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* 1. Please rate the impact of the following objectives: As a result of attending this activity, I am better able to ...

  Strongly Agree Agree Neutral Disagree Strongly Disagree N/A
Objective:  Discuss issues surrounding death and dying and the role of the interdisciplinary team in providing quality care to patients  facing a life limiting illness.
Objective:  Identify key ethical issues and legal concerns impacting end-of-life care and decision making.
Objective:  Define the influence of culture in the care of patients experiencing a life limiting illness.
Objective:  Define importance of ongoing communication while caring for a patient with a life limiting illness.
Objective:   Define loss, mourning, grief, and bereavement and identify support systems used in coping.
Objective:   Identify barriers to adequate pain relief as well as therapies used at end-of-life for adults and children.
Objective:   Identify causes, assessment, and management of common end-of-life symptoms for adults and children.
Objective:   Discuss the role of the interdisciplinary team surrounding death of a patient.

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* 2. Please rate the projected impact of this activity on your knowledge, competence, performance, and patient outcomes*:        (Competence is defined as the ability to apply knowledge, skills, and judgment in practice (knowing how to do something.)    
*The Accreditation Council for CME requires us to analyze changes in learners’ competence, p
erformance, or patient outcomes.

  Yes No No change
a) This activity increased my knowledge.
b) This activity increased my competence.
c) This activity will improve my performance.
d) This activity will improve my patient outcomes.

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* 3. Do you feel the activity was scientifically sound and free of commercial bias* or influence?
*Commercial bias is defined as a personal judgment in favor of a specific product or service of a commercial interest.

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* 4. Please identify how you will change your practice as a result of attending this activity (select all that apply).

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* 5. Please indicate any barriers you perceive in implementing these changes (Please check all that apply).

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* 6. Will you attempt to address these barriers in order to implement changes in your competence, performance, and/or patients’ outcomes?

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* 7. The content of this activity matched my current (or potential) scope of practice.

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* 8. For the content presented, how might the format of this activity be improved (select all that apply)?

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* 9. Overall, were the speakers knowledgeable regarding the content?

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* 10. Overall, were the presentations balanced, objective, and scientifically rigorous?

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* 11. Describe any presentations that were exceptional?

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* 12. Describe any presentations that did not meet your needs or expectations.

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* 13. For future educational activities, please describe any clinical situations that you find difficult to manage or resolve that you would like to see addressed.

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* 14. Do you work in primary care?

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* 15. The major strengths of this education activity are: (check all that apply)

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* 16. Where did you attend this program?

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* 17. How did you hear about this event?

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