• For inpatient patients: Direct communication referring team and OSPG prior to discharge is mandatory. 

•  Life-limiting illness requiring symptom management or end of life care at home. PPS ≤ 70 or ECOG ≤ 2.   

•  Prognosis and referral to OSPG discussed and agreed upon by the patient and/or POA

• DNR signed by patient and/or POA. 

• Home and Community Care Support Services (previously LHIN) palliative care caseload arranged. 

• Signed MD referral form (Above): Information for direct contact of referring physician and billing number.

• Patient has either no GP or GP is unable to provide home palliative care (in select cases we will consider co-care)

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If available, please attached supporting documents with referral.

• Care protocols attached. e.g wound care, PICC line, drainage care (pleurX), symptom management kit

• Most recent consult/clinic notes, imaging, labs, medications/allergies. 

• Hospital discharge summary if available

Please print and fax referral form to 613-212-2238