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END OF LIFE CARE EXPERIENCE

We would like to ask you a few questions about your recent experience of the end of life care for a loved one.

If your loved one died suddenly or did not receive end of life care and you prefer not to answer the questions, then you should not complete this questionnaire.

The information you provide will be used to improve palliative and end of life care in our Long Term Care Homes.

Please note that everyone is completely free to respond or not to any question. No names will be included in any report that results from this questionnaire.

For each of the following questions, please check the response which best matches your view and provide comments if you can.

Thank you very much for your help.
1.Check Site:
2.How long had your loved one been ill before they died?
3.Would you mind telling us what your loved one died of?
4.When did your loved one die?
Date
5.Where did your loved one die?
6.Would this have been their chosen place? Please answer to the best of your knowledge.
7.If no, where would they have preferred?
8.Did your loved one have an advanced care plan? An advanced care plan is a list of their preferences for care.
9.Do you feel your loved one's wishes were achieved? Please answer to the best of your knowledge.
10.Are there any comments you wish to make about your loved one's wishes?
11.Was the MICs Group of Health Services Hospice involved in your loved one's care?
12.If yes, can you describe briefly what Hospice did?
13.In your particular case, was the amount of Hospice involvement?
14.In your particular case, was the timing of Hospice involvement?
15.Overall, how satisfied are you with the palliative and end of life care received in the last 3 months of life?
16.The care provided to your loved one during the day?
17.The care provided to your loved one during the night or at weekends?
18.The dignity with which your loved one was treated by professional careers (doctors, nurses, health care assistants)?
19.How well your loved one's comfort was attended to?
20.How well your loved one's symptoms were dealt with?
21.How well professionals listened to the needs and concerns of family?
22.How well professionals explained your loved one's condition and progress to family?
23.The dignity with which family and friends were treated by professionals?
24.The emotional support offered to family and friends?
25.The practical support offered to family and friends?
26.Overall, how satisfied are you with the care received by your loved one in the last days of life?
27.The care provided to your loved one during the day?
28.The care provided to your loved one during the night or at weekends?
29.The dignity with which your loved one was treated by professional carers (doctors, nurses, health care assistants)?
30.How well your loved one's comfort was attended to?
31.How well your loved one's symptoms were dealt with?
32.How well professionals listened to the needs and concerns of family?
33.How well professionals explained your loved one's condition and progress to family?
34.The dignity with which family and friends were treated by professionals?
35.The emotional support offered to family and friends?
36.The practical support offered to family and friends?
37.Additional comments on any aspect of your experience
38.About you:
39.Age:
40.Relationship to the deceased
Would you like to give us more in-depth information about your experience, either soon or in a few months?

Please contact us at XXX and mention the End of Life Experience survey.

Thank you very much for your help.
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