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2025 Palliative Care - Family

Client Experience Questionnaire

Tell us about your experience! Your feedback helps us to improve the way we provide care. This questionnaire was built upon our Patient Values (Dignity, Respect and Trust, Information Sharing, Participation, Accessibility and Responsiveness and Quality).

If the question does not apply, please leave blank.

For purposes of this survey – the Palliative Care Client may be referred to as “your loved one”.
What is your relationship to the Palliative Care client:
In which of the following settings did your loved one receive services?
Choose all that apply.
What was the main illness of your loved one?
Dignity, Respect and Trust:
(If question does not apply, leave blank)
Strongly Agree
Agree
Disagree
Strongly Disagree
a. My loved one was treated with respect.
b. My loved one's privacy was respected as best it could be.
c. My loved one's cultural needs were considered. (e.g. individuals’ own beliefs, customs, social standards, traditions or religious beliefs)
d. Before providing care, staff members introduced themselves to my loved one/family supports, where appropriate.
e. In general, staff were compassionate.
Information Sharing:
(If question does not apply, leave blank)
Always
Usually
Sometimes
Never
a. Staff talked to my loved one/family supports about what medications they were taking at home. (e.g. prescription, supplements, herbal, etc.)
b. Staff talked to my loved one/family supports about health care options. (e.g. procedures/tests)
c. My loved one's health care provider used words we could understand.
d. My loved one/family supports had the necessary information needed to make good decisions about their health.
e. The staff kept my loved one's information confidential and secure.
Participation:
(If question does not apply, leave blank)
Always
Usually
Sometimes
Never
a. Staff involved my loved one/family supports in making decisions about their care.
b. My loved one's/family supports were encouraged to take part in their care as much as they/we were able.
c. My loved one's/family choices were respected.
d. My loved one/family supports were comfortable expressing concerns about their care.
Accessibility and Responsiveness:
(If question does not apply, leave blank)
Strongly Agree
Agree
Disagree
Strongly Disagree
a. My loved one's care was well coordinated.
b. My loved one was cared for in a timely manner.
c. My loved one had access to the care they needed.
d. My loved one's/family supports concerns were taken seriously.
e. I am aware of the Prairie Mountain Health (PMH) services and programs available to get the support I need for my health care journey.
Quality:
(If question does not apply, leave blank)
Always
Usually
Sometimes
Never
a. I saw the health care provider(s) clean their hands before providing care to my loved one.
b. My loved one's identity was confirmed before receiving care. (e.g. asked loved one's name, checked their wrist band, asked their date of birth)
Quality:
(If question does not apply, leave blank)
Strongly Agree
Agree
Disagree
Strongly Disagree
c. The healthcare provider discussed risks or hazards that could cause falls/slips/trips (e.g. proper footwear, wet floors, icy sidewalks, uneven surfaces, etc.).
d. I felt staff were up to date on the skills needed to provide care to my loved one.
e. Overall, I was satisfied with the quality of care my loved one received.
Palliative Care - Family Program Specific Questions-
(If question does not apply, leave blank)
Strongly Agree
Agree
Disagree
Strongly Disagree
a. The health care providers made an effort to make contact with me, if requested.
b. My loved one/family supports were able to talk openly with health care providers.
c. The health care providers met my expectations in the care of my loved one.
d. When the need was identified, health care providers were supportive in the management of my loved ones pain.
e. When the need was identified, health care providers were supportive in the management of my loved ones other symptoms (Nausea, shortness of breath, etc.).
f. I was offered emotional support.
g. I was offered spiritual support.
h. I’m aware that Palliative volunteer support was available for my loved one.
i. I was offered bereavement support after end of life.
j. My loved one was treated with dignity.
Palliative Care - Family Program Specific Questions-
(If question does not apply, leave blank)
Yes
No
Unknown
k. Was location of choice or end of life discussed with you and your loved one?
Palliative Care - Family Program Specific Questions-
(If question does not apply, leave blank)
Yes
No
l. Were you connected with the Palliative Care program?
If you feel Palliative Care services could be improved, we welcome your suggestions:
Demographics: (of the patient)
Collected for statistical purposes only to target improvements.
Gender:
Ethnicity
Age:
Comments:
Forward additional concerns or compliments regarding your care to Patient Relations.
Patient Relations: email patientrelations@pmh-mb.ca or call 1-800-735-6596

Palliative Care Patient Partner Volunteers Needed!! Someone just like you helped to design this survey!
We want to partner with existing Palliative Care patients or family members who might be interested in helping us review, design or provide feedback to our services.

If you would like more information or if you think you might be interested in becoming a Patient Partner, please click on the link below or contact Patient Relations by calling 1-800-735-6596.

https://prairiemountainhealth.ca/forms/patient-partner/
Questions or concerns related to this survey can be sent to ceq@pmh-mb.ca

Thank you for your participation!