Survey Templates Surveys Quality Care at the End of Life Survey

Quality Care at the End of Life Survey

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Structure and Processes of Care

How likely is it that the following occurs at your institution?

	Very Likely	Likely	Somewhat Likely	Unlikely	Very Unlikely
1. The plan of care is based on patient and family goals with consideration of the changing benefits/burdens of care.	Very Likely	Likely	Somewhat Likely	Unlikely	Very Unlikely

2. Staff have the necessary knowledge and skills required to care for dying patients and their families.	Very Likely	Likely	Somewhat Likely	Unlikely	Very Unlikely

3. There is effective continuity of care across settings (ICU, inpatient units, hospice).	Very Likely	Likely	Somewhat Likely	Unlikely	Very Unlikely

4. Multi-disciplinary team meetings are conducted to consider any of the following: determining patient wishes, assisting in decision-making, enhancing communication.	Very Likely	Likely	Somewhat Likely	Unlikely	Very Unlikely

Please include any comments about your answers from this section of the survey:

Physical Aspects of Care

How frequently does the following occur at your institution?

	Very Frequently	Frequently	Somewhat Frequently	Infrequently	Very Infrequently
5. Pain is effectively assessed and managed.	Very Frequently	Frequently	Somewhat Frequently	Infrequently	Very Infrequently

6. Other symptoms (e.g. dyspnea, agitation)are effectively assessed and managed.	Very Frequently	Frequently	Somewhat Frequently	Infrequently	Very Infrequently

7. Consultation is available in the management of pain and other symptoms.	Very Frequently	Frequently	Somewhat Frequently	Infrequently	Very Infrequently

8. Treatment of pain and symptom management addresses physical aspects.	Very Frequently	Frequently	Somewhat Frequently	Infrequently	Very Infrequently

9. Treatment of pain and symptom management addresses psychological, social and/or spiritual aspects.	Very Frequently	Frequently	Somewhat Frequently	Infrequently	Very Infrequently

10. Treatment of pain and symptom management incorporates both pharmacologic and nonpharmacologic or supportive therapies.	Very Frequently	Frequently	Somewhat Frequently	Infrequently	Very Infrequently

Please include any comments about your answers from this section of the survey:

Psychological/Psychiatric Aspects of Care

How frequently does the following occur at your institution?

	Very Frequently	Frequently	Somewhat Frequently	Infrequently	Very Infrequently
11. Consultation is available by a clinical psychologist.	Very Frequently	Frequently	Somewhat Frequently	Infrequently	Very Infrequently

12. Consultation is available by a psychiatrist.	Very Frequently	Frequently	Somewhat Frequently	Infrequently	Very Infrequently

13. Consultation is available by other staff skilled in bereavement.	Very Frequently	Frequently	Somewhat Frequently	Infrequently	Very Infrequently

14. Assessment is used to identify people at risk of complicated grief and bereavement.	Very Frequently	Frequently	Somewhat Frequently	Infrequently	Very Infrequently

15. Bereavement services are provided to families following the death of a patient.	Very Frequently	Frequently	Somewhat Frequently	Infrequently	Very Infrequently

Please include any comments about your answers from this section of the survey:

Social Aspects of Care

How frequently does the following occur at your institution?

	Very Frequently	Frequently	Somewhat Frequently	Infrequently	Very Infrequently
16. Consultation is available by clinical social work.	Very Frequently	Frequently	Somewhat Frequently	Infrequently	Very Infrequently

17. The plan of care reflects important information regarding family relationships.	Very Frequently	Frequently	Somewhat Frequently	Infrequently	Very Infrequently

18. Family meetings are conducted to consider any of the following: providing information, assisting in decision-making, determining wishes, enhancing communication.	Very Frequently	Frequently	Somewhat Frequently	Infrequently	Very Infrequently

19. Family members are supported through this time of critical illness and death.	Very Frequently	Frequently	Somewhat Frequently	Infrequently	Very Infrequently

Please include any comments about your answers from this section of the survey:

Spiritual and Existential Aspects of Care

How likely is it that the following occurs at your institution?

	Very Likely	Likely	Somewhat Likely	Unlikely	Very Unlikely
20. Staff are knowledgeable about diverse religious/spiritual needs.	Very Likely	Likely	Somewhat Likely	Unlikely	Very Unlikely

21. Staff are sensitive to diverse religious/spiritual needs.	Very Likely	Likely	Somewhat Likely	Unlikely	Very Unlikely

22. Spiritual assessment is used to identify preferences, rituals, beliefs and concerns.	Very Likely	Likely	Somewhat Likely	Unlikely	Very Unlikely

23. Pastoral care/chaplaincy is available to patients and their families.	Very Likely	Likely	Somewhat Likely	Unlikely	Very Unlikely

24. Pastoral care/chaplaincy contributes to the overall care and support of patients and their families.	Very Likely	Likely	Somewhat Likely	Unlikely	Very Unlikely

Please include any comments about your answers from this section of the survey:

Cultural Aspects of Care

How likely is it that the following occurs at your institution?

	Very Likely	Likely	Somewhat Likely	Unlikely	Very Unlikely
25. Staff are considerate of the cultural background, concerns and needs of the patient.	Very Likely	Likely	Somewhat Likely	Unlikely	Very Unlikely

26. The cultural background, concerns and needs of the patient are documented.	Very Likely	Likely	Somewhat Likely	Unlikely	Very Unlikely

27. Staff are considerate of the cultural background, concerns and needs of the family.	Very Likely	Likely	Somewhat Likely	Unlikely	Very Unlikely

28. The cultural background, concerns and needs of the family are documented.	Very Likely	Likely	Somewhat Likely	Unlikely	Very Unlikely

29. Communication with patients and families is respectful of their cultural preferences regarding disclosure, truth telling and decision making.	Very Likely	Likely	Somewhat Likely	Unlikely	Very Unlikely

Please include any comments about your answers from this section of the survey:

Ethical Issues

How likely is it that the following occurs at your institution?

	Very Likely	Likely	Somewhat Likely	Unlikely	Very Unlikely
30. Patient or surrogate preferences are documented through advance care planning.	Very Likely	Likely	Somewhat Likely	Unlikely	Very Unlikely

31. Patient or surrogate preferences are honored.	Very Likely	Likely	Somewhat Likely	Unlikely	Very Unlikely

32. Ethical concerns are recognized as they arise.	Very Likely	Likely	Somewhat Likely	Unlikely	Very Unlikely

33. Ethical concerns are addressed once they are identified.	Very Likely	Likely	Somewhat Likely	Unlikely	Very Unlikely

34. There is appropriate referral to an Ethics Committee where necessary.	Very Likely	Likely	Somewhat Likely	Unlikely	Very Unlikely

35. Do Not Resuscitate orders are issued appropriately.	Very Likely	Likely	Somewhat Likely	Unlikely	Very Unlikely

How frequently do you face the following situations in your practice setting?

	Very Frequently	Frequently	Somewhat Frequently	Infrequently	Very Infrequently
36. Balancing providing honest information against destroying hope	Very Frequently	Frequently	Somewhat Frequently	Infrequently	Very Infrequently

37. Enabling informed patient choices	Very Frequently	Frequently	Somewhat Frequently	Infrequently	Very Infrequently

38. Patient and family with differing goals	Very Frequently	Frequently	Somewhat Frequently	Infrequently	Very Infrequently

39. Use of advanced directives	Very Frequently	Frequently	Somewhat Frequently	Infrequently	Very Infrequently

40. Withholding /withdrawing life sustaining treatments (ventilators)	Very Frequently	Frequently	Somewhat Frequently	Infrequently	Very Infrequently

41. Withholding/withdrawing food/fluids	Very Frequently	Frequently	Somewhat Frequently	Infrequently	Very Infrequently

42. Discontinuing life supports	Very Frequently	Frequently	Somewhat Frequently	Infrequently	Very Infrequently

43. Fear of causing patient death by administering pain medications	Very Frequently	Frequently	Somewhat Frequently	Infrequently	Very Infrequently

44. Uncertainty about patient prognosis	Very Frequently	Frequently	Somewhat Frequently	Infrequently	Very Infrequently

45. Continuing unnecessary lab work or diagnostic procedures	Very Frequently	Frequently	Somewhat Frequently	Infrequently	Very Infrequently

	Very Frequently	Frequently	Somewhat Frequently	Infrequently	Very Infrequently
46. Providing futile care (care with no hope of success)	Very Frequently	Frequently	Somewhat Frequently	Infrequently	Very Infrequently

47. Continuing futile care in fear of lawsuits	Very Frequently	Frequently	Somewhat Frequently	Infrequently	Very Infrequently

Please include any comments about your answers from this section of the survey:

Care of the Imminently Dying Patient

How likely is it that the following occurs at your institution?

	Very Likely	Likely	Somewhat Likely	Unlikely	Very Unlikely
48. The patient’s transition to active dying is recognized and documented.	Very Likely	Likely	Somewhat Likely	Unlikely	Very Unlikely

49. The patient’s transition to active dying is communicated appropriately to the patient.	Very Likely	Likely	Somewhat Likely	Unlikely	Very Unlikely

50. The patient’s transition to active dying is communicated appropriately to the patient's family.	Very Likely	Likely	Somewhat Likely	Unlikely	Very Unlikely

51. The patient’s transition to active dying is communicated appropriately to the staff.	Very Likely	Likely	Somewhat Likely	Unlikely	Very Unlikely

52. The patient is offered choices when possible regarding place of death.	Very Likely	Likely	Somewhat Likely	Unlikely	Very Unlikely

53. The family is offered choices when possible regarding place of death.	Very Likely	Likely	Somewhat Likely	Unlikely	Very Unlikely

54. Families are educated regarding signs and symptoms of approaching death.	Very Likely	Likely	Somewhat Likely	Unlikely	Very Unlikely

55. Emotional and spiritual support is provided to the patient during the dying process.	Very Likely	Likely	Somewhat Likely	Unlikely	Very Unlikely

56. Emotional and spiritual support is provided to the patient's family during the dying process and bereavement period.	Very Likely	Likely	Somewhat Likely	Unlikely	Very Unlikely

Please include any comments about your answers from this section of the survey:

Barriers to Delivering Quality Care

Please rate the severity of the following potential barriers to the delivery of quality care at your institution:

	Severe Barrier		Somewhat of a Barrier		Not a Barrier
57. Unknown prognosis	Severe Barrier		Somewhat of a Barrier		Not a Barrier

58. Time expenditure needed for dying patients	Severe Barrier		Somewhat of a Barrier		Not a Barrier

59. Staff avoidance of dying patients	Severe Barrier		Somewhat of a Barrier		Not a Barrier

60. Cultural factors influencing end of life care	Severe Barrier		Somewhat of a Barrier		Not a Barrier

61. Legal/regulatory restrictions	Severe Barrier		Somewhat of a Barrier		Not a Barrier

62. Other cost considerations	Severe Barrier		Somewhat of a Barrier		Not a Barrier

63. Patient reluctance to accept death	Severe Barrier		Somewhat of a Barrier		Not a Barrier

64. Family reluctance to accept death	Severe Barrier		Somewhat of a Barrier		Not a Barrier

65. Focus on cure versus comfort	Severe Barrier		Somewhat of a Barrier		Not a Barrier

66. Focus on research versus comfort	Severe Barrier		Somewhat of a Barrier		Not a Barrier

	Severe Barrier		Somewhat of a Barrier		Not a Barrier
67. Reluctance to make palliative care a core goal	Severe Barrier		Somewhat of a Barrier		Not a Barrier

Quality of Care

Overall, please rate the quality of the following:

	Very High Quality	High Quality	Somewhat High Quality	Low Quality	Very Low Quality
68. Your own practice in end of life care.	Very High Quality	High Quality	Somewhat High Quality	Low Quality	Very Low Quality

69. Your colleagues' practice in end of life care.	Very High Quality	High Quality	Somewhat High Quality	Low Quality	Very Low Quality

70. Your institution’s overall care for dying patients.	Very High Quality	High Quality	Somewhat High Quality	Low Quality	Very Low Quality

Personal Demographics

What is your job title?

MD

RN

Social Worker

Chaplain

Administrator

Board Member

Other

In what setting do you practice?

Hospital

Public Health Clinic

University Educational Health Center

Long Term Care Facility

Hospice

Other

What type of services do you provide?

Inpatient

Outpatient/Clinic

ICU

Long Term Care Unit

Palliative Care Services

Other

Please share below any additional comments/thoughts you have about care for patients and families facing death. We would welcome your thoughts about both the strengths and weaknesses of the care provided at your institution:

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