Dudley community Voices bereavement survey We are interested in the quality of care provided to patients, their families, close friends and carers by their GP practices at the end of life. This information will help us to improve the care and support we provide to people at this difficult time. All information is confidential and you do not need to include your name unless you wish us to contact you. Question Title * 1. Please tell us the GP surgery that was involved in your relative’s/friend’s care Question Title * 2. During this last period of care, how would you assess the overall level of support given in the following areas from those caring for your relative/friend?(Pick one box for each question) Excellent Good Fair Poor Does not apply Don't know Relief of pain Relief of pain Excellent Relief of pain Good Relief of pain Fair Relief of pain Poor Relief of pain Does not apply Relief of pain Don't know Relief of symptoms other than pain Relief of symptoms other than pain Excellent Relief of symptoms other than pain Good Relief of symptoms other than pain Fair Relief of symptoms other than pain Poor Relief of symptoms other than pain Does not apply Relief of symptoms other than pain Don't know Spiritual support Spiritual support Excellent Spiritual support Good Spiritual support Fair Spiritual support Poor Spiritual support Does not apply Spiritual support Don't know Emotional support Emotional support Excellent Emotional support Good Emotional support Fair Emotional support Poor Emotional support Does not apply Emotional support Don't know Support to stay where they wanted to be Support to stay where they wanted to be Excellent Support to stay where they wanted to be Good Support to stay where they wanted to be Fair Support to stay where they wanted to be Poor Support to stay where they wanted to be Does not apply Support to stay where they wanted to be Don't know Treated with dignity andrespect Treated with dignity andrespect Excellent Treated with dignity andrespect Good Treated with dignity andrespect Fair Treated with dignity andrespect Poor Treated with dignity andrespect Does not apply Treated with dignity andrespect Don't know Question Title * 3. Overall, do you feel that the care they got from the surgery during that time was: Excellent Good Fair Poor Don't know Doctors Doctors Excellent Doctors Good Doctors Fair Doctors Poor Doctors Don't know Nurses Nurses Excellent Nurses Good Nurses Fair Nurses Poor Nurses Don't know Other staff Other staff Excellent Other staff Good Other staff Fair Other staff Poor Other staff Don't know Question Title * 4. Were you given the opportunity to talk with any of the doctors involved in your relative’s care? Yes No (if no, go to question 6) Question Title * 5. If you spoke to a doctor, was there ever a problem understanding what the doctor was saying to you about what was happening and what to expect? Yes No If yes, please try to tell us more Question Title * 6. While your relative was ill was the possibility that they may not recover ever discussed with you? Yes No Question Title * 7. Did a health professional tell you that your relative may die? Yes No Question Title * 8. If yes, did you feel you had enough privacy when you were told your relative may die? Yes No Question Title * 9. Was there ever a discussion about where your relative wanted to be cared for in their last days? Yes No Don't know Question Title * 10. Were you given a chance to talk to someone about any concerns you had? Yes No Question Title * 11. Did you feel there was ever a decision made about their care without enough involvement from yourself? Yes No If yes, please try to tell us more Question Title * 12. Did you feel that their personal wishes were respected by those caring for them? Yes No Question Title * 13. Did you feel that their religious/cultural/spiritual beliefs were taken into consideration by those caring for them? Yes No Question Title * 14. After your relative died was there anything that could have been improved? Yes No If yes, please try to tell us more Question Title * 15. Since your relative died, have you been able to talk to anyone from the surgery about your feelings regarding their illness or death? Yes (go to question 14) No (go to question 13) Question Title * 16. If no, was this because: I/we did not wish/need to contact anyone No information was given as to who I/we could contact Question Title * 17. If you did talk with any of the following about your experience, how would you rate their helpfulness? Helpful Not at all helpful Doctors Doctors Helpful Doctors Not at all helpful Doctors Doctors Doctors Nurses Nurses Helpful Nurses Not at all helpful Nurses Nurses Nurses Other staff Other staff Helpful Other staff Not at all helpful Other staff Other staff Other staff Question Title * 18. On balance, did you feel that home was the right place for your relative to spend their last days? Yes No If no, please specify preferred place Question Title * 19. Overall, how would you rate the staff on the following points of care? Good Average Poor Communication Communication Good Communication Average Communication Poor Emotional support Emotional support Good Emotional support Average Emotional support Poor Respect and dignity Respect and dignity Good Respect and dignity Average Respect and dignity Poor Question Title * 20. Do you have any additional comments that you want to tell us about? Question Title * 21. What was your relationship with the person you have completed this questionnaire about? husband/wife/partner son/daughter brother/sister son/daughter in law other relative carer friend neighbour care home staff warden (sheltered accommodation) someone else Question Title * 22. Was your relative/friend: Male Female Question Title * 23. What was their age when they died? 18-20 21-29 30-44 45-59 60-69 70-79 80+ Question Title * 24. To which of these ethnic groups would you say they belonged? White British White Irish White Other White / Black White / Asian Mixed Other Indian Pakistani Bangladeshi Asian Other Caribbean African Black Other Chinese Other Ethnic Group Please state if selected other Question Title * 25. Did they consider themselves to have a disability? Yes No Question Title * 26. If you would like someone to contact you regarding anything you have included on this questionnaire, please write your name and contact number below:(NB there is no obligation to leave your contact details, please do so only if you wish to be contacted) Name Address Address 2 Town Postal Code Phone Number THANK YOU VERY MUCH FOR YOUR HELP Done