Please have this survey completed by the person in your household who knows the most about the person who received hospice care. 
 
 

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* 1. How are you related to the hospice patient?

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* 2. For this survey, the phrase "family member" refers to the person receiving hospice care. In what locations did your family member receive care from this hospice? Please choose all that apply.

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* 3. While your family member was in hospice care, how often did you take part in or oversee care for him/her?

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* 4. For this survey section, the hospice team includes all the nurses, doctors, social workers, chaplains and other people who provided hospice care to your family member. While your family member was in hospice care, did you need to contact the hospice team during evenings, weekends, or holidays for questions or help with your family member's care?

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* 5. How often did you get the help you needed from the hospice team during evenings, weekends, or holidays? 

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* 6. While your family member was in hospice care, how often did the hospice team keep you informed about when they would arrive to care for your family member? 

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* 7. While your family member was in hospice care and you or your family member asked for help from the hospice team, how often did you get help as soon as you needed it?

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* 8. While your family member was in hospice care, how often did the hospice team explain things in a way that was easy to understand?

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* 9. While your family member was in hospice care, how often did the hospice team keep you informed about your family member's condition?

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* 10. While your family member was in hospice care, how often did anyone from the hospice team give you confusing or contradictory information about your family member's condition or care? 

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* 11. While your family member was in hospice care, how often did the hospice team treat your family member with dignity and respect? 

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* 12. While your family member was in hospice care, how often did you feel that the hospice team really cared about your family member? 

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* 13. While  your family member was in hospice care, did you talk with the hospice team about any problems with your family member's hospice care? 

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* 14. How often did the hospice team listen carefully to you when you talked with them about problems with your family member's hospice care? 

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* 15. While your family member was in hospice care, did he/she have any pain? 

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* 16. Did your family member get as much help with pain as he/she needed? 

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* 17. While your family member was in hospice care, did he/she receive any pain medicine? 

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* 18. Side effects of pain medicine include things like sleepiness. Did any member of the hospice team discuss side effects of pain medicine with your or your family member? 

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* 19. Did the hospice team give you the training you needed about what side effects to watch for from pain medicine? 

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* 20. Did the hospice team give you the training you needed about if and when to give more pain medicine to your family member? 

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* 21. While your family member was in hospice care, did they ever have trouble breathing or receive treatment for trouble breathing?

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* 22. How often did your family member get the help he/she needed for trouble breathing?

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* 23. Did the hospice team give you the training you needed on how to help your family member if he/she had trouble breathing?

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* 24. While your family member was in hospice care, did they ever have trouble with constipation?

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* 25. How often did your family member get the help he/she needed for trouble with constipation? 

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* 26. While your family member was in hospice care, did he/she show any feelings of anxiety or sadness? 

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* 27. How often did your family member get the help he/she needed  from the hospice team for feelings of anxiety or sadness?

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* 28. While your family member was in hospice care, did he/she ever become restless or agitated? 

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* 29. Did the hospice team give you the training you needed on what to do if your family member became restless or agitated?

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* 30. Moving your family member includes things like helping him/her turn over in bed, or get in and out of bed or a wheelchair. Did the hospice team give you the training you needed on how to safely move your family member?

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* 31. Did the hospice team give you as much information as you wanted about what to expect while your family member was dying? 

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* 32. Some people receive hospice care while they are living in a nursing home. Did your family member receive care from this hospice while he/she was living in a nursing home? 

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* 33. While your family member was in hospice care, how often did the nursing home staff and hospice team work well together to care for your family member? 

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* 34. While your family member was in hospice care, how often was the information you were given about your family member by the nursing home staff, differ from the information you were given by the hospice team?

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* 35. While your family member was in hospice care, how often did the hospice team listen carefully to you?

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* 36. Support for religious or spiritual beliefs includes talking, praying, quiet time, or other ways of meeting your religious or spiritual needs. While your family member was in hospice care, how much support for your religious and spiritual beliefs did you get from the hospice team?

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* 37. While your family member was in hospice care, how much  emotional support did  you get from the hospice team?

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* 38. In the weeks after your family member died, how much  emotional support did  you get from the hospice team?

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* 39. Please answer the following questions about your family member's care from the hospice team. Do not include care from other hospices in your answers.

Using a number 0 to 10, where 0 is the worst hospice care possible and 10 is the best, what number would you use to rate your family member's hospice care?

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* 40. Would you recommend this hospice to your friends and family? 

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* 41. What is the highest grade or level of school that  your family member completed?

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* 42. Was your family member of Hispanic, Latino, or Spanish origin or descent? 

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* 43. What was your family member's race? Please choose all that apply. 

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* 44. What is your age?

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* 45. Are you male or female?

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* 46. What is the highest grade or level of school that  you have completed?

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* 47. What language do you mainly speak at home? 

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* 48. Is there anything else that you would like to tell us about the care provided by the hospice team? 

Thank you for your time!
If you have additional information or concerns please feel free to contact :


Tiffany Cook
Hospice Director

816-630-9228
tcook@esmc.org

T