Please Return This Form to the Local Specialist Palliative Care Service

CONFIDENTIAL ALL FIELDS MUST BE COMPLETED. PLEASE NOTE THAT IF THE REFERRAL FORM IS INCOMPLETE IT MAY LEAD TO A DELAY IN PROCESSING SAME

Hospice Use Only Date received: Ref No:

REFERRAL TO COMMUNITY AND INPATIENT UNIT SPECIALIST PALLIATIVE CARE SERVICES Patient Date of Name Birth H&C No Sex Address Marital Status Ethnic Origin Post Code Religion Tel No Occupation Mobile No No of Dependents (under 18 years)

Next of Kin Main Carer (if different from Next of Kin) Name Name Address Address

Post Code Post Code Tel No Tel No Mobile No Mobile No Relationshi Relationshi p to Patient p to Patient

Referrer GP Name of Name of GP Referrer Address Address

Post Code Post Code

Tel No Tel No

District Other Healthcare Professional Nurse Name of DN Consultant Address Palliative Care Nurse Specialist Palliative Medicine Consultant Post Code Social Worker CONFIDENTIAL Tel No Other

ELCOS Status D = C = Possibly A = may be B = Could Probably months/we years ☐ be last year ☐ ☐ last few ☐ eks days Reason for Service(s) Requested (please select) Referral (please select ) Symptom Inpatient Manageme ☐ Unit ☐ nt Admission Rehabilitati Day on ☐ Therapy ☐ End of Life Outpatient Support Clinic ☐ Community Palliative ☐ ☐ Care Nurse Specialist Other Other (please (please specify) specify) The patient is currently (please select one option) At Home ☐ At Hospital ☐ Other At Nursing ☐ (please ☐ Home specify) Patient Diagnosis Primary Diagnosis and date Secondary Diagnosis and date Histology (if known) Current (enter details of unresolved complex physical, social, psychological and spiritual symptoms problems including concerns affecting carer/family, give details of what interventions you have trialled)

Treatments (enter details of Consultant and hospital for all treatments) to date and further treatment planned Additional Information (e.g. details of results from previous scans, x-rays, blood tests, etc)

2IF THIS REFERRAL REQUIRES AN URGENT RESPONSE IT MUST BE ACCOMPANIED BY TELEPHONE CONTACT FROM THE REFERRER CONFIDENTIAL

Past Medical History

Medication Current medication as per Syringe Pump discharge letter (obligatory) ☐ Known Allergies

(enter details) Mobility (please select all Mobile ☐ Mobile with difficulty ☐ that are appropriate) (stiffness, pain) Mobile with assistance, ☐ Immobile ☐ equipment or aids Oxygen Therapy

(enter details) Nutritional Therapy Oral ☐ PEG ☐ NG ☐ (please select all that are Any feeding difficulties? appropriate)

Infection Status e.g. MRSA, C.Diff, Pseudomonas

(enter details)

Advance Care Plan Has an Advance Care Plan been completed? (if yes, Yes ☐ No ☐ N/A ☐ please forward details) Preferred Place of Care Please state Patient’s preferred place of care Date

CPR Status

Has CPR Status been Yes No discussed with the patient? ☐ ☐ Not Current Status (please DNACPR For CPR select) ☐ ☐ Known ☐

Has GP been notified of Yes No status? ☐ ☐

3IF THIS REFERRAL REQUIRES AN URGENT RESPONSE IT MUST BE ACCOMPANIED BY TELEPHONE CONTACT FROM THE REFERRER CONFIDENTIAL Care Package

Is there a care package in Yes No N/A place? ☐ ☐ ☐ If you have answered Yes to the above question, please enter details

Communication Is the patient experiencing communication difficulties? Please enter details including if an interpreter is required.

Patient Insight Next of Kin/Main Carer Insight Has the patient agreed to Is the NOK/Main Carer N Yes No Yes this referral? ☐ ☐ aware of the referral? ☐ o ☐ Is the patient aware of their Is the NOK/Main Carer N diagnosis? Yes No aware of the patient’s Yes ☐ ☐ ☐ o ☐ diagnosis? If No, please explain why If No, please explain the patient is not aware of why NOK/Main Carer is their diagnosis. not aware of the diagnosis. Has prognosis been Has prognosis been N discussed with the patient? Yes No discussed with Yes ☐ ☐ ☐ o ☐ NOK/Main Carer? If No, please explain why If No, please explain the prognosis has not been why the prognosis has discussed. not been discussed.

Submission Has the Patient’s GP been made aware of this referral Yes No by the Referrer (Community only)? ☐ ☐ Please confirm name of GP contacted and date of call Insert name of GP Date

Authorisation Please confirm that you have reviewed this form and all Date relevant information has been completed Signature of Referrer (please insert your name as your signature) Designation of Referrer

PLEASE RETURN THIS FORM TO THE LOCAL SPECIALIST PALLIATIVE CARE SERVICE

4IF THIS REFERRAL REQUIRES AN URGENT RESPONSE IT MUST BE ACCOMPANIED BY TELEPHONE CONTACT FROM THE REFERRER