SPC referral form

Great Yarmouth & Waveney Specialist Palliative Care Team Referral Form

Referrals are accepted for patients over 18 years of age with a life limiting/progressive illness at any time following diagnoses and/or who have unresolved/complex symptoms/complex psychosocial/spiritual needs that cannot be met by the usual healthcare profession team. This may include complex family needs as well.

The patient needs to consent to the referral unless they do not have capacity to do so.

You can also contact the SPC team for advice, 7 days a week, 24 hours a day on 0800 567 0111.

The specialist palliative care nurses will triage all new referrals that are received. All triaged patients assessed to have a SPC need will have a specialist palliative care holistic needs assessment, in order to identify specialist needs. This will ensure that patients receive the appropriate care by the right professional.

Carer/ Next of kin details

Name of main carer/ Next of kin *

Relationship to patient *

Contact details *

Carer/ Next of kin address *

If the patient requires an interpreter, please specify language *

Advance care planning

Does the patient have an advance care plan document: If yes then which ones?

Preferred place of care Death CPR Status Advance decision to refuse treatment Other No Don't know

If yes where is the preferred place of care/ death:

Is the patient on the Gold Standards Framework Register:

Yes No

If yes please specify

Other professionals involved (name and telephone number)

Consultants

District/ Community Nurse

Clinical Nurse Specialist

Social Services

Referrers Details

Name of referrer

Designation

Department

E-Mail address

Contact number

Date of referral *