Patient Referral Form

Hospice Care

Frequent hospitalizations and/or emergency department visits over the last six months
Declining functional status as determined by: dependence in 3 of 6 Activities of Daily Living (ADLs)
Patient chooses comfort care rather than curative treatment
Would you be surprised if the patient survived beyond 6 months?

Inpatient Services

Pain or symptom crisis not managed by changes in treatment in the current setting or that requires frequent medication adjustments and monitoring
Intractable nausea/vomiting
Advanced open wounds requiring changes in treatment and close monitoring
Unmanageable respiratory distress
Intractable delirium with behavior issues
Sudden decline necessitating intensive nursing intervention

Other services offered at Inpatient Centers

Rapidly progressing disease
Dyspnea at rest
Needs O2 at rest
Poor oral intake of food or fluid
Weight loss
Recurrent infection (such as pneumonia, pyelonephritis or sepsis) or recurrent fever after antibiotics
Decubitus ulcers
Vital capacity < 40% of normal
Desire not to be intubated
Desire not to be hospitalized
Other comorbid disease that may shorten survival
Difficulty with feeding, ambulation, continence, transfer, bathing, or dressing

Weight loss
Metastatic disease
Progression from an earlier stage despite therapy
Desire to no longer pursue curative treatment (palliative radiation may be continued)
Desire not to be hospitalized if the illness worsens
Other comorbid disease that may shorten survival
Difficulty with feeding, ambulation, continence, transfer, bathing, or dressing

Difficulty speaking intelligibly
Difficulty sitting up
Difficulty smiling or holding up the head
Decubitus ulcers
Infection during the past year (such as pneumonia, pyelonephritis or sepsis) or recurrent fever after antibiotics
Weight loss
Poor oral intake of food or fluid or dysphagia
Desire not to be hospitalized if the illness worsens
Other comorbid disease that may shorten survival
Difficulty with feeding, ambulation, continence, transfer, bathing, or dressing

CD4 count < 25 cells/mcL or viral load > 100,000 copies/mL
Weight loss
Debility
Chronic diarrhea
Serum albumin < 2.5 gm/dL
Antiretroviral therapy no longer effective or too toxic
Cancer such as CNS or systemic lymphoma, visceral Kaposi’s sarcoma
AIDS dementia or progressive multifocal leukoencephalopathy
Infection such as Mycobacterium avium complex bacteremia, toxoplasmosis, Cryptosporidium
Ongoing substance abuse
Other comorbid disease such as CHF, liver disease or renal failure that may shorten survival
Not to be hospitalized if the illness worsens
Difficulty with feeding, ambulation, continence, transfer, bathing, or dressing

Desire to stop or forego dialysis
Creatinine clearance < 15-20 cc/min orserum creatinine > 6 mg/dL
Cachexia or serum albumin < 3.5 gm/dL
Uremia
Hyperkalemia
Uremic pericarditis
Fluid overload or oliguria
Hepatorenal syndrome
GI bleeding, DIC or platelets < 25,000
Infection such as HIV or sepsis
Other comorbid disease such as heart, liver or chronic lung disease that may shorten survival
Desire not to be hospitalized if the illness worsens
Difficulty with feeding, ambulation, continence, transfer, bathing, or dressing

Weight loss
Serum albumin < 2.5 gm/dL
Dysphagia or aspiration
Poor intake of food or fluid
Infection (such as pneumonia, pyelonephritis, or sepsis) or recurrent fever after antibiotics
Decubitus ulcers
Large-volume hemorrhage, ventricular extension of hemorrhage, midline shift, or obstructive hydrocephalus by CT
Large infarcts
Basilar or bilateral vertebral artery occlusion
Other comorbid disease that may shorten survival
Desire not to be hospitalized if the illness worsens
Difficulty with feeding, ambulation, continence, transfer, bathing, or dressing

Two or more hospital admissions in the past year for chronic illness
Length of stay > 7 days without evidence of improvement
Patients with one or more visits per month to the Emergency Department for the same or similar diagnosis
Admission of 3 or more days to ICU in one hospitalization
Patients/families who would benefit from education and support regarding goals of care and medical decisions
Patients whose primary diagnosis is complicated by additional co-morbidities
Patients with multi-system organ failure
Patients with uncontrolled pain or symptoms such as nausea, vomiting, anxiety, constipation or depression associated with serious illness, such as cancer, COPD, CAD, CHF, renal disease, liver failure, advanced dementia or failure to thrive
Patients from long-term care facilities with multiple chronic conditions
Patients with neurological or neuromuscular diseases where feeding tubes are being considered
Patients with unexplained weight loss; increased fatigue; increasing need for assistance with Activities of Daily Living; frequent falls; declining mental status