6. How satisfying is your life?

Not at all 0    1    2    3    4    5    6    7    8    9    10 Completely

7. How much anxiety do you have?

None at all 0    1    2    3    4    5    6    7    8    9    10 A great deal

8. How free are you to express feeling of sadness, grief, and anger?

Not at all 0    1    2    3    4    5    6    7    8    9    10 Completely

9. Do you have enough opportunity to talk about your loved one’s illness, experiences, and possible death?

Not at all 0    1    2    3    4    5    6    7    8    9    10 Completely

10. Do you have enough opportunity to talk with others about how your loved one’s illness has affected you and how you are doing?

Not at all 0    1    2    3    4    5    6    7    8    9    10 Completely

11. How much do you feel like your loved one’s care is manageable for you and your family?

Not at all 0    1    2    3    4    5    6    7    8    9    10 Completely

12. How much do you worry about family and friends not being there for you?

Not at all 0    1    2    3    4    5    6    7    8    9    10 Completely

13. Have family / friends given specific support without you asking?

Not at all 0    1    2    3    4    5    6    7    8    9    10 A great deal

14. Do you have opportunities to talk openly about your experiences with family and friends?

Not at all 0    1    2    3    4    5    6    7    8    9    10 A great deal

15. Is the amount of support you receive from others sufficient to meet your needs?

Not at all 0    1    2    3    4    5    6    7    8    9    10 Completely

16. How much isolation do you feel is caused by your family member’s illness or treatment?

None 0    1    2    3    4    5    6    7    8    9    10 A great deal

17. Do you know your loved one’s care and treatment wishes and goals?

Not at all 0    1    2    3    4    5    6    7    8    9    10 Completely

18. If you are still working, has your work place been supportive? (leave blank if not still working)

Not at all 0    1    2    3    4    5    6    7    8    9    10 A great deal

19. To what degree has your family member’s illness and treatment interfered with your employment?

No problem 0    1    2    3    4    5    6    7    8    9    10 Severe problem

20. To what degree has your family member’s illness and treatment interfered with your activities at home?

No problem 0    1    2    3    4    5    6    7    8    9    10 Severe problem

21. How much financial burden resulted from your family member’s illness or treatment?

None 0    1    2    3    4    5    6    7    8    9    10 Extreme

22. How much has there been a problem receiving needed support to meet your financial needs?

No problem 0    1    2    3    4    5    6    7    8    9    10 Severe problem

23. How important to you is your participation in spiritual or religious experiences (e.g. meditation, spiritual traditions or rituals, praying, or going to a place of worship)?

Not at all 0    1    2    3    4    5    6    7    8    9    10 Very Important

24. Is the amount of support you receive from religious activities such as going to church or temple sufficient to meet your needs?

Not at all 0    1    2    3    4    5    6    7    8    9    10 Completely

25. To what extent has your loved one’s illness made positive changes in your life?

None at all 0    1    2    3    4    5    6    7    8    9    10 A great deal

26. Do you sense a purpose / mission for your life or a reason for being alive?

None at all 0    1    2    3    4    5    6    7    8    9    10 A great deal

27. How hopeful do you feel?

Not at all hopeful 0    1    2    3    4    5    6    7    8    9    10 Very hopeful

28. How much opportunity have you had to reflect with your family member on his/her life?

None at all 0    1    2    3    4    5    6    7    8    9    10 A great deal

29. Do you view time as precious and value each minute of life?

Not at all 0    1    2    3    4    5    6    7    8    9    10 A great deal

30. Have you experienced healing in spiritual, emotional, relational areas of your life?

Not at all 0    1    2    3    4    5    6    7    8    9    10 A great deal

1. Your loved one’s experience receiving effective and timely pain management

No problem 0    1    2    3    4    5    6    7    8    9    10 Severe problem

2. Your loved one’s experience receiving effective and timely symptom relief, e.g. difficulty breathing, nausea, constipation.

No problem 0    1    2    3    4    5    6    7    8    9    10 Severe problem

3. Adequate help for meeting your loved one’s physical needs at home

No problem 0    1    2    3    4    5    6    7    8    9    10 Severe problem

4. Were you given enough information about your loved one’s care and treatment choices to prepare you for his/her care and treatments?

Not at all 0    1    2    3    4    5    6    7    8    9    10 Completely

5. How difficult was it to find out information about your loved one’s illness, care, and treatment choices?

Not at all 0    1    2    3    4    5    6    7    8    9    10 A great deal

6. If there was a conflict over your loved one’s care, did you feel supported in having your care wishes honored?

Not at all 0    1    2    3    4    5    6    7    8    9    10 A great deal

7. Did you feel that you had appropriate control over your loved one’s care choices and health care experiences?

Not at all 0    1    2    3    4    5    6    7    8    9    10 Completely

8. Did you feel free to refuse care or treatments for your loved one?

Not at all 0    1    2    3    4    5    6    7    8    9    10 Completely

9. Did you and your family feel welcomed 24 hours a day and with each appointment?

Not at all 0    1    2    3    4    5    6    7    8    9    10 A great deal

10. Was your privacy and confidentiality respected?

Not at all 0    1    2    3    4    5    6    7    8    9    10 A great deal

11. Were you given information about support groups for yourself and your loved one or put in touch with others who had similar experiences?

Not at all 0    1    2    3    4    5    6    7    8    9    10 A great deal

12. Do you have access to and opportunity to talk with professional counselors?

Not at all 0    1    2    3    4    5    6    7    8    9    10 A great deal

13. Were you given the opportunity to have chaplains or others to pray with and for you and your loved one or to say no to their praying with or for you?

Not at all 0    1    2    3    4    5    6    7    8    9    10 A great deal

14. Did the health care team ask about your loved one’s Living Will or advance care planning?

Not at all 0    1    2    3    4    5    6    7    8    9    10 A great deal

15. Please rate your overall experience with the quality of your health services

Very inconsistent 0 1 2 3 4 5 6 7 8 9 10 Consistently high

16. Have those caring for your loved one had a good understanding of the illness, treatment, and care wishes?

Not at all 0    1    2    3    4    5    6    7    8    9    10 A great deal

17. Have people consistently followed through on you and your loved one’s care wishes?

Not at all 0    1    2    3    4    5    6    7    8    9    10 A great deal

18. Did you get enough help obtaining and completing applications and financial forms, e.g. insurance, social security, disability?

Not at all 0    1    2    3    4    5    6    7    8    9    10 A great deal

19. Did you get enough help finding needed resources and support, e.g. transportation or homemaker assistance?

Not at all 0    1    2    3    4    5    6    7    8    9    10 A great deal

20. Have you felt caring, respect, and genuine presence from your loved one’s doctors?

Not at all 0    1    2    3    4    5    6    7    8    9    10 A great deal

21. Have you felt caring, respect, and genuine presence from your nurses and others?

Not at all 0    1    2    3    4    5    6    7    8    9    10 A great deal

22. Was your loved one’s doctor’s communication with you easy to understand and consistent?

Not at all 0    1    2    3    4    5    6    7    8    9    10 A great deal

23. Was your loved one’s nurses' communication with you easy to understand and consistent?

Not at all 0    1    2    3    4    5    6    7    8    9    10 A great deal

24. Did you feel supported by your loved one’s doctors if you looked for second opinions and other care choices?

Not at all 0    1    2    3    4    5    6    7    8    9    10 A great deal

25. If you had questions about "complementary therapies", did your loved one’s doctors’ answer your questions to your satisfaction?

Not at all 0    1    2    3    4    5    6    7    8    9    10 A great deal

26. How much do you worry about physicians and other professionals not being there for you?

Not at all 0    1    2    3    4    5    6    7    8    9    10 Completely

27. To what extent has communication with healthcare personnel assisted you to maintain hope?

Not at all 0    1    2    3    4    5    6    7    8    9    10 A great deal

28. Have your doctor(s) provided you the opportunity to discuss your loved one’s possible death?

Not at all 0    1    2    3    4    5    6    7    8    9    10 A great deal

29. Have your nurses / others provided you the opportunity to discuss your loved one’s possible death?

Not at all 0    1    2    3    4    5    6    7    8    9    10 A great deal