East Cheshire NHS Trust
MACMILLAN SPECIALIST PALLIATIVE CARE TEAM
REFERRAL FORM AND CRITERIA
Referrals should only be made to the Macmillan Service for patients with existing complex
needs, over and above that which should be provided by the key worker.
Face to face contact by the Macmillan Nurse may not always be required, please ring for advice if
unsure on 01606 544155 (answer phone service). Telephone advice to the key worker may be
sufficient without the need for a full referral
Referrals should ONLY be made:

If the patient consents to referral to the Macmillan Service *

For patients who are aware of their diagnosis *

For patients with a diagnosis of cancer or life limiting illness who have problems with pain
or other uncontrolled symptoms that have not responded to first-line interventions

For patients with complex social, psychological or spiritual needs over and above those
that the key worker can provide
* unless a patient has a mental health issue which affects their awareness (please give details).
When the referral is received, the patient will be allocated to a nurse who will make contact with
the patient. Once the patient’s problems have been resolved they will be discharged back to the
key worker for ongoing supportive care.
The Referral form will require the completion of the Palliative Performance Indicator (PPI)
– a performance and prognostic indicator. This is in line with the NHS National End of Life
Care Programme. Guidance can be found at the end of the referral form.
Reasons for referral should be one of the following – in conjunction with the
criteria outlined above




Complex psychological support at diagnosis or recurrence
Complex symptom control / management
Palliative care only
Financial Advice (alongside any of the above)
This referral form has been disseminated in a form integrated into patient administration systems;
EMIS and VISION.
PLEASE NOTE: Any form that is incomplete will be returned to the referrer causing a delay in the patient being
contacted. If a referral is deemed to be urgent please complete form, but also contact office to discuss reasons
for urgency. Additional referral information and guidelines are available on the intranet.
Community Macmillan Nurses Referral Form [April 2011] v1
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East Cheshire NHS Trust
COMMUNITY MACMILLAN REFERRAL FORM
PLEASE COMPLETE ALL THE QUESTIONS CLEARLY, IN FULL AND SEND TO COMMUNITY
MACMILLAN NURSES AT ST. LUKE’S HOSPICE, QUEENSWAY, WINSFORD, CHESHIRE, CW7 1BH.
TELEPHONE 01606 544155 - FAX NUMBER 01606 861912
Referrals should ONLY be made for patients whose complex needs
CANNOT be managed by other primary healthcare professionals.
REFERRAL DATE:________________________
NHS NO:________________________________
REGISTERED GP: ________________________
SURGERY: _____________________________
TEL NO: _______________________________
DATE OF BIRTH: _________________________
CONSULTANT/S:_________________________
PATIENT SURNAME:_____________________
FORENAME(S): __________________________
HOSPITAL:______________________________
TEL NO: ________________________________
KNOWN AS: _____________________________
MAIN LANGUAGE:________________________
ADDRESS:______________________________
ETHNICITY: _____________________________
_______________________________________
NEXT OF KIN (include first name):
_______________________________________
_______________________________________
_______________POST CODE _____________
RELATIONSHIP to PATIENT:
TEL NOs: _______________________________
_______________________________________
_______________________________________
ADDRESS:______________________________
_______________________________________
OCCUPATION:___________________________
MARITAL STATUS: _______________________
___________________ POST CODE ________
TEL NO ________________________________
RELIGION: ______________________________
REASON FOR REFERRAL(please refer to referral criteria and give details)
___________________________________________________________________________________
___________________________________________________________________________________
___________________________________________________________________________________
___________________________________________________________________________________
CONFIRMED DIAGNOSIS Please supply additional information with (if available) scan results, letters etc
SITE of PRIMARY:
_______________________________________________________________________
SITE(S) OF METASTASES _______________________________________________________________________________
PAST TREATMENT: SURGERY _______________ CHEMOTHERAPY _______________ RADIOTHERAPY ___________
Community Macmillan Nurses Referral Form [April 2011] v1
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East Cheshire NHS Trust
Patient Name: _____________________________________
NHS NO: _____________________________
IS THE PATIENT AWARE OF:
DIAGNOSIS ________
PROGNOSIS ________
REFERRAL _____________
IS THE RELATIVE AWARE OF:
DIAGNOSIS ________
PROGNOSIS ________
REFERRAL _____________
If unaware of above please give further details:________________________________________________________________
______________________________________________________________________________________________________
_____________________________________________________________________________________________________
Palliative Performance
Index Score
Please detail current physical condition (include performance status score)
__________________________________________________________________
_______________________________________________________________________________
(out of 15)
___________________________________________________________________________________________
(Please tick if applicable) Pain_____ Nausea_____ Constipation_____ Breathlessness_____ Agitation____
Co existing medical conditions_____________________________________________________________
___________________________________________________________________________________________
___________________________________________________________________________________________
Current Drugs and Doses: ______________________________________________________________________
___________________________________________________________________________________________
___________________________________________________________________________________________
Psycho-Social and Spiritual Information_________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
___________________________________________________________________________________________
Any RISKS associated with Home Visits: __________________________________________________________
___________________________________________________________________________________________
Other Services Involved with Patient:
Social Services
Home Care
District Nurses
Hospital Macmillan
Site Specific Specialist
Other support
Details:___________________________________________________________________________________
__________________________________________________________________________________________
REFERRED BY: (Print name) ________________________________ STATUS:________________________
FULL TEL. NUMBER (in case of query)_____________________________ FAX: ______________________
Community Macmillan Nurses Referral Form [April 2011] v1
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East Cheshire NHS Trust
Patient Name: ___________________________________________
NHS NO: ________________________
Performance Indicator tool for Community Macmillan Nurse Referral
First determine the Palliative Performance Scale (PPS), using table below.
PPS
Level
Ambulation
100%
Full
90%
Full
80%
Full
70%
Reduced
60%
Reduced
50%
Mainly Sit /
Lie
40%
Mainly in Bed
30%
20%
10%
Activity & Evidence of
Disease
Totally Bed
Bound
Totally Bed
Bound
Totally Bed
Bound
Normal activity & work
No evidence of disease
Normal activity & work
Some evidence of disease
Normal activity with Effort
Some evidence of disease
Unable Normal Job/Work
Significant disease
Unable hobby/house work
Significant disease
Unable to do any work
Extensive disease
Unable to do most activity
Extensive disease
Unable to do any activity
Extensive disease
Unable to do any activity
Extensive disease
Unable to do any activity
Extensive disease
Death
-
0%
Palliative Performance Scale
Performance Indicator (below).
Self-Care
Intake
Conscious
Level
Full
Normal
Full
Full
Normal
Full
Full
Full
Occasional assistance
necessary
Considerable
assistance
required
Mainly assistance
Total Care
Total Care
Total Care
Normal or
reduced
Normal or
Reduced
Normal or
Reduced
Normal or
Reduced
Normal or
Reduced
Normal or
Reduced
Minimal to
Sips
Mouth care
only
Full
or Confusion
Full
or Confusion
Full or Drowsy
+/- Confusion
Full or Drowsy
+/- Confusion
Full or Drowsy
+/- Confusion
Drowsy or Coma
+/- Confusion
-
-
-
%
Full
Full
is then used when calculating the Palliative
This score, when combined with clinical symptoms - oral intake, oedema, dyspnoea at rest and delirium
provides a valuable prognostic indicator. If the PPI is greater than 6.0, survival is likely to be less than
three weeks.
Palliative Performance Index (PPI)
Palliative
Performance
Scale (%)
Oral Intake
Oedema
Dyspnoea at
rest
Delirium
10 or 20
30 or 40 or 50 or 60
70+
Severely reduced (less than mouthfuls)
Moderately reduced (mouthfuls)
Normal
Present
Absent
Present
Absent
Present
Absent
PPI
score
4.0
2.5
0
2.5
1.0
0
1.0
0
3.5
0
4.0
0
Total
Maximum
Possible
Patient’s
Score
4.0
2.5
1.0
3.5
4.0
15
This Palliative Performance Index score should then be recorded in the Referral Form
Community Macmillan Nurses Referral Form [April 2011] v1
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(This page is for your information only. It is not part of the referral form
and does not need to be sent back to us)
Instructions for Use of PPS.
1. PPS scores are determined by reading horizontally at each level to find a ‘best fit’ for the
patient which is then assigned as the PPS% score.
2. Begin at the left column and read downwards until the appropriate ambulation level is reached,
then read across to the next column and downwards again until the activity/evidence of disease
is located. These steps are repeated until all five columns are covered before assigning the
actual PPS for that patient. In this way, ‘leftward’ columns (columns to the left of any specific
column) are ‘stronger’ determinants and generally take precedence over others.
Example 1: A patient who spends the majority of the day sitting or lying down due to fatigue
from advanced disease and requires considerable assistance to walk even for short
distances but who is otherwise fully conscious level with good intake would be scored
at PPS 50%.
Example 2: A patient who has become paralyzed and quadriplegic requiring total care would
be PPS 30%. Although this patient may be placed in a wheelchair (and perhaps
seem initially to be at 50%), the score is 30% because he or she would be otherwise
totally bed bound due to the disease or complication if it were not for caregivers
providing total care including lift/transfer. The patient may have normal intake and full
conscious level.
Example 3: However, if the patient in example 2 was paraplegic and bed bound but still able
to do some self-care such as feeding themselves, then the PPS would be higher at
40 or 50% since he or she is not ‘total care.’
3. PPS scores are in 10% increments only. Sometimes, there are several columns easily placed
at one level but one or two which seem better at a higher or lower level. One then needs to make
a ‘best fit’ decision. Choosing a ‘half-fit’ value of PPS 45%, for example, is not correct. The
combination of clinical judgment and ‘leftward precedence’ is used to determine whether 40% or
50% is the more accurate score for that patient.
4. PPS may be used for several purposes. First, it is an excellent communication tool for quickly
describing a patient’s current functional level. Second, it may have value in criteria for workload
assessment or other measurements and comparisons. Finally, it appears to have prognostic
value.
Copyright © 2001 Victoria Hospice Society
For further guidance on prognostic scores see:Gold Standards Framework Site – Prognostic Indicator Guidance
http://www.goldstandardsframework.nhs.uk/Resources/Gold%20Standards%20Framework/PIG%
20Paper%20v33%20Sept%2008.pdf
This referral form has been disseminated to GP practices in a form integrated into patient
administration systems; EMIS and VISION.
Community Macmillan Nurses Referral Form [April 2011] v1
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