(Patient Name/Label) Palliative Care Hospice & In-Patient Referral Admission Location GRH Freeport-Kitchener SJHCG-Guelph GMCH-Fergus Requested: Lisaard House Hospice Wellington-Guelph – Referral Source: Designation: Facility / Community Agency: First Contact Person (Referral Source): Phone: ext: Pager: Fax: Second Contact Person (Referral Source): Phone: ext: Pager: Fax: Primary Palliative Diagnosis: Metastatic Spread (if malignant) Relevant Co-morbidities □ Back Up Plan □ Pain & Symptom Management Uncontrolled □ End of Life Care (EOL) EOL care includes ongoing pain & symptom management Reason for Referral □ EOL care exceed capacity of care at home □ Caregiver/s and/or support system inability to cope at home □ Individual does not wish to die at home □ (specify) ____________________________________ Most recent PPS Score: _____ date of last assessment_________ PPS Scores over last month________ ________ ________ _________ PPI Score:_______ (if available) Prognosis: < 1 month < 3 month < 6 months as determined by: Palliative Health Care Practitioner _______________________________ Prognosis Individual aware of: Diagnosis Prognosis Does not wish to know Family are aware of: Diagnosis Prognosis Does not wish to know If family is not aware, individual has given consent to inform family of: Diagnosis Yes No Prognosis Yes No (Patient Name/Label)
(Patient Name/Label) Palliative Care Hospice & In-Patient Referral Admission Location Requested: GRH Freeport-Kitchener SJHCG-Guelph GMCH-Fergus Lisaard House – Hospice Wellington-Guelph Referral Source: Facility / Community Agency: Designation: First Contact Person (Referral Source): Phone: ext: Pager: Fax: Second Contact Person (Referral Source): Phone: ext: Pager: Fax: Primary Palliative Diagnosis: Metastatic Spread (if malignant) Relevant Co-morbidities Reason for Referral □ Back Up Plan □ Uncontrolled Pain & Symptom Management □ End of Life Care (EOL) EOL care includes ongoing pain & symptom management □ EOL care exceed capacity of care at home □ Caregiver/s and/or support system inability to cope at home □ Individual does not wish to die at home □ (specify) ____________________________________ Prognosis Most recent PPS Score: _____ date of last assessment_________ PPS Scores over last month________ ________ ________ _________ PPI Score:_______ (if available) Prognosis: < 1 month < 3 month < 6 months as determined by: Palliative Health Care Practitioner _______________________________ Individual aware of: Diagnosis Prognosis Does not wish to know Family are aware of: Diagnosis Prognosis Does not wish to know If family is not aware, individual has given consent to inform family of: Diagnosis Yes No Prognosis Yes No (Patient Name/Label)
palliative_care_referral_final_ver_june_14_2011_2.docx