Family Survey for the Care on the Palliative Care Unit G5

Thank you very much for taking the time to complete this survey.

Sharing your experiences will contribute towards our goal of providing excellent care to the patients and families that we serve.

Please do not include any personal health or identifiable information on the forms below.

Were you satisfied with the following:

Questions	Yes	No	Maybe	Not applicable
Knowledge of staff	Yes	No	Maybe	Not applicable
Skill level of staff	Yes	No	Maybe	Not applicable
Caring of staff	Yes	No	Maybe	Not applicable
Professionalism of staff	Yes	No	Maybe	Not applicable
Response of staff to requests	Yes	No	Maybe	Not applicable
Timely giving of medication	Yes	No	Maybe	Not applicable
Delivery of Personal Hygiene	Yes	No	Maybe	Not applicable
Assistance with getting in/out of bed and walking	Yes	No	Maybe	Not applicable
Gentleness of care given	Yes	No	Maybe	Not applicable
Information given on your family member's condition	Yes	No	Maybe	Not applicable
Updates given on condition changes	Yes	No	Maybe	Not applicable
Availability of staff to answer your questions	Yes	No	Maybe	Not applicable
Availability of the Physician for answering your questions	Yes	No	Maybe	Not applicable

If somewhat unsatisfied or less with timeliness of the response of staff, please let us know during what time of the day you experienced these challenges:

Comments:

Were you satisfied with the team’s offering of:

Questions	Yes	No	Maybe	Not applicable
Respect of your loved one	Yes	No	Maybe	Not applicable
Respect of you	Yes	No	Maybe	Not applicable
Kindness given to your loved one	Yes	No	Maybe	Not applicable
Kindness given to you	Yes	No	Maybe	Not applicable
Meeting your loved one's care needs	Yes	No	Maybe	Not applicable
Interest in your loved one's goals and hopes	Yes	No	Maybe	Not applicable
Care specific to the patient's goals and hopes	Yes	No	Maybe	Not applicable
Dignity for your loved one	Yes	No	Maybe	Not applicable
Dignity for yourself	Yes	No	Maybe	Not applicable
Privacy given to your loved one	Yes	No	Maybe	Not applicable
Privacy for yourself	Yes	No	Maybe	Not applicable

Comments:

Did your loved one experience any of the following symptoms? If yes, how satisfactory was the team’s management of them?

Questions	Yes	No	Maybe	Did not experience
Pain	Yes	No	Maybe	Did not experience
Shortness of breath	Yes	No	Maybe	Did not experience
Nausea/vomiting	Yes	No	Maybe	Did not experience
Constipation	Yes	No	Maybe	Did not experience
Agitation	Yes	No	Maybe	Did not experience
Anxiety	Yes	No	Maybe	Did not experience
Anger	Yes	No	Maybe	Did not experience
Confusion	Yes	No	Maybe	Did not experience
Fear	Yes	No	Maybe	Did not experience
Loneliness	Yes	No	Maybe	Did not experience
Sadness	Yes	No	Maybe	Did not experience

Comments:

Were you satisfied with the team’s offering of:

Questions	Yes	No	Maybe	Not applicable
End of life discussions	Yes	No	Maybe	Not applicable
Care during the last hours prior to death	Yes	No	Maybe	Not applicable
Emotional support at time of death	Yes	No	Maybe	Not applicable
Communication during time of death	Yes	No	Maybe	Not applicable

Comments:

Questions	Yes	No	Unknown
Was your family member offered a spiritual care provider?	Yes	No	Unknown
Was your family member seen by a social worker?	Yes	No	Unknown
Did your family member receive emotional support?	Yes	No	Unknown
Was your family member offered any additional services or resources?	Yes	No	Unknown
Were you offered a spiritual care provider	Yes	No	Unknown
Were you offered the services of a social worker	Yes	No	Unknown
Did you receive emotional support for yourself?	Yes	No	Unknown
Were you offered any additional services or resources?	Yes	No	Unknown
Were you offered any suggestions for bereavement support?	Yes	No	Unknown
Did the team involve you and your loved one in decision-making?	Yes	No	Unknown
Did you feel welcomed on the unit?	Yes	No	Unknown

Comments:

Were you satisfied with:

Questions	Yes	No	Maybe	Not applicable
Food and fluids offered	Yes	No	Maybe	Not applicable
The accessibility of our unit	Yes	No	Maybe	Not applicable
The layout of our unit	Yes	No	Maybe	Not applicable
The cleanliness of our unit	Yes	No	Maybe	Not applicable
The transition to our unit	Yes	No	Maybe	Not applicable

Comments:

Is there anything else that you would like to add about your experience?

Thank You! The survey is confidential and your name will not be connected with your responses. However, if you would like to share more details or would like us to follow up directly with you please connect with Sandra Marche, Palliative Care Specialist, email: sandra.march@tehn.ca, phone: 416-461-8272 ext. 7652.

Would you like to share your insights as a patient or family advisor here at MGH and help us grow and improve our services? Please connect with Sandra Marche, Palliative Care Specialist, email: sandra.march@tehn.ca, phone: 416-461-8272 ext. 7652.

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Family Survey for the Care on the Palliative Care Unit G5