Health professional referral - Katharine House Hospice

Step 1 of 7 - Introduction

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This field is for validation purposes and should be left unchanged.

To talk to us about the referral please call the Patient Pathway team on 01785 270832 — 09:00–17:00 Mon–Fri.

For out of hours support, please call the 24/7 Palliative Care Advice Line on 01785 270832.

To refer to Hospice at Home call 07966 502551 between 8:00–17:00 Mon – Fri.

For out of hours Hospice at Home referrals call 07966 502551 between 17:00 - 20:00 Mon - Friday and 8:00 - 20:00 Saturday and Sunday.

Complete as much of this form as possible to help us prioritise and allocate care based on patient needs.

SECTION 01 Consent, Capacity & Awareness

Before completing this referral: Prior to referral, patients with mental capacity must consent. For patients who lack mental capacity, a decision to refer must be made in the patient's best interests and where applicable a Lasting Power of Attorney (LPA) or Independent Mental Capacity Advocate (IMCA) should be involved.

Patient is aware of…

This referral(Required)

Yes

Their diagnosis(Required)

Yes

Their prognosis(Required)

Yes

If No to any of the above — please give more detail

SECTION 02 Service Required

Please indicate which service is required(Required)

Palliative Care Nurse Specialists (Community)

Inpatient

Outpatient

Family Support Services

Lymphoedema

Hospice at Home

Out-of-hours Hospice at Home referrals: call 07966 502551 Mon–Fri 17:00–20:00 | Sat–Sun 08:00–20:00

This referral will undergo an assessment process. If the referral is urgent please ring the palliative care advice line: 01785 270832

Katharine House Hospice Inpatient Unit is a SHORT STAY UNIT. If the patient has had their immediate palliative care needs fully met by the hospice it may be necessary to discharge them for onwards care either into their own home (with a suitable care package if required) or into a long term care facility such as a nursing home.

Reason for referral(Required)

Pain / Symptom Control

End of Life Care

Assessment

Emotional / Psychological Support

Bereavement

Carer Support

Further details (e.g. who has passed away, diagnosis or prognosis)

Is the patient likely to die in the next 24 hours?(Required)

Yes

Is the patient likely to die within the next week?(Required)

Yes

SECTION 03 Patient Details

First name(Required)

Surname(Required)

Date of birth(Required)

NHS number

10-digit number (no spaces or dashes)

GP practice(Required)

SECTION 04 Patient Location & Preferences

Is the patient able to attend our Therapy & Wellbeing Centre in person?(Required)

Yes

Patients must be able to attend our Therapy & Wellbeing Centre in person. If the patient is not able to attend they will be triaged and signposted to appropriate support.

Patient's current location(Required)

Home

Hospital

Hospital & ward(Required)

If different from address above, please give home address

Next of kin

Relationship to patient

Telephone

Is the patient known to a Community Nursing Team (District Nurse)?

Yes

If unknown, please leave blank.

Community Nursing Team Name

Based at

Telephone number

Please consider making a referral to the Community Nursing Team in addition to this referral.

SECTION 05 Diagnosis & Clinical Information

If this patient has NOT been under the care of University Hospital of North Midlands, please attach any recent scans, blood results and clinic letters when submitting.

Attach supporting documents

Drop files here or

Accepted file types: pdf, jpg, jpeg, png, doc, docx, Max. file size: 15 MB, Max. files: 5.

Current diagnosis(Required)

Relevant past medical history

Troublesome symptoms at present(Required)

Pain

Breathlessness

Anxiety

Nausea and/or vomiting

Agitation

Other (please specify)

Troublesome symptoms at present(Required)

Pain

Breathlessness

Anxiety

Nausea and/or vomiting

Other (please specify)

Please specify other symptoms(Required)

Summary & steps already taken to address symptoms / issues(Required)

Prognosis

Days

Weeks

Months +

ReSPECT in place

Yes

Recommended Summary Plan for Emergency Care and Treatment

DNAR in place

Yes

Do Not Attempt Cardiopulmonary Resuscitation

Please attach current medications list, recent investigation results and recent hospital letters with this referral.

Allergies

Medications

Does the patient require any bariatric equipment?

Yes

Please specify equipment required(Required)

Mobility

Independent

Mobility Aids / Carer Support

Wheelchair

Bedbound

Note: Bedbound patients are not suitable for Outpatient referral.

Does the patient have a current infection?

Yes

Please provide details (e.g. MRSA / Covid / C. Diff / ESBL)(Required)

Does this patient have any pressure ulcers?

Yes

Unknown

Has a Safeguarding been raised?(Required)

Yes

Date of Safeguarding referral(Required)

Safeguarding reference number(Required)

Any other comments / other information

SECTION 06 Referrer Details

Name(Required)

Contact No(Required)

Email(Required)

Job title

Ext / Bleep

Date

Surgery / Hospital / Organisation

Organisation(Required)

Community Nursing Team

Clinical Nurse Specialist (CNS)

Hospital

Other

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SECTION 01 Consent, Capacity & Awareness

Patient is aware of…

SECTION 02 Service Required

SECTION 03 Patient Details

SECTION 04 Patient Location & Preferences

SECTION 05 Diagnosis & Clinical Information

SECTION 06 Referrer Details