Synopsis
Refer according to complexity and need rather than diagnosis or an arbitrary prognosis, explain the full range of hospice and specialist services, provide a decision-ready referral and maintain urgent and generalist care while specialist support is arranged.
- Hospice and specialist palliative care are for complex symptom, decision, psychosocial, spiritual and family needs; referral does not require cancer, imminent death or stopping active treatment.
- First-line referral assessment defines the unresolved problem, severity, trajectory, prior treatment, urgency, patient goals, capacity, communication needs, family situation and current clinical owner.
- Hospice care can include community teams, outpatient clinic, day services, rehabilitation, short respite, hospice-at-home, inpatient symptom control, last-days care and bereavement support.
- Generalist palliative care remains the responsibility of all clinicians; referral should add expertise rather than transfer every aspect of care or leave symptoms untreated while waiting.
- Refer urgently for uncontrolled pain or breathlessness, refractory agitation, complex medicine conversion, rapid deterioration, severe family conflict or a planned withdrawal of life-sustaining treatment.
- Use emergency services and disease-specific acute pathways for immediately life-threatening deterioration; a routine hospice referral is not a substitute for ABCDE care.
- A useful referral names the clinical question and includes current opioid and patch exposure, renal and liver function, allergies, swallow, performance, advance decisions and what has already been tried.
- Ask permission and explain what the service offers; avoid presenting hospice as a place to go only when treatment has failed or as a guaranteed inpatient bed.
- Service thresholds, geography, opening hours and inpatient criteria vary, so check the local pathway and create interim support if the preferred service cannot respond promptly.
- Review benefit and close the loop: confirm acceptance, triage time, responsible team and recommendations, then communicate changes to GP, pharmacy, nursing and out-of-hours records.
Key red flags
Severe uncontrolled pain, breathlessness, agitation or vomiting despite repeated rescue requires urgent reassessment, not routine waiting.
New weakness, retention, stridor, haemorrhage, shock or prolonged seizure follows an emergency pathway immediately.
Increasing sedation, myoclonus or hallucinations during opioid escalation suggests toxicity and requires urgent dose and organ review.
A planned withdrawal of ventilation or dialysis without specialist symptom preparation risks avoidable severe distress.
Serious patient-family-team disagreement needs early senior, ethics and sometimes legal support before crisis.
A rejected or unacknowledged referral with no interim clinical owner creates a dangerous responsibility gap.
Safeguarding, homelessness or inability to store medicine safely may make the assumed community plan unworkable.
Airway compromise, severe bleeding, new neurological deficit, sepsis, fracture or uncontrolled crisis needs urgent clinical treatment while specialist palliative help is contacted.
Investigation priorities
Define the unresolved symptom, decision, psychosocial, spiritual or family problem and what current clinicians have attempted.
Management branches
Complex need is present without immediate life-threatening deterioration.
- Explain specialist palliative and hospice options, obtain consent and identify the outcome the person wants from referral.
- Send a complete decision-ready referral with trajectory, treatments, medicines, organ function, goals, communication and family context and the explicit clinical question.
- Confirm receipt and timeframe, continue generalist care and communicate recommendations and ownership across all relevant teams.