Referral form
Refer a patient to the ISLHD Community Palliative Care Service
** Urgent referrals should be communicated via telephone in the first instance followed with relevant documentation. **
Referral Criteria for the Community Palliative Care Service
- 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 time 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.
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 in bed or chair).
- Extreme frailty
- Significant weight loss and not eating or drinking much.
- Impaired swallow, risk of aspiration
- Increased dependence on others for physical, emotional and cognition needs
- Older 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
Carer 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).
Referral information for Medical Officers, Referral to the Palliative Care Service must be completed by a medical officer. Referrals should ideally include:
- Patient information and consent to palliative care referral.
- Carer or 'person responsible' details.
- Diagnosis and date of diagnosis.
- Current medications, relevant scans and pathology reports.
- Summary of medical officers' concerns for patient, including concerns for carers.
How to refer?
All referrals are made via the ISLHD Access and Referral Centre (ARC) using the ISLHD Specialist Community Palliative Care Referral Form. Please email or fax referral directly to ARC on
ISLHD-AccessandReferralCentre@health.nsw.gov.au or Fax: 0242530355 Tel: 1300 792 755
NOTE: Further information is also available for medical officers on Health Pathways.