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.

* 1.  Please tell us the GP surgery that was involved in your relative’s/friend’s care

* 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 symptoms other than pain
Spiritual support
Emotional support
Support to stay where they wanted to be
Treated with dignity and


* 3. Overall, do you feel that the care they got from the surgery during that time was:

  Excellent Good Fair Poor Don't know
Other staff

* 4. Were you given the opportunity to talk with any of the doctors involved in your relative’s care?

* 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?

* 6. While your relative was ill was the possibility that they may not recover ever discussed with you?

* 7. Did a health professional tell you that your relative may die?

* 8. If yes, did you feel you had enough privacy when you were told your relative may die?

* 9. Was there ever a discussion about where your relative wanted to be cared for in their last days?

* 10. Were you given a chance to talk to someone about any concerns you had?

* 11. Did you feel there was ever a decision made about their care without enough involvement from yourself?

* 12. Did you feel that their personal wishes were respected by those caring for them?

* 13. Did you feel that their religious/cultural/spiritual beliefs were taken into consideration by those caring for them?

* 14. After your relative died was there anything that could have been improved?

* 15. Since your relative died, have you been able to talk to anyone from the surgery about your feelings regarding their illness or death?

* 16. If no, was this because:

* 17. If you did talk with any of the following about your experience, how would you rate their helpfulness?

  Helpful Not at all helpful
Other staff

* 18. On balance, did you feel that home was the right place for your relative to spend their last days?

* 19. Overall, how would you rate the staff on the following points of care?

  Good Average Poor
Emotional support
Respect and dignity

* 20. Do you have any additional comments that you want to tell us about?

* 22. Was your relative/friend:

* 23. What was their age when they died?

* 25. Did they consider themselves to have a disability?

* 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)