Share a Case

If you are able to support Palliative Care ECHO by sharing a case or issue for discussion, we would love to hear from you. Cases may be submitted using the form below. The form is a guide only to help provide information.  You do not need to complete all fields/ respond to each question.

If you have any questions, please get in touch via the Contact Us page.

To fill out this form offline, download the case discussion template.

Please remember to de-identify all patient information.

Site Name *

Case Presenter Name *

Case Presenter Phone

Case Presenter Email *

Has there been any communication with a specialist palliative care team for this person? *

• Yes
• No

Why is the case being presented?

Summary paragraph and Issues list

Patient Age

Patient Gender

• M
• F
• Non-Binary

Patient Identified As

• Aboriginal Person
• Torres Strait Islander Person
• Both
• Neither

Current Place of Care

• Hospital
• Nursing Home
• Community

Primary Diagnosis: Relevant physical symptom issues

Primary Diagnosis: Past treatment

Primary Diagnosis: Current treatment

Primary Diagnosis: Planned treatment

Relevant Comorbidities

Allergy/Adverse Drug Reaction Profile

Medication/CAM profile

Assessment of Prognosis

• Days to weeks
• Weeks to months
• Months to years

See: https://www.caresearch.com.au/Portals/10/Documents/Palliative-and-EOL-Care-Framework.pdf

Case Conference/Goals of Care

Terminal Care Planning

Relevant psychosocial issues/supports

Relevant Spiritual issues/supports

Bereavement issues/supports

Practical and functional issues/supports

Current services and planned services

Other issues to consider

Submit