/ Electronic Palliative Care
Co-ordination System (EPaCCS) Patient/Client Referral Form
Patient Surname: / Patient First Name:
NHS Number: / Date of birth:

Core Information Requiredon Referral

Yes / No / Comments
Is the patient already on the end of life register?
Do you have verbal consent from the patient to add them or update them to the register? /
  • If no capacity to consent
  • consider best interest decision

If Person does not have Mental capacity when was a Best Interest decision made and by whom?
Date of Best Interest Decision: By Whom:
If the patient has declined consent have you informed them their demographic information will be captured, and the fact they have declined recorded so that they do not keep getting asked if they would like to be added to the register?
What is the patients’ diagnosis? (if unknown write reasons)
Where is the patients’ preferred place of death?
1st choice: 2nd choice:
Does the patient have a “preferred priorities of care document”? / If yes, please state where copies are kept:
Has someone been appointed lasting power of attorney for personal welfare?
With/Without authority to make life sustaining decisions / If yes state name and contact details:
Date of Best Interest Decision
By Whom
Does the patient have an advanced decision to refuse treatment (ADRT)? / If yes, please state where copies are kept:
Does the patient have a Treatment Escalation Plan (TEP)?* / If yes, please state where copies are kept:
.
Does the patient have ‘Just in case’ (JIC) medication in the house?
Is the patient and their main carer aware of the diagnosis?
What is the patient’s resuscitation status? / Please state:

Patient Status on admission to the registerRed □ Amber □ Green □

Red: Patient’s condition rapidly changing/deteriorating

There is a social crisis (carer breakdown)

Patient is in the dying phase

Amber: Patient’s need changing/condition deteriorating

Social situation has potential to breakdown

Discharged from alternative care within 2 weeks

Green: Patient will need palliative care but stable now

The patient has a stable social situation

Referred From:

Signature: / Date:
Print Full Name: / Band and Designation:
Care Setting/Service Name (e.g. care home name/ Community nurse locality) / Care setting/Service Address/Tel no:

*PLEASE NOTE TEP FORMS CAN BE SCANNED AND EMAILED TO DEVON DOCTORS TO BE UPLOADED TO EPACCS*

Version 1 21.06.17 Devon Drs EPaCCS Referral Documents

Fax: 01392823564 email: Tel: 01392 823157