Referral to Te Kahi Pairuri Hospice Taranaki Specialist Palliative Care Services

Please ensure this referral is fully completed as delays may result if incomplete.
You are able to type over the greyed-out areas. Please add more paper if necessary.

Where Hospice Service Input Required	Urgency for either service
☐	Community	☐	Urgent Within 24 hours
(Community, including aged residential care and other facilities)	☐	24-72 hours
☐	Hospital inpatient	☐	Non-urgent
Email all referrals to: hospicereferrals@hospicetaranaki.org.nz please call 067537830 for urgent referral

Reason for referral: (please ): referral may be appropriate if the patient has active, progressive, advanced disease and the level of palliative care need exceeds that which the current provider can offer.
☐	Uncontrolled or complicated symptoms	☐	Last days of life support: patient, family/whānau/staff/ facility
☐	Emotional, psychological, or existential issues related to the illness	☐	Other: Click to enter text.

Patient aware of diagnosis	☐ Yes | ☐ No	Patient/advocate consents to referral	☐ Yes | ☐ No
Patient aware of prognosis	☐ Yes | ☐ No	Family/whanau /NOK aware of referral	☐ Yes | ☐ No

Patient details / Patient label DOB: Click to type DOB	Patient NHI:	Patient NHI
Surname:	Click to enter Patient Surname.	First Name/s: Click to enter Patient First Name.
Address: Click to enter Address.
Current location: Click to enter Location.	Contact Phone Number: Click to enter Phone No.

Usual accommodation:	Level of current support (select one):
☐Private residence (incl. retirement village)	☐Lives with others with no care/support provided
☐Residential aged care, low level of care (level 2)	☐Lives alone with no care/support provided
☐Residential aged care, high level of care (hospital)	☐Lives alone with external professional support
☐Other: Click or tap here to enter text. ☐Risk to Staff (if any, please describe): Click or tap here to enter text.	☐Lives with others who provide care/support
☐Lives with others with external support
☐Not stated/inadequately described/Not applicable.
Next of kin/ contact persons details:
Surname: Click to enter Surname.	First name/s: Click to enter First Name/s.
Address: Click to enter Address.
Phone number: Click to enter Phone No	Relationship: Click to enter Relationship.
EPOA (Health and/or Finance) in Place? ☐ Yes | ☐ No	Name of EPOA: Click enter name.
Health Professional details:
GP: Click to enter GP Clinic / Name.	Consultant: Click to enter Consultant Name.
Address: Click to enter Health Professional’s Address.
Disease Status:
Diagnosis: Click or tap here to enter text.	Date of Diagnosis: Click to enter Date of Diagnosi.s
Past/current management of this diagnosis (including date of any major surgery in past year): Click or tap here to enter text.
Site of Metastasis (if malignancy): Click to enter details.
Past medical history: Click to enter details.
Current Medications: (please add more paper, if required) Click or tap here to enter text. Use additional sheets, if needed.	Allergies/Adverse Drug reactions: Click to enter. Use additional sheets, if needed.
Current issues requiring specialist palliative care:
Uncontrolled physical symptoms: Click to enter details. Psychological issues: Click to enter details. Family social circumstances: Click to enter details. Additional relevant Information (e.g., barriers to communication – language/ hearing): Click to enter details.
For community patients: Please supply the most recent hospital or OPD letters/discharge summaries. ☐ Attached ☐ Not available. Date of last medical Consultation: Click to enter date of last medical consultation.
Community Patients	Hospital Inpatients
Name of referring Dr or NP: Click to enter name.	Name of referring Dr or NP: Click to enter name.
GP Practice: Click to enter GP Practice.	Name of Consultant: Click to enter name.
Contact phone number. Click to enter Ph.	Hospital clinic/specialty: Click to enter details.
Registration No: Click to enter Reg No.	Registration No: Click to enter Reg No.
Date: Click to enter Referral Date.	Date: Click to enter Referral Date.

Please ensure this referral is fully completed as delays may result if incomplete.

GENERAL REFERRAL CRITERIA FOR ACCEPTANCE BY TE KAHU PAIRURI HOSPICE TARANAKI INC.

All referrals must meet All of these criteria:

Must be a resident of Taranaki or a visitor to the region and registered with another hospice service.

The patient has documented active, progressive and advanced disease; prognosis is limited to less than 12 months despite optimal tolerated therapy.

The focus of care is quality of life.

The patient has an extraordinary level of need (physical, psychological, spiritual) that exceeds the resources of the primary palliative care provider.

Patient consents to the referral but if incompetent to do so, an advocate or nominated EPOA for the patient agrees.

Hospice Taranaki uses the Gold Standards Framework: Proactive Indicator Guidance to assess patients for acceptance into the service. Referrers can access this information at http://www.goldstandardsframework.org.uk **If the patient does not meet these criteria and is in serious need, please discuss with the hospice team.

Performance status is an important predictor of survival. Pre-existing disease, prior treatment, psychological status and social support may affect the length of survival in a terminal illness.

Karnofsky Performance Scale (KPS)

%	Criteria
100	Normal; no complaints; no evidence of disease
90	Able to carry out normal activity; minor signs or symptoms of disease
80	Normal activity with effort; some signs of symptoms of disease
70	Cares for self; unable to carry on normal activity or do active work
60	Requires occasional assistance, but is able to care for most of his/her needs
50	Requires considerable assistance and frequent medical care
40	Disabled; requires special care and assistance
30	Severely disabled; hospitalisation is indicated although death is not imminent
20	Very sick; hospitalisation necessary, active supportive treatment necessary
10	Moribund; fatal processes progressing rapidly
0	Dead

The Palliative Performance Scale (PPS) is a modification of the Karnofsky Performance Scale (KPS) designed specifically for measurement of physical status in palliative care.

Palliative Performance Scale (PPS)

%	Ambulation	Activity and Evidence of Disease	Self-care	Intake	Level of consciousness
100	Full	Normal activity, no evidence of disease	Full	Normal	full
90	Full	Normal activity, some evidence of disease	Full	Normal	Full
80	Full	Normal activity with effort, some evidence of disease	Full	Normal or reduced	Full
70	Reduced	Unable to do normal job/work	Full	Normal or reduced	full
60	Reduced	Unable to do hobby/housework, significant disease	Occasional assistance	Normal or reduced	Full or confusion
50	Mainly sit/lie	Unable to do any work, extensive disease	Considerable assistance required	Normal or reduced	Full or confusion
40	Mainly in bed	As above	Mainly assistance	Normal or reduced	Full or drowsy or confusion
30	Bedbound	As above	Total care	Reduced	Full or drowsy or confusion
20	As above	As above	Total care	Minimal sips	Full or drowsy or confusion
10	As above	As above	Total care	Mouth care	Drowsy or coma
0	Death	-	-	-	-