Form VA Form 10-21081(N VA Form 10-21081(N Bereaved Family Member Satisfaction Survey_Administered

OMB Number 2900-0701

Respondent Burden: 10 min

Expiration: XX/XX/XXXX

Bereaved Family Member Satisfaction Survey

For Surveys Administered by Facility Staff

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 2900-0701 in accordance with section 3507 of the Paperwork Reduction Act of 1995. We estimate that it will take about 10 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.

DEMOGRAPHIC INFORMATION

Family Relationship at End of Life (FREL) First can you tell me how you are related to [PATIENT’S NAME]?

Participant is the deceased’s ___________________

Spouse……………………	1	Partner…………………….	8
Parent…………………….	2	Niece/Nephew…………….	9
Child……………………..	3	Son/Daughter-in-law………	10
Sibling……………………	4	Sister/Brother-in-law……...	11
Grandparent………………	5	Grandchild………………..	12
Aunt/Uncle……………….	6	Cousin…………………….	13
Friend…………………….	7	Other_________________	14

Next I’d like to ask you about [PATIENT’S NAME].

Q1) 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

Q2) 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

Q3) During [PATIENT’S] last month of life, how often were the doctors and other staff who took care of [PATIENT’S NAME] kind, caring, & respectful?

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

Unsure …10

Q4) During [PATIENT’S] last month of life, how often did the doctors and other staff who took care of [PATIENT’S NAME] 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

Q5) Did anyone alert you or your family when [PATIENT’S NAME] was about to die?

Yes…1 No…0

Unsure …10

Q6) 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

Q7) In the last month of [HIS/HER] life, did [PATIENT’S NAME] have pain or did [HE/SHE] take medicine for pain?

Yes…1 No…0

Unsure…10

Q8) [IF YES to Q7:] How often did [PATIENT’S] pain make [HIM/HER] uncomfortable?

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

Unsure …10

Didn’t have pain…99

Q9) Some veterans near the end of life re-experience the stress and emotions that they had when they were in combat. Did this happen to [PATIENT’S NAME] in the last month of life?

Yes…1 No…0

Unsure…10

Q10) [IF YES to Q9:] How often did [PATIENT’S] stress make [HIM/HER] uncomfortable?

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

Unsure …10

Did not re-experience stress and emotions of combat…99

Q11) In [PATIENT’S] last month of life, how much of the time did the doctors and other staff who took care of [PATIENT’S NAME] provide you and [PATIENT’S NAME] 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

Q12) In [PATIENT’S] last month of life, how much of the time did the doctors and other staff who took care of [PATIENT’S NAME] provide you and [PATIENT’S NAME] 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

Q13) What about after [PATIENT’S] death—How much of the time did the doctors and other staff who took care of [PATIENT’S NAME] 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

Q14) Would it have been helpful if the VA had provided more information about benefits for surviving spouses and dependents?

Yes…1 No…0

Q15) Would it have been helpful if the VA had provided more information about burial and memorial benefits?

Yes…1 No…0

Q16) Would it have been helpful if the VA had provided more help with [PATIENT’S] funeral arrangements?

Yes…1 No…0

Q17) 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

Q18) Is there anything else that you would like to share about [PATIENT’S] care during the last month of life?

_____________________________________________

_____________________________________________

Q19) Is there anything else that you would like to share about how the care could have been improved for [PATIENT’S NAME]?

_____________________________________________

_____________________________________________

THANK RESPONDENT AND TERMINATE INTERVIEW

The Paperwork Reduction Act of 1995 requires us to notify you that this information collected is in accordance with the clearance requirements of section 3507 of this Act. The public reporting burden for this collection of information is estimated to average 10 minutes per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. No person will be penalized for failing to furnish this information if it does not display a currently valid OMB control number. This collection of information is intended to fulfill the need identified by the Department of Veterans Affairs in their call for the development of needed improvements to the current VHA program. Response to this survey is voluntary and failure to furnish this information will have no effect on any of your benefits.

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VA Form 10-21081(NR)