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Palliative and End of Life Care Referral Form

All sections of this form must be completed to ensure that the process is not slowed down by services having to check details with the referrer.

Patient Details - Step 1 of 11
Patient Name
Address

For urgent same day response referrals please telephone: Community services Team – 024 7686 5441

Criteria for Referral: The patient has a diagnosis of advancing life limiting illness and

  • Symptom control or other complex problems, which are escalating or are unable to be managed by the current clinical team. These symptoms may be physical, psychological, spiritual, social, or family and carer orientated issues.
  • Complex social needs resulting from their illness or whose families show exceptional emotional distress.
  • Prior to referral patients with capacity must consent. Referral must be judged to be in the best interests of patients who lack capacity.