Referrers

Inpatient palliative care services include:

• Hospital Consult Services based at The Wollongong Hospital and Shoalhaven District Memorial Hospital. These services include in-reach consultation to patients in other hospitals including Bulli, Shellharbour, Coledale and Milton Ulladulla.
• Specialist Palliative Care Wards in Bulli District Hospital and David Berry Hospital.

Not all patients at end-of-life need to be seen by a palliative care medical specialist. Patients who are not distressed and are dying comfortably can be managed by their existing specialist teams.

Eligibility Criteria 

Eligibility for specialist palliative care services referral:   

• The patient has progressive, life limiting or life threatening disease (malignant and/or non-malignant) and any of the following:  

  • The patient has symptoms that require specialist assessment/ management and which are beyond the capacity of the treating team to manage optimally. 

  • The patient and/or their family have psychological, social or spiritual needs that require specialist assessment.  

  • The patient is dying, and the treating team requires additional support and/or advice.  

  • Assistance with end of life decision making (i.e. withdrawal of active treatment, artificial hydration etc.)   

Admission Criteria 

The Palliative Care Unit will provide specialist palliative care to people with care needs that cannot be met in their current place of care, whether home, RACF (Residential Aged Care Facilities) or another hospital setting.

This care may include: 

• Symptoms requiring specialist assessment and management 

• Complex end of life care 

• Complex psychosocial issues impacting on care 

• Care needs in the last days of life that cannot be met elsewhere 

Inclusion Criteria 

Patients must: 

• Be 18 years of age or older 

• Have a life limiting and progressive illness 

• Consent to admission (or person responsible must consent) 

• Be stable enough for transfer to the unit, and be expected to survive transfer 

• Be accepted for admission by a specialist palliative care consultant or designate 

Exclusion Criteria 

• Patients with palliative care needs that can be met in their current place of care. This includes patients at home, RACF, and other hospital settings/wards 

  • Patients who are in their last days of life without complicated symptoms are generally in this category 

• Patients with an expected prognosis of greater than two weeks and no specialist palliative needs (for whom alternative accommodation may be more appropriate, eg RACF). 

• Patients whose goals of care are discordant with palliative management  

  • For CPR

  • Escalation to ICU (Intensive care Unit)

  • Inotropic support

  • Ventilatory support / BiPAP / CPAP (except where on home ventilation or stable settings)

  • Patients receiving significant active intervention and reversal of acute illnesses, including patients on complex antibiotics, active intravenous chemotherapy

• Patients with complications of recent radiotherapy, chemotherapy or targeted therapy, (for instance, neutropaenic sepsis) 

• Patients requiring admission for management of chronic non-malignant pain 

• Patients with challenging behaviour outside of the terminal phase

• Patients admitted for the purpose of VAD (Voluntary Assisted Dying)

The Illawarra Shoalhaven Community Palliative Care Service supports the population from Helensburgh to North Durass in the south. The service operates out of community health centres across the district. 

The Community Palliative Care Service consists of multiple specialist care clinicians including Palliative Care Medical Specialists, Nurse Practitioners, Clinical Nurse Consultants, Clinical Nurse Specialists, Registered Nurses, Allied Health Clinicians, Allied Health Assistants, Senior Aboriginal Health Workers, Community Volunteers, and the specialist Bereavement Counselling service. 

The Service works with ISLHD Community Health Nurses and with external services such as General Practitioners, Pharmacies, Residential Aged Care Facilities (RACFs), Disability Supported Accommodation, Non-Government Organisations, Primary Health Network (Coordinare), NSW Ambulance and other agencies. 

Referral Criteria for the Community Palliative Care Service  

Patient must meet the primary criteria below: 

• People of all ages who have a life limiting illness with a poor prognosis 6 - 12 months with complex pain and symptoms related to their illness  

• People approaching a terminal phase that requires specialist palliative care input to ensure a safe and quality dying experience  

• People who are aware of what a palliative care referral involves and have given informed consent to service provision  

• People whose goals of care are for symptom control, pain management, and quality of life  

• People who are residing in the Illawarra / Shoalhaven Local Health District area or who are visiting the ISLHD for a short period eg. Holiday. 

Triggers for Referral  

The ‘surprise question’ is a screening tool that aims to identify people nearing their end of life. The question “Would you be surprised if this person was to die in the next 6-12 months?” can be used by the referrer to identify the correct timing of referral for people in the context of a life limiting illness.  

A person must meet the referral criteria above and two or more of the following criteria should also be present:   

• Irreversible deterioration and persistent symptoms despite optimal treatment   

• Unplanned hospital admissions (x 2 +)  

• Change in care needs that exceed the capacity of primary care team(s) or carers  

• Falls (two or more in last 6 months assessed using the FROP-COM Assessment)   

• Infections not responsive to interventions  

• Deteriorating function with weakness and fatigue (50% or more time spent in bed or chair)  

• Extreme frailty  

• Significant weight loss and not eating or drinking much  

• Impaired swallow and/or risk of aspiration  

• Increased dependence on others for physical, emotional and cognitive needs  

• Older patients (95+)  

• Patient and/or family requesting palliative care, treatment withdrawal/limits and a focus on quality of life and remaining at home 

Reasons for Referral  

• Complex pain/symptom control                                        

• Functional decline   

• End of life care in the home                                               

• Early referral for care needs in the context of a palliative illness 

Who is not eligible for referral?  

• People whose goals of care are for curative measures AND where treatment is for curative intent  

• People who do not have a life limiting illness   

• People who are not informed about palliative care and do not consent to a referral  

• People who do not live within the Illawarra Shoalhaven Local Health District  

• Patients who are referred for non-palliative pain management or early dementia management 

Who can refer?   

General Practitioners (GP), Medical Specialists or Palliative Care Nurse Practitioners (NP).  

 **Urgent referrals should be communicated via telephone in the first instance followed with relevant documentation** 

How to refer?  

All referrals are made via the ISLHD Access and Referral Centre (ARC) using the ISLHD Community Palliative Care Referral Form.  

Please email or fax referral directly to:

ARC on ISLHD-AccessandReferralCentre@health.nsw.gov.au or  

Fax: 02 4253 0355     

Tel: 1300 792 755 

If a referral has insufficient information to process, the referring practitioner will be notified of the need to provide additional information. If the additional information has not been received within 14 days, the referral is classed as “not accepted” and the medical practitioner will be notified by letter that the referral has not been processed.  

For a patient to continue to be seen after the initial referral period has expired, a continuation referral is required to maintain the episode of care. 

Not all patients referred to the specialist community palliative care team require input from the entire service and may be better suited for review by a specialist clinic, either medical, nursing, or allied health. If this is determined by the team, the community encounter will be closed and a referral to the appropriate clinic will be required. 

The Palliative Care Symptom Management Outpatient Clinic (SMOC) is available for patients who require symptom management or input from a Palliative Care Specialist Doctor, but do not require the support of the entire community service including nursing, allied health and volunteers in the home. 

Clinics are currently being run in the Illawarra area only.

Please email referrals to the Symptom Management Outpatient Clinic to:

islhd-aphc-symptommanagementoutpatientclinic@health.nsw.gov.au