Making a referral for adult community specialist palliative care

Registered with a NWL GP and living within north west London

Aged 18 years or over

Diagnosis of advanced, progressive, life-limiting illness - usually an illness that worsens over time and has no cure or  considerable uncertainty regarding potential for recovery.

All end-stage conditions, including but not limited to: cancer, motor neurone disease, Parkinson’s disease, dementia, multiple sclerosis, chronic obstructive pulmonary disease (COPD), heart failure, kidney failure, lung disease, advanced liver disease, and HIV/AIDS.

Complex symptoms or circumstances requiring expert management and specialised palliative care input*.

Needs might be physical, social and/or spiritual and could include:

• Symptom control - e.g. pain, breathlessness

• Psychological, emotional and spiritual support

• Carer or social issues

• Complex grief, e.g. young families

• Complex decision making and advance care planning

These needs can no longer be met by regular care teams in the community or primary care alone i.e. unpaid carer, district nurses, GPs, hospice at home, social care package, or continuing health care. Input is required from palliative care specialists for shared care of the patient.

Consent for referral gained from patient or best interest decision made

Meets all core criteria for CSPC services

The patient must reside in the borough that the provider serves. The patient must also be registered with a NW London GP.

Meets all core criteria for CSPC services

Meets all core criteria for CSPC services

Expected prognosis of less than 6 months

The patient must reside in the borough that the provider serves. The patient must also be registered with a NW London GP.

Requires additional support for up to two weeks for crisis management or care in the last days of life

Meets all core criteria for CSPC services

Requires daily input from specialist palliative care consultant and wider MDT

Requires admission for one of the following reasons:

• Symptom control for complex symptoms that are unmanageable in usual place of residence.

• Rehabilitation for patients needing specialist physical, psychological, and spiritual support after palliative care treatments.

• Respite - Short-term in-patient stays for patients with very complex specialist palliative care needs to support their carers who require a break and where other community respite options are not appropriate.

• Specialist end-of-life terminal care for patients in the advanced stages of a terminal illness.

Requires more intensive support that can be offered in the community which is not expected to exceed two weeks OR cannot or does not want to receive care at home or in outpatient clinics due to medical needs, social circumstances, or lack of necessary equipment.

Meets all core criteria for CSPC services

Expected life expectancy of around 3 months

Likely to need 24/7 bedded care for longer than 2 weeks

Requires weekly input from specialist palliative care consultant and wider MDT

Cannot or does not want to receive care at home or in outpatient clinics due to medical needs, social circumstances or suitability of home environment, or lack of necessary equipment

Meets all core criteria for CSPC services

Meets all core criteria for CSPC services

Has primary or secondary lymphoedema, regardless of underlying cause

Meets all core criteria for CSPC services or is the family member or carer of a patient who meets the core criteria.