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Palliative Care Referral
□ Urgent (24 hr response) Call 705-856-2334 ext 3413
□ Routine (72 hr response) Fax 705-856-1651
REFERRING PRINCIPLES
Completion of this referral is a request for referral to Supportive Care Program and/or admission to LDHC Palliative Suite.
I have informed the patient and/or SDM about the philosophy of hospice palliative care* which focuses on supporting any issues that may
arise including physical, disease management, psychological, social, spiritual, practical, loss, grief and end of life / death management. The
goal is to provide management of pain and other symptoms to achieve comfort, reduce suffering and improve the quality of life and dying.
(* CHPCA Model to Guide HPC 2002)
□ Yes, I have completed this task
Referral completed by: __________________________
REASON FOR REFERRAL – (Select all that apply)
 Pain and Symptom Management


Symptoms that require management?
__________________________ ESAS: (attach if available)
Short term Palliative Respite (less than 1 week)
Hospice Volunteer Visiting
Date: _______________
Title: __________________________
 End of Life Care (EOL)

□ EOL care needs exceed capacity of care at home
□ Caregiver inability to cope at home
□ Individual does not wish to die at home
□ Other: ____________________________
Back Up Plan (Palliative Care Suite only)
Palliative Diagnosis:
Care Concerns:
Prognosis:
Medications:
Goals of Care (attach copy)
POAPC/SDM
Most Recent PPS Score _____ %
Allergies:
□ C = Comfort Care
Name:
PPI score _______
□ M= Medical Care
Telephone:
List of current medications attached:
□ Not discussed/ Not completed
□
ADMISSION CRITERIA - PALLIATIVE CARE SUITE ONLY
Given that making a referral to our palliative care suite may be part of the advance-care planning process, we recognize that at the time of the
referral the individual may not meet the established admission criteria.
The admission criteria are provided as a guideline for consideration of admission to our palliative care suite ONLY.
 Client is in the final stages of a life threatening illness
 Significantly decreased functional abilities, Palliative Performance Scale (PPS) of 50% or less.
 Requires pain and symptom management and/or end of life care.
 Has care needs that cannot be met at home. Priority will be given to clients in the community who live alone and cannot manage at home.
 Patient or designated decision maker wishes for no further aggressive or invasive treatment that is intended to cure disease, and agrees to
transfer to an appropriate care setting (e.g. facility, home) if condition stabilizes.
 Has goals of care promoting a comfort approach rather than aggressive treatment.
 Resident of Algoma or has family in the district.
 No age restriction.
Exclusion Criteria:
 Able to manage well at home with resources.
 Chronic prognosis that is not end stage.
PALLIATIVE COORDINATOR USE ONLY - REVIEW OF REFERRAL AND OUTCOMES
LDHC Supportive Care Program
Date Accepted
LDHC Palliative Care Suite
Date Accepted
PLACED ON WAIT LIST
Notification of Acceptance/Decline:
Patient/Family
Referral Review and Consultations completed by:
□
□
Date Declined
Date Declined
□
□
Reason:
Reason:
Nursing Department
Title:
Date
http://ltctoolkit.rnao.ca/sites/default/files/resources/EndofLifeCare/AssessmentTools/Pg101_PPI_EndofLifeBPG2011.pdf
Nursing Best Practice Guidelines
Home
Palliative Prognostic Index (PPI)
The PPI relies on the assessment of performance status using the Palliative Performance Scale (PPS, oral intake, and the presence or
absence of dyspnea, edema, and delirium.
Performance status/Symptoms
Palliative Performance Scale
10–20
30–50
>60
Oral Intake
Mouthfuls or less
Reduced but more than mouthfuls
Normal
Edema
Present
Absent
Dyspnea at rest
Present
Absent
Delirium
Present
Absent
Partial score
4
2.5
0
2.5
1
0
1
0
3.5
0
4
0
Scoring
PPI score > 6 = survival shorter than 3 weeks
PPI score >4 = survival shorter than 6 weeks
PPI score ≤4 = survival more than 6weeks
Reprinted from Journal of Pain and Symptom Management, Vol. 35, No. 6, Stone, C., Tierman, E., & Dooley, B., Prospective Validation of the
Palliative Prognostic Index in Patients with Cancer, 617–622, Copyright (2008).