Palliative Care Quality Perception Survey
Your feedback will help us improve the quality of our palliative care services. Please answer the following questions based on your experience.
What is your relationship to the patient receiving palliative care?
*
Patient
Family member
Caregiver (non-family)
Other
How long have you or your loved one been receiving palliative care services?
*
Please Select
Less than 1 week
1–4 weeks
1–6 months
More than 6 months
Which age group best describes the patient?
*
Please Select
Under 18
18–29
30–49
50–69
70 or older
Please rate your perception of the following aspects of our palliative care services:
*
Rows
Excellent
Good
Fair
Poor
Symptom management (pain, discomfort, etc.)
1
2
3
4
Emotional support provided
5
6
7
8
Communication from care team
9
10
11
12
Respect for patient’s wishes
13
14
15
16
Support for family/caregivers
17
18
19
20
How satisfied are you with the overall quality of palliative care services provided?
*
1
2
3
4
5
Did the care team explain information clearly and answer your questions?
*
Always
Usually
Sometimes
Never
Were your (or your loved one's) cultural, spiritual, or personal values respected by the care team?
*
Always
Usually
Sometimes
Never
How would you rate the environment and facilities where palliative care was provided?
*
Excellent
Good
Fair
Poor
What was the most helpful aspect of the palliative care services you received?
Please share any suggestions or comments to help us improve our palliative care services.
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