003eOlanzapine\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003e10\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 263px;\"\u003e\n \u003cp\u003e8.5%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 217px;\"\u003e\n \u003cp\u003ePantoprazole\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 263px;\"\u003e\n \u003cp\u003e1.7%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 217px;\"\u003e\n \u003cp\u003eRanitidine\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003e3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 263px;\"\u003e\n \u003cp\u003e2.6%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 217px;\"\u003e\n \u003cp\u003eOther\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003e4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 263px;\"\u003e\n \u003cp\u003e3.4%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003ctable border=\"0\" cellspacing=\"0\" cellpadding=\"0\" width=\"545\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"2\" valign=\"bottom\" style=\"width: 296px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eTable 3. Non-Pharmacological Measures (N=117)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 94px;\"\u003e\n \u003cp\u003eCount\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 155px;\"\u003e\n \u003cp\u003ePercentage\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 228px;\"\u003e\n \u003cp\u003eNasogastric tube Insertion\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 68px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 94px;\"\u003e\n \u003cp\u003e80\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 155px;\"\u003e\n \u003cp\u003e68.6%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 228px;\"\u003e\n \u003cp\u003eSurgical referral for consideration of a venting gastrostomy\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 68px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 94px;\"\u003e\n \u003cp\u003e29\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 155px;\"\u003e\n \u003cp\u003e24.8%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 228px;\"\u003e\n \u003cp\u003eI would not recommend these options\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 68px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 94px;\"\u003e\n \u003cp\u003e36\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 155px;\"\u003e\n \u003cp\u003e30.8%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u003cbr\u003e\u003c/p\u003e\n\u003ctable border=\"0\" cellspacing=\"0\" cellpadding=\"0\" width=\"586\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"2\" valign=\"bottom\" style=\"width: 402px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eTable 4. Clinician Attitudes\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 79px;\"\u003e\n \u003cp\u003eCount (N=117)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 104px;\"\u003e\n \u003cp\u003ePercentage\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"5\" valign=\"top\" style=\"width: 271px;\"\u003e\n \u003cp\u003eI can easily access my preferred pharmacotherapies for the treatment of nausea and vomiting for malignant bowel obstruction at my primary place of practice in palliative medicine\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 131px;\"\u003e\n \u003cp\u003eStrongly Agree\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 79px;\"\u003e\n \u003cp\u003e41\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 104px;\"\u003e\n \u003cp\u003e35.0%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 131px;\"\u003e\n \u003cp\u003eAgree\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 79px;\"\u003e\n \u003cp\u003e54\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 104px;\"\u003e\n \u003cp\u003e46.2%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 131px;\"\u003e\n \u003cp\u003eNeutral\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 79px;\"\u003e\n \u003cp\u003e13\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 104px;\"\u003e\n \u003cp\u003e12.0%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 131px;\"\u003e\n \u003cp\u003eDisagree\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 79px;\"\u003e\n \u003cp\u003e6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 104px;\"\u003e\n \u003cp\u003e5.1%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 131px;\"\u003e\n \u003cp\u003eStrongly Disagree\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 79px;\"\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 104px;\"\u003e\n \u003cp\u003e1.7%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"5\" valign=\"top\" style=\"width: 271px;\"\u003e\n \u003cp\u003eI follow a standard approach to prescribing pharmacotherapy for nausea and vomiting in malignant bowel obstruction:\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 131px;\"\u003e\n \u003cp\u003eStrongly Agree\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 79px;\"\u003e\n \u003cp\u003e20\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 104px;\"\u003e\n \u003cp\u003e17.1%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 131px;\"\u003e\n \u003cp\u003eAgree\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 79px;\"\u003e\n \u003cp\u003e70\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 104px;\"\u003e\n \u003cp\u003e59.8%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 131px;\"\u003e\n \u003cp\u003eNeutral\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 79px;\"\u003e\n \u003cp\u003e21\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 104px;\"\u003e\n \u003cp\u003e17.9%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 131px;\"\u003e\n \u003cp\u003eDisagree\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 79px;\"\u003e\n \u003cp\u003e6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 104px;\"\u003e\n \u003cp\u003e5.1%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 131px;\"\u003e\n \u003cp\u003eStrongly Disagree\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 79px;\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 104px;\"\u003e\n \u003cp\u003e0%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"5\" valign=\"top\" style=\"width: 271px;\"\u003e\n \u003cp\u003eAt my primary place of practice, there is a standard approach to prescribing pharmacotherapy for nausea and vomiting in malignant bowel obstruction.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 131px;\"\u003e\n \u003cp\u003eStrongly Agree\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 79px;\"\u003e\n \u003cp\u003e4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 104px;\"\u003e\n \u003cp\u003e3.4%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 131px;\"\u003e\n \u003cp\u003eAgree\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 79px;\"\u003e\n \u003cp\u003e48\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 104px;\"\u003e\n \u003cp\u003e41.0%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 131px;\"\u003e\n \u003cp\u003eNeutral\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 79px;\"\u003e\n \u003cp\u003e37\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 104px;\"\u003e\n \u003cp\u003e31.6%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 131px;\"\u003e\n \u003cp\u003eDisagree\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 79px;\"\u003e\n \u003cp\u003e25\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 104px;\"\u003e\n \u003cp\u003e21.4%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 131px;\"\u003e\n \u003cp\u003eStrongly Disagree\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 79px;\"\u003e\n \u003cp\u003e3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 104px;\"\u003e\n \u003cp\u003e2.6%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"5\" valign=\"top\" style=\"width: 271px;\"\u003e\n \u003cp\u003eI believe there is a standard approach in Australia and New Zealand regarding prescribing pharmacotherapy for the management of nausea and vomiting in malignant bowel obstruction.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 131px;\"\u003e\n \u003cp\u003eStrongly Agree\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 79px;\"\u003e\n \u003cp\u003e3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 104px;\"\u003e\n \u003cp\u003e2.6%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 131px;\"\u003e\n \u003cp\u003eAgree\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 79px;\"\u003e\n \u003cp\u003e30\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 104px;\"\u003e\n \u003cp\u003e25.6%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 131px;\"\u003e\n \u003cp\u003eNeutral\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 79px;\"\u003e\n \u003cp\u003e41\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 104px;\"\u003e\n \u003cp\u003e35.0%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 131px;\"\u003e\n \u003cp\u003eDisagree\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 79px;\"\u003e\n \u003cp\u003e39\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 104px;\"\u003e\n \u003cp\u003e33.4%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 131px;\"\u003e\n \u003cp\u003eStrongly Disagree\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 79px;\"\u003e\n \u003cp\u003e4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 104px;\"\u003e\n \u003cp\u003e3.4%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"malignant bowel obstruction, palliative care, pharmacotherapy, prescribing, Australia and New Zealand","lastPublishedDoi":"10.21203/rs.3.rs-8363554/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-8363554/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003ePurpose:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003ePharmacological management of malignant bowel obstruction can be complex with a variety of treatment options available, many of which are used off-label for this condition. The current prescribing practices of Palliative Care Clinicians in Australia and New Zealand remain unclear.\u003c/p\u003e\n\u003cp\u003eTo capture current prescribing preferences among palliative care clinicians, assess the presence of variability in prescribing practices, and explore the rationale behind their choices as well as any potential barriers to pharmacological management.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMethods:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eA cross-sectional online survey of palliative medicine clinicians in 2024 used a clinical vignette to elicit prescribing preferences for first, second, and third-line agents, including the number of agents used and factors influencing decisions.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eResults:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e117 responses were collected. For initial therapy, clinicians chose to prescribe Dexamethasone (78%) and Haloperidol (69%). For second and third line therapy Cyclizine (42%) and Levomepromazine (42%) were the most common responses. The number of agents prescribed was diverse, with results showing 24% initiating one agent, 33% two agents and 43% initiating three or more agents. Only 28% of respondents agreed or strongly agreed that there was a standard approach to prescribing in Australia and New Zealand.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConclusion:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eResponses revealed variation in prescribing practices despite a dominant first-line strategy. No clear consensus was found for second and third-line choices. The comparison to the 2021 MASCC guidelines revealed a disconnect between reported prescribing patterns and the level of supporting evidence. These findings highlight the need for further research and the need for localised guidelines to reduce variability.\u003c/p\u003e","manuscriptTitle":"Prescribing for Malignant Bowel Obstruction in Palliative Care: A Cross-Sectional Australia and New Zealand Survey of Palliative Medicine Practitioners","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2026-01-23 14:50:26","doi":"10.21203/rs.3.rs-8363554/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"69e2d8e7-b5f8-4384-8e72-412d20b30225","owner":[],"postedDate":"January 23rd, 2026","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2026-01-27T21:24:37+00:00","versionOfRecord":[],"versionCreatedAt":"2026-01-23 14:50:26","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-8363554","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-8363554","identity":"rs-8363554","version":["v1"]},"buildId":"XKTyCvWXoU3ODBz1xrDgd","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}