Referring Source

Hamilton General Hospital  Henderson General Hospital  St. Joseph’s Hospital Date:______

MUMC/Chedoke McMaster  CCAC  Other(specify)______

Referral Contact: Phone- Ext. # Pager-
Referral Contact e-mail:
Alternate Contact: Phone- Ext. # Pager-

FAX Referral to: (905)-549-4030

Admitting and Health Information

St. Peter’s Hospital

88 Maplewood Avenue

Hamilton, Ontario L8M 1W9

Phone: 905-77PETES (777-3837)

ADMISSION DEMOGRAPHIC REFERRAL

Patient’s Personal Information

Last Name / First Name / Male 
Female 
Address / Apt. / City / Prov. / Postal Code
Home Telephone: / Present Location: / Date Admitted (dd/mm/yy)
Date of Birth (mm/dd/yy) / Age / Marital Status:  Single  Married/Partner
 Separated  Widowed  Divorced
Preferred Language: / Other Languages: / Religion:
Diagnosis:
Family Physician: / Phone: / Fax:
Consulting Physician: / Phone: / Fax:

Health Insurance Information

Is patient covered under Ontario Health Insurance Plan?  Yes  No If NO, indicate other health insurance plan: / Health Card Number:
/ / / / / / / / / / / Version
Code:

Contact Information

Next-of-Kin:
Relationship: / Power of Attorney:
 Personal Care  Financial
Address: / City: Province: Postal Code:
Telephone (home): ( ) / Telephone (work): ( ) Ext.
Primary Contact:
Relationship: / Power of Attorney:
 Personal Care  Financial
Address: / City: Province: Postal code:
Telephone (home): ( ) / Telephone (work): ( ) Ext.

Patient Name: ______

Clinical Alerts – Mandatory Section – Must be complete for processing
Allergies: No  Yes  Specify:
Diabetic: No  Yes  / CPR Status:  Full Code:  No Code  Not discussed:
Current Infections: MRSA: No  Yes  VRE: No  Yes  C-Diff: No  Yes  Other:
Site:______

GOALS OF ADMISSION (please check all that apply):

 Assessment and ongoing management of symptoms Caregiver relief

 Stabilization of symptoms with potential for discharge Management of the actively dying patient

Please describe goal(s) / patient & family expectations of admission: ______

______

______

______

______

Diagnosis &History of Disease (please include primary diagnosis, date of onset, treatment, metastases, secondary diagnoses and attach recentPatient History/Consultation Reports): ______

______

______

______

______

______

______

CLINICAL INFORMATION:

  1. Please describe current functional level: (Palliative Performance Scale (PPS) Level____% or N/A )

Key:I=independenceS=supervised no “hands-on” assistA=assist D=dependent on staff N/A

Function:Washing=_____Dressing=_____Feeding=_____Transfers=_____

Ambulation=_____W/C Mobility=_____Bladder=_____Bowel=______

Please describe any unique circumstances / equipment / supplies required:______

  1. Symptoms (check all that apply):

 Pain Nausea/Vomiting  Dyspnea

 Confusion/Restlessness  Nutritional needs Skin Issues

Please describe symptom(s): ______

______

______

Patient Name: ______

  1. Behaviours (check all that apply):

 Wandering Exit seeking Bed exiting

 Aggression Noise Making Restraints

Please describe behaviour(s): ______

______

______

  1. Special Treatment & Equipment Needs (check all that apply):

 I.V. Central Line Oxygen Isolation Room Tracheotomy

 I.V. Peripheral Line Suction Specialty Mattress Ostomy

 Pain pump Bipap Enteral Feed Catheter

 Blood Transfusions CPAP TPN Communication Device

 Other (e.g. special call bell, specialty wound care / dressings, etc.)

Please describe all specialty needs: ______

______

______

  1. Medications- including dosages (please write below or attach list): ______

________

______

______

________

______

Follow-up appointments and/or procedures and tests: ______

______

______

Additional Comments: ______

______

______

NAME & POSITION OF PERSON COMPLETING REFERRAL: ______

Agency: ______Date: _________

Contact Numbers: ______

Attach recent Patient History/Consultation Reports

Attach recent Edmonton Symptom Assessment Scale (ESAS) if available

#of additional pages = ______

Patient Name: ______

Information Sheet for Patients / Families Referred to the

Palliative Care Program at St. Peter’s Hospital

St. Peter's Palliative Care Program provides in-patient beds for terminally ill patients who are in the final stages of their illness. Members of the Palliative Care team provide skilled, comprehensive and compassionate care for the dying and their families. Care focuses on maintaining the quality of life, comfort, autonomy and dignity of each patient through the assessment and management of potentially distressing symptoms.

Palliative Care:

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  • Affirms life
  • Regards life and dying as a normal process
  • Provides relief from pain and other distressing symptoms
  • Supports the spiritual needs of the patient
  • Offers a support system to help patients live as actively as possible until death
  • Offers a support system to help the family cope during the patient’s illness and in their bereavement

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People Admitted to the Palliative Care Program include those who:

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  • Are in the final stages of a life threatening illness
  • Have a life expectancy ranging from several hours up to 12 months duration
  • Require the expertise of an on-site palliative care interdisciplinary team for the management of pain and other troubling issues
  • Have goals of care promoting a comfort approach rather than aggressive treatment
  • Have care needs that cannot be met at home or in another setting with the available resources
  • Do not require day-to-day services of an acute care hospital
  • Are aged 18 years or older

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CPR Code Status:

Generally, patients who are referred to a Palliative Care Program are expected to die from their primary diagnosis in the foreseeable future. They are considered very poor candidates for Cardiopulmonary Resuscitation (CPR) and placement on a ventilator. The majority of patients referred to this program have a “Do Not Resuscitate Order” (often called a “No Code Order”). St. Peter’s Hospital is a ComplexContinuingCareHospital (often referred to as a ChronicCareHospital). We are not an Acute Care Facility, so there is no on-site Emergency Department or Intensive Care Unit.

If you wish to receive CPR in the event of an arrest, St. Peter’s Hospital can only provide the following:

Basic Life Support Procedures at St. Peter’s

  • CPR is attempted with in-patients only if the collapse is witnessed
  • Basic Life Support (BLS) procedures involve bag-mask ventilation and chest compressions
  • 911 is called and BLS procedures are maintained until the arrival of Emergency Medical Services (EMS) personnel and ambulance
  • EMS takes control of the scene and transports the patient to an acute care facility if vital signs are present

Referral Source – This section must be completed and accompany the referral:

 I have reviewed the above information with ______(patient name) and/or ______(SDM name).

 This patient is: “No Code” for CPR_____“Full Code” for CPR_____*

 I have given the patient / family a copy of this information sheet.

Form Completed By:______(print)______(sign)

Profession:______Date:______

*Patients wishing a Full Code Status will require a review by one of our physicians prior to acceptance to the Program waiting list.

February 2008

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