SURVEY INSTRUCTIONS-(see bottom)or Print now and fax to (970) 565-9543
Please answer each question by choosing the answer that best describes your experience and the patient’s experience while under the care of hospice.
Answer all the questions that apply to you by checking the box to the left of your answer or writing in the information in the space provided.
You are sometimes told to skip over some questions in this survey. When this happens you will see an arrow with a note that tells you what question to answer next, like this:
□ Yes □ No ® If No, Go to Question A2
Section A
A1) For about how many days or months did the patient receive hospice services? ______ □ days □ months
Section B
B1) While under the care of hospice, did the patient have pain or take medicine for pain?
□ Yes □ No ® If No, Go to Question B5
B2) How much medicine did the patient receive for his/her pain
□ Less than was wanted □ Just the right amount □ More than patient wanted
B3) Did you or your family receive any information from the hospice team about the medicines that were used to manage the patient’s pain?
□ Yes □ No □ Don’t Know
B4) Did you want more information than you got about the medicines used to manage the patient’s pain?
□ Yes □ No
B5) While under the care of hospice, did the patient have trouble breathing?
□ Yes □ No ® If No, Go to Question B9
B6) How much help in dealing with his/her breathing did the patient receive while under the care of hospice?
□ Less than was wanted □ Just the right amount □ More than patient wanted
B7) Did you or your family receive any information from the hospice team about what was being done to manage the patient’s trouble with breathing?
□ Yes □ No □ Don’t Know □ No treatments used for breathing ® Go to Question B9
B8) Did you want more information than you got about what was being done for the patient’s trouble with breathing?
□ Yes □ No
B9) While the patient was under the care of hospice, did he/she have any feelings of anxiety or sadness?
□ Yes □ No ® If No, Go to Question C1
B10) How much help in dealing with these feelings did the patient receive?
□ Less than was wanted □ Right amount □ More help or attention to these feelings than patient wanted
Section C
C1) How often were the patient’s personal care needs – such as bathing, dressing, and changing bedding – taken care of as well as they should have been by the hospice team?
□ Always □ Usually □ Sometimes □ Never □ Hospice team was not needed or wanted for personal care
C2) How often did the hospice team treat the patient with respect?
□ Always □ Usually □ Sometimes □ Never
Section D
D1) While the patient was under the care of hospice, did you participate in taking care of him/her?
□ Yes □ No ® If No, Go to Question D5
D2) Did you have enough instruction to do what was needed?
□ Yes □ No
D3) How confident did you feel about doing what you needed to do in taking care of the patient?
□ Very confident □ Fairly confident □ Not confident
D4) How confident were you that you knew as much as you needed to about the medicines being used to manage the patient’s pain, shortness of breath, or other symptoms?
□ Very confident □ Fairly confident □ Not confident
D5) How often did the hospice team keep you or other family members informed about the patient’s condition?
□ Always □ Usually □ Sometimes □ Never
D6) Did you or your family receive any information from the hospice team about what to expect while the patient was dying?
□ Yes □ No
D7) Would you have wanted more information about what to expect while the patient was dying?
□ Yes □ No
Section E
E1) Did any member of the hospice team talk with you about your religious or spiritual beliefs?
□ Yes □ No
E2) Did you have as much contact of that kind as you wanted?
□ Yes □ No
E3) How much emotional support did the hospice team provide to you prior to the patient’s death?
□ Less than was wanted □ Right amount □ More attention than was wanted
E4) How much emotional support did the hospice team provide to you after the patient’s death?
□ Less than was wanted □ Right amount □ More attention than was wanted
Section F
F1) How often did someone from the hospice team give confusing or contradictory information about the patient’s medical treatment?
□ Always □ Usually □ Sometimes □ Never
F2) While under the care of hospice, was there always one nurse who was identified as being in charge of the patient’s overall care?
□ Yes □ No
F3) Was there any problem with hospice doctors or nurses not knowing enough about the patient’s medical history to provide the best possible care?
□ Yes □ No
Section G
G1) Overall, how would you rate the care the patient received while under the care of hospice?
□ Excellent □ Very good □ Good □ Fair □ Poor
G2) How would you rate the way the hospice team responded to your needs in the evenings and weekends?
□ Excellent □ Very good □ Good □ Fair □ Poor □ Never contacted evening or weekend services
G3) Based on the care the patient received, would you recommend hospice services to others?
□ Yes □ No
G3a) In your opinion, was the patient referred to hospice too early, at the right time, or too late during the course of his/her final illness?
□ Too early ® Go to Question H1 □ At the right time ® Go to Question H1 □ Too late ® Please explain
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G3b) While under the care of hospice, was the patient in a nursing home?
□ Yes ® Go to Question G3c □ No ® Go to Question H1
G3c) After hospice became involved, would you say the quality of end-of-life care the patients received:
□ Improved □ Stayed the same □ Decreased
Section H
Please give us the following information about your loved one:
H1) How old was the patient when he/she died? ______ year’s old
H2) Was the patient male or female? □ Male □ Female
H3) Please choose the one disease group that best describes the primary illness that caused the patient to be referred to hospice. Please choose only one.
□ Cancers – all types □ Heart & circulatory diseases □ Lung & breathing diseases Kidney diseases
□ Liver diseases □ Strokes □ Dementia & Alzheimer’s disease □ AIDS & other infectious diseases
□ Frailty and decline due to old age □ Another disease (Please write in) ____________________________
H4) What is the highest grade or level of school that the patient completed?
□ 8th grade or less □ Some high school but did not graduate □ High school graduate or GED
□ 1-3 years of college □ 4-year college graduate □ More than a 4-year college degree
H5) Was the patient of Hispanic or Spanish family background? □ Yes □ No
H6) Which of the following best describes the patient’s race?
□ American Indian or Alaskan Native □ Asian or Pacific Islander □ Black or African-American
□ White □ Another race or multiracial (Please write in) ______________________
Section I
Please give us the following information about yourself:
I1) What is your relationship to the patient?
□ Spouse □ Partner □ Child □ Parent □ Sibling □ Other Relative □ Friend
□ Other (Please write in) __________________________
I2) How old were you on your last birthday? _______ year’s old
I3) Are you male or female? □ Male □ Female
I4) What is the highest grade or level of school that you have completed?
□ 8th grade or less □ Some high school but did not graduate □ High school graduate or GED
□ 1-3 years of college □ 4-year college graduate □ More than a 4-year college degree
I5) Are you of Hispanic or Spanish family background? □ Yes □ No
I6) Which of the following best describes your race?
□ American Indian or Alaskan Native □ Asian or Pacific Islander □ Black or African-American
□ White □ Another race or multiracial (Please write in) ______________________
Section J
J1) Is there anything else that you would like to tell us about the care provided by the hospice team?
□ Yes □ No
Please explain.
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Thank you very much for your time!
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You may also print and fax to: (970) 565-9543
