Ambulance Wish Referral Form

Ambulance Wish Referral Form

Ambulance Wish Referral Form

The form is 2 pages long and will take 10-15 minutes to complete.
Who is Referring the person?
Patient Information
Name

First NameLast Name
Date of Birth

DayMonthYear
Date
NHS Number
Patient Diagnosis
Home Address

Street Address

Street Address Line 2

CityCounty

Post Code
Current Location if not home
Patients or Family Contact Number
About the Wish
What would the patient like to do?
Why would they like to do this?
Location of the Wish including postcode
How long will the wish last? (Approximately)
Any escorts travelling with patient (family member, friend, partner etc)
We can take one person as routine but discussion is required on needing 2. Max of 2 escorts due to weight limits and space.
Medical Information
Lead Clinicians Name (GP or Consultant)

First NameLast Name
Email for Clinicians Name
Hospice or Community Palliative Care Team Contact Details
Does the patient have the mobility to complete the journey without ambulance assistance?
What is the Goal of palliation of symptoms?
Patient aware of goal of care?
Family aware of goal of care?

Other
Patient's prognosis considered < 4 weeks
Patient's prognosis considered 12 Months - 1 Month?
Has a DNACPR form has been completed?

Other
Has a RESPECT form has been completed?

Other
Current mobility. When planning a wish we need to assess access. Is the patient...

Other
Current mobility. How does the patient transfer

Other
Patients Weight (KG)
Please list any medications that the patient may require during the wish, including route of administration. This enables us to identify the grade of volunteer ambulance clinician needed. (With regards to analgesia, please consider if what they are taking now when in a comfortable environment will be as effective when out on the wish i.e. the ambulance journey can be bumpy, The movement of stretcher/wheelchair over bumps or uneven surfaces etc)
Is the patient likely to require the use of suction?

Other
Does the patient have a tracheostomy?

Other
Please list any possible complications when moving the patient such as pathological fracture, cord compression, c-spine instability.
Is the patient infectious?

Other
To help us plan any toileting requirements during the wish, please tell us if the patient has a catheter, stoma, wears pads etc. Or, if the patient uses the toilet, are they able to weight bear to transfer from stretcher/wheelchair onto the toilet?
Is the patient for escalation of care?

YES (explain)
Instruction should patient become unwell during journey (e.g. return home/ to place of care/ hospital etc )
Instruction should patient die during journey (e.g. return home/ to place of care )

Closing Questions
Can the Wish trip be posted that it is taking place without reviling the patients identity?

Other
Can Photos be taken for a wish memory book?
Any other information?
Helpful Information

Cancelof
Completion of the Form

The information provided in this form must be completed accurately and to the best of your ability. Any incomplete or inaccurate information may result in delays to the wish and its associated process.
Person completing the form

First NameLast Name
Role
Email Address
Phone number
Signature
Should be Empty: