West London Palliative Care Referral Form

Hillingdon Palliative Care Team Meadow House Hospice St Luke’s Kenton Grange Hospice (Hillingdon Hospital) (Ealing) (Harrow and North Brent) Tel: 01895 279412 Tel: 020 8967 5179 Tel: 020 8382 8001 Fax: 01895 279452 Fax: 020 8967 5756 Fax: 020 8382 8080 Harlington Hospice Michael Sobell House Trinity Hospice (Hillingdon) (Hillingdon) (Lambeth) Tel: 020 8759 0453 Tel: 01923 844302 Tel: 020 7787 1000 Fax: 020 8759 4652 Fax: 01923 844565 Fax: 020 7787 1067 Harrow Community Palliative Care Team Pembridge Palliative Care Centre St Johns Palliative Care Centre (St Luke’s Kenton Grange Hospice) (Kensington & Chelsea) (Westminster) Tel: 020 8382 8084 Tel: 020 8962 4410 Tel: 020 7806 4065 Fax: 020 8382 8085 Fax: 020 8962 4407 Fax: 020 7806 4041 (PLEASETICK) PLEASE SEND COPIES OF RECENT CLINICAL CORRESPONDENCE WITH THIS FORM PLEASE PRINT CLEARLY AND USE BLACK INK Patient Details

Surname Male/Female Patient consent to Office use

First Name Palliative Care

Address involvement

 Yes  No Postcode Tel Mobile Tel Is GP aware of referral? Marital Status Ethnicity

NHS No DoB Age  Yes  No Primary diagnosis(es)

Communication First Language if not English: Communication in English Good Fair Poor (please circle) Would interpreter be helpful to patient and Palliative Care staff?  Yes  No Other barriers to communication e.g. hearing loss, confusion

Next of Kin/Patient District Nurse Yes  No  General Practitioner Representatives Name Name Name Address Based at Address Telephone Telephone Fax Relationship to patient Postcode Main Carer (if different from above) Social Services Yes  No  Telephone Name Name Telephone Based at Fax/email Relationship to patient Tel Fax Continuing care assessment completed: Yes/No PCT number: Reason for Referral – please tick Service required – please tick Patient is currently – please tick  Pain/symptom control  Home assessment and support  at home  Emotional/psychological support  Hospital assessment  in hospital (see over)  Social/financial  Admission (circle)  elsewhere (e.g. Nursing Home)  Assessment for hospice admission respite/symptom control / terminal care  Carer support  Day Care Does patient live alone  Yes  No  Other reason e.g. (spiritual, lymphoedema) _ Outpatient assessment Patient Mobility:

IS REFERRAL URGENT (assess within 2 working days)?  Yes  No IF URGENT, PLEASE PHONE US FOR IMMEDIATE ADVICE West London Palliative Care Referral Form

PATIENT NAME ………………………………………………. In-Patient details Hospital Telephone Ward Direct Ward Ext. Date of discharge (if known) Consultant (1) Consultant (2) Name and tel no. of key Hospital Palliative Care nurse and team: MRSA Status  Positive  Negative Not known

Name and tel no. of community Palliative Care nurse and team:

Brief History of diagnosis(es) and Key treatments Date Progression of disease and investigations/treatment Consultant and hospital

Current problems 1. 4.

Referrer’s expectation of current treatment (circle) symptom control / life prolonging / curative

Estimated prognosis (circle) days / weeks / months / years

Current Past Medical and Psychiatric History Medication/Allergies

Insight Has patient been told diagnosis?  Yes  No Is the carer aware of patient’s diagnosis?  Yes  No Does patient discuss the illness freely  Yes  No Can we write to GP?  Yes  No Any other comments/information

Please ensure patients are aware information will be held on computer according to the Data Protection Act.

Referrer’s signature: Name: (please print) Job title: Contact number: Bleep no: Surgery or Hospital: Date: West London Palliative Care Referral Form FAX

Date: ______

Number of pages including cover sheet: ______

To: ______From: ______

______

Fax No: ______Phone No. ______

Fax no: ______

Catchment areas of palliative care centres by PCT (Primary Care Trust)

PCT (Local Authority) Main Palliative Care Options

Brent Pembridge Palliative Care Centre, St John’s Palliative Care Centre, St Luke’s Kenton Grange Hospice

Ealing Meadow House Hospice

Hammersmith & Fulham Pembridge Palliative Care Centre, Trinity Hospice

Harrow Harrow Community Palliative Care Team, Michael Sobell House, St Luke’s Kenton Grange Hospice

Hillingdon Hillingdon Palliative Care Team, Michael Sobell House

Hounslow Meadow House Hospice

Kensington & Chelsea Pembridge Palliative Care Centre, Trinity Hospice

Westminster St John’s Palliative Care Team, Pembridge Palliative Care Centre, Trinity Hospice

N.B. St John’s Hospice provides an HIV service to all PCTs.