QUALITY OF DYING AND DEATH QUESTIONNAIRE FOR NURSES VERSION 3.2A

Transcription

1 UNIVERSITY OF WASHINGTON SCHOOL OF MEDICINE QUALITY OF DYING AND DEATH QUESTIONNAIRE FOR NURSES VERSION 3.2A Plas rurn your compld qusionnair in h nclosd nvlop o: [Rurn Addrss] RNID PID Copyrigh by h Univrsiy of Washingon. All righs rsrvd. Do no duplica wihou wrin prmission.

2 A QUESTIONNAIRE FOR NURSES ABOUT A PATIENT S EXPERIENCES AT THE END OF LIFE Th following qusions ar abou xprincs ha your pain may hav had during h im h/sh was in h ICU. In answring hs qusions, plas bas your raings on how you hink hs xprincs affcd h qualiy of your pain s dying and dah, no how you hink your pain would hav rad hs xprincs. W undrsand ha you wr no prsn h whol im, bu plas mak your bs sima. On h raing scal blow, 0 = a rribl xprinc and 10 = an almos prfc xprinc. If your pain did no hav, or did no appar o hav, a paricular xprinc or if you do no know nough o ra i, you may chck h box on h righ. 1. Appar o hav his/hr pain undr conrol 2. Appar o hav conrol ovr wha was going on around him/hr 3. B abl o fd himslf/hrslf 4. Appar o brah comforably 5. Appar o fl a pac wih dying 6. Appar o b unafraid of dying Trribl Exprinc Prfc Exprinc 7. Laugh, smil 8. Appar o kp his/hr digniy and slf-rspc 9. Spnd im wih his/hr family or frinds 10. Spnd im alon 2

3 11. B ouchd or huggd by lovd ons 12. Say goodby o lovd ons 13. Clar up bad flings wih ohrs 14. Hav on or mor visis from a rligious or spiriual advisor 15. Hav a spiriual srvic or crmony bfor his/hr dah Trribl Exprinc Prfc Exprinc MEDICAL CARE AT THE END OF LIFE Th following qusions ar abou aspcs of mdical car ha your pain rcivd in h ICU. 1a. Did your pain rciv mchanical vnilaion during his or hr say in h ICU? (Circl on numbr) 1 Ys 3 know >>>>>>>>>> Go o Qusion 2a. b. How would you ra his aspc of your pain s dying xprinc? (Circl on numbr) Trribl Prfc 3

4 2a. Did your pain rciv dialysis during his or hr say in h ICU? (Circl on numbr) 1 Ys 3 know >>>>>>>>>> Go o Qusion 3a. b. How would you ra his aspc of your pain s dying xprinc? (Circl on numbr) Trribl Prfc 3a. Do you hink ha your pain rcivd h righ amoun of sdaion during his or hr say in h ICU? (Circl on numbr) 1 Ys 3 know >>>>>>>>>> Go o Qusion 4a. b. How would you ra his aspc of your pain s dying xprinc? (Circl on numbr) Trribl Prfc 4a. Did your pain discuss his or hr wishs for nd of lif car wih his or hr docor - - for xampl, rsusciaion or innsiv car? (Circl on numbr) 1 Ys 3 know >>>>>>>>>> Go o Qusion 5. b. How would you ra his aspc of your pain s dying xprinc? (Circl on numbr) Trribl Prfc 4

5 5. Do you hink ha your pain was kp aliv oo long? (Circl on numbr) 1 Ys 3 know, unsur EXPERIENCES AT THE MOMENT OF DEATH Th nx qusions ar abou your pain s momn of dah. 1a. Was anyon, including family, frinds or saff, prsn a h momn of your pain s dah? (Circl on numbr) 1 Ys 3 know >>>>>>>>>> Go o Qusion 2a. b. How would you ra his aspc of your pain s dah? (Circl on numbr) Trribl Prfc 2a. In h momn bfor your pain s dah, was h/sh: (Circl on numbr) 1 Awak 2 Aslp 3 In a coma or unconscious 4 know >>>>>>>>>> Go o Qusion 3 b. How would you ra his aspc of your pain s dah? (Circl on numbr) Trribl Prfc 5

6 3. Ovrall, how would you ra h qualiy of your pain s dying? (Circl on numbr) Trribl Prfc OVERALL RATINGS OF CARE 1. Ra h car your pain rcivd in h las svral days of his/hr lif whil in h ICU from all docors and ohr halh car providrs combind. (Circl h numbr) Wors Halhcar Possibl Bs Halhcar Possibl 2. Ra h car your pain rcivd in h las svral days of his/hr lif whil in h ICU from his/hr docor. (Circl h numbr) Wors Halhcar Possibl Bs Halhcar Possibl REMEMBER: IF YOU HAVE ANY QUESTIONS, PLEASE CALL. 6

7 SOME QUESTIONS ABOUT YOU Las, w would lik o ask you a fw qusions ha will hlp dscrib our nurs sampl. Som of hs qusions ar rquird by h Naional Insius of Halh. 1. Whn wr you born? (Plas wri h yar) Wha is your gndr? (Circl on numbr) 1 Mal 2 Fmal 3. Wha is your hniciy? (Circl on numbr) 1 Hispanic n-hispanic 4. Wha is your rac? (Circl all ha apply) 1 Whi 2 Black / African Amrican 3 Asian 4 Pacific Islandr 5 Naiv Amrican or Alaskan Naiv 6 Ohr (plas spcify) 5. In your nursing ducaional prparaion, wha is h highs dgr you hav compld? (Circl on numbr) 1 Diploma 2 Associa dgr 3 Baccalaura 4 Masrs in Nursing 5 Ohr (plas spcify) 7

8 6. Wha spcial crificaions do you hold? (Circl on numbr) 1 CCRN (Criical Car Crificaion) 2 CEN (Crifid Emrgncy Nurs) 3 CHPN (Crifid Hospic and Palliaiv Nurs) 4 CNRN (Nuroscinc Crificaion) 5 OCN (Crifid Oncology Nurs) 6 ACLS (Advancd Cardiac Lif Suppor) 7 Non 8 Ohr (plas spcify) 7. How many yars hav you workd in nursing? (Plas fill in) yars 8. How many yars hav you workd in criical car nursing? (Plas fill in) yars 9. Wha yar did you compl your las clinical dgr (nursing school)? (Plas wri h yar) 10. Wha raining in nd-of-lif opics hav you had sinc compling your formal nursing ducaion? (Circl on numbr) 1 End-of-Lif Nursing Educaion Consorium (ELNEC) Projc 2 Coninuing ducaion in nd-of-lif opics for a oal of 6 hours or mor 3 Coninuing ducaion in nd-of-lif opics for a oal of lss han 6 hours 4 Non 5 Ohr (plas spcify) 11. Today s da is (Plas fill in oday s da) / / monh day yar IF YOU HAVE ANY ADDITIONAL COMMENTS, PLEASE FEEL FREE TO ADD THEM HERE OR TO THE BACK OF THIS PAGE. THANK YOU FOR YOUR HELP WITH THIS STUDY. 8