This document is a referral form for the North Shore Palliative and Supportive Care Program at Lions Gate Hospital in Vancouver, Canada. It requests information about a patient being referred such as their name, PHN, DOB, diagnosis, prognosis, goals of care discussions, referring physician details, and clinical information. The form provides options to accept, hold, or reject the referral and includes space for comments.

1. Lions Gate Hospital
part of the Vancouver Coastal Health Authority
NORTH SHORE PALLIATIVE AND
SUPPORTIVE CARE PROGRAM
REFERRAL
For URGENT referrals, please call Palliative Physician On Call at 604 984 5738
NAME: PHN: DOB: SEX:
Patient Telephone: Patient Address:
LOCATION OF PT:  HOME  IN PT  UNIT:
DATE OF REFERRAL:
REFERRED BY: CONTACT NUMBER:
PATIENT AND/OR FAMILY AWARE OF REFERRAL?  Yes  No
DIAGNOSIS (Check all that apply)
METASTATIC CANCER Type:
CHF / COPD Severe disease or >2 Exacerbation hospital admissions in 365 days
ALS / MOTOR NEURON
At diagnosis or ASAP
DISEASE
Persistent vegetative state, post CVA dementia or no improvement in
CVA
3 months
No option or no choice for dialysis or transplant or severe
ENDSTAGE KIDNEY DISEASE
comorbidities
DEMENTIA / FRAILTY Palliative Performance Scale <50%
Reduced independence, swallowing problems, reduced drug
PARKINSONS
effectiveness
OTHER - please elaborate
COMMUNITY GP:  GP Will follow patient  Assign PC Physician
PROGNOSIS:  <1YR  <3 MONTHS  DAYS/WEEKS  IMMINENTLY TERMINAL
 NO CPR DISCUSSED?  ACCEPTED?  SIGNED?  IN PROCESS  NOT YET APPROPRIATE
 Palliative Benefits Application submitted?
SPECIFIC REFERRAL GOALS?
Please attach as much clinical information as possible including No CPR Form, Palliative Drug Benefits
forms if completed.
FAX REFERRAL TO LGH PCU AT 604 984 3798
NSPCP USE ONLY Assessed by: Date:  Accept  Hold  Reject
 Open HCN Comments:
VCH.CO.NSPSCP.0001 | FEB.2011