Bereaved Family Member Satisfaction Survey

Bereaved Family Member Satisfaction Survey

Hello, I am from the VA and have called to ask you for a few minutes of your time to answer some important questions about the quality of care provided to veterans at end of life. Our records show that you’ve experienced a recent loss with the death of (PATIENT’S NAME).

The Office of Management and Budget has approved this survey under OMB Number 2900-new in accordance with section 3507 of the Paperwork Reduction Act of 1995. We estimate that it will take about 15 minutes to answer these questions. Your responses will be used to measure veterans’ and their families’ perceptions of the health care VA provides. Your participation is voluntary and confidential. If you choose not to participate, it will not affect your benefits in any way.

May I proceed with the questions? If NO, terminate interview and thank respondent. If, YES, proceed.

QUESTIONS:

1) During (PATIENT’S) last month of life, how often did the doctors and other staff who took care of [PATIENT’S NAME] speak in an understandable way?

Would you say: Always…3 Usually…2 Sometimes…1 Never…0

Did not speak to staff who took care of [PATIENT’S NAME]…99

2) During (PATIENT’S) last month of life, how much of the time were the doctors and other staff who took care of [PATIENT’S NAME] willing to take time to listen?

Would you say: Always…3 Usually…2 Sometimes…1 Never…0

Did not speak to staff who took care of [PATIENT’S NAME]…99

3) During (PATIENT’S) last month of life, how often did [PATIENT’S NAME] receive medication or medical treatment that you and [HE/SHE] did NOT want?

Would you say: Always…3 Usually…2 Sometimes…1 Never…0

Unsure …10

Did not receive treatment…..99

4) During (PATIENT’S) last month of life, how often were the doctors and other staff who took care of [PATIENT] kind, caring, & respectful?

Would you say: Always…3 Usually…2 Sometimes…1 Never…0

Unsure …10

5) During (PATIENT’S) last month of life, how often did the doctors and other staff who took care of [PATIENT] keep you or other family members informed about [HIS/HER] condition and treatment?

Would you say: Always…3 Usually…2 Sometimes…1 Never…0

Unsure …10

6) Did anyone tell you what would happen during [PATIENT’S NAME]’s last hours of life?

Yes…1 No…0

Unsure…10

Death was unexpected…99

7) From what you know about [PATIENT’S] time as an inpatient, how often do you think [HIS/HER] personal care needs - such as bathing, dressing, and eating meals – were taken care of as well as they should have been?

Would you say: Always…3 Usually…2 Sometimes…1 Never…0

Unsure…..10

Staff was not needed or wanted for personal care…98

Not an inpatient in last month of life…..99

8) In the last month of [HIS/HER] life, did [PATIENT] have pain or did [HE/SHE] take medicine for pain?

Yes…1 No…0

Unsure…10

9) [IF YES:] How often did [PATIENT’S NAME’S] pain make [HIM/HER] uncomfortable?

Would you say: Always…3 Usually…2 Sometimes…1 Never…0

Unsure …10

Didn’t have pain…99

10) In [PATIENT’S] last month of life, how much of the time did the doctors and other staff who took care of [PATIENT] provide you and [PATIENT] the kind of spiritual support that you and [HE/SHE] would have liked?

Would you say: Always…3 Usually…2 Sometimes…1 Never…0

Did not want/need spiritual support…98

11) In [PATIENT’S] last month of life, how much of the time did the doctors and other staff who took care of [PATIENT] provide you and [PATIENT] the kind of emotional support that you and [HE/SHE] would have liked prior to [HIS/HER] death?

Would you say: Always…3 Usually…2 Sometimes…1 Never…0

Did not want/need emotional support…98

12) What about after [PATIENT’S] death—How much of the time did the doctors and other staff who took care of [PATIENT] provide you the kind of emotional support you would have wanted?

Would you say: Always…3 Usually…2 Sometimes…1 Never…0

Did not want/need emotional support…98

13) Would it have been helpful if the VA has provided more help with [PATIENT’S] funeral arrangements?

[ ] YES

[ ] NO

14) Overall, how would you rate the care that [PATIENT’S NAME] received in the last month of [HIS/HER] life?

Would you say: Excellent…4 Very good…3 Good…2 Fair…1 Poor…0

15) Is there anything else that you would like to share about [PATIENT’S] care during the last month of life?

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16) Is there anything else that you would like to share about how the care could have been improved for [PATIENT]?

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**** THANK RESPONDENT AND TERMINATE INTERVIEW

VA FORM	10-21081(NR)
MAR 2006

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