Please Cite: Vo H et al. GeriatrNurs. 2011 32(1):58-62

NY Hospital Employee Anonymous Survey

Please complete this voluntary, anonymous, and completely confidentialsurvey to aid researchers and staff to assess palliative care needsin XXX Hospital. This information will be used as aggregated data only. By completing and returning the form to DR XXX, principal investigator, you are giving consent to participate. If you desire more information, contactDr XXX at: Dr .

Abbreviations: POLST=Physician Orders for Life-Sustaining Treatment, EOL=End of Life, AD=Advance Directives

Part 1:EOL Experience

1. How often in the last 12 months have you been asked to fill out or administer a DNR or POLST?

Never 1 to 10 times 11 to 20 times 21-30 times >30 times

2. How many times in the last 12 months have you been asked to honor a DNR or POLST in the hospital setting?

Never 1 to 10 times 11 to 20 times 21-30 times >30 times

3. How often in the last 12 months have you been asked to ignore an existing DNR, POLST, or another advance directive by a surrogate decision maker or family member?

Never 1 to 10 times 11 to 20 times 21-30 times >30 times

4. How often in the last 12 months have you met with a family member regarding EOL decisions?

Never 1 to 10 times 11 to 20 times 21-30 times >30 times

5. How often in the last 12 months have you met with a patient regarding EOL decisions?

Never 1 to 10 times 11 to 20 times 21-30 times >30 times

6. A POLST form must be signed by a physician to be valid. True False Don’t Know

7. A POLST form must be pink to be valid. True False Don’t Know

Part 2: EOL Attitudes

Please check the box that best describes your feelings. / Agree
Strongly / Agree / Neutral / Disagree / Disagree Strongly
8. Patients who have filled out DNRand POLST forms have better pain management
9. All long-term hospital patients should have a POLST form executed
10. It is the responsibility of Social Workers to discuss the POLST with patients at EOL
11. It is the responsibility of Nurses to discuss the POLST with patients at EOL
12. It is the responsibility of Doctors to discuss the POLSTwith patients at EOL
13. Patients have the right to refuse a medical treatment, even if the treatment prolongs life
14. Patients dying of chronic illness inhospitals should receive specialized palliative care or be referred to hospice.
15. Having a POLST form can reduce unnecessary hospitalizations at the end of life
16. The length and detail of the POLST make it difficult to fill out
17. I feel comfortable performing a family conference
18. I feel comfortable filling out a POLST form with a resident

Part 3: EOL Training

19. What is your professional background (circle one)

Medical attending Medical staff Nurse RN Nurse LPN Social Worker Other______

20. How many years have you been in this profession? 0 1-5 6-10 11-20 >20

  1. How many years have you been employed atyour current facility? 0 1-5 6-10 11-20 >20
  1. Please indicate your gender: Male Female
  1. Please indicate your age: ______Years
  1. What religion are you? Buddhist Catholic Jewish Hindu Muslim Protestant None Other______
  1. How religious are you? Not at all Not very A little Somewhat Very religious
  1. Where do you work? San Diego Other______
  1. Have you received an in-service about the POLST form? Yes No Don’t know
  1. Have you ever been asked to honor a DNR or POLST? Yes No Don’t know
  1. Is there time allotted for EOL discussionsin the Hospital where you work? Yes No Don’t know
  1. Were you personally involved with clinical situations where the POLST helped to avoid unnecessary hospitalization?

Yes No Don’t know

  1. Who is the most likely team member to have an End of Life discussion with a patient?

Medical attending Medical staff Nurse RN Nurse LPN Social Worker Other______