Appendix: Survey

Part 1: Background Information

Please provide the following background information

  1. What is your health discipline?

Medical resident

Medical fellow

Staff physician

Registered nurse

Licensed practical nurse

Other (please specify) ______

2.What is your area of specialization?

Palliative medicine/Palliative care

Family medicine

Anesthesia and Pain medicine

Oncology

Internal medicine

Other (please specify) ______

3a.How many years have you been working in Palliative Care?

3b.How many years have you been working in chronic pain?

4.Is English your first language?

Yes

No

1

Part 2: ESAS Experience

The ESAS is a well recognized clinical tool used to assess patients for nine symptoms commonly encountered in palliative care settings. It has also been used in non-palliative care settings for symptom assessment. Please answer the following questions about your experience with using the ESAS in clinical practice.

1.In which of the following settings have you used the ESAS
(Please check all that apply)?

Tertiary palliative care

Hospice

Home

Acute care, in-patients

Acute care, out-patients (palliative care)

Acute care, out-patients (chronic pain)

Other (please specify)

2.How long have you been using the ESAS?

2 weeks or less

More than 2 weeks to 1 month

More than 1 month and less than 6 months

More than 6 months

3.On average, how often have you used the ESAS during
the past 6 months?

once

once a month

once a week

2-3 times a week

every day

  1. How do you use the ESAS in your clinical practice?
    (Please check all that apply)

assisting patients to complete the tool

directing treatment

assessing treatment success

other (please specify)

1

Part 3: ESAS Knowledge

1.Which of the following best describes “tiredness”?
Please check all that apply:

Sleepy

Drowsy

Lazy

Low energy

Other (please specify) ......

Do not know

2.Which of the following best describes “depression”?

Please check all that apply:

Restless

Blue

Exhaustion

Sad

Other (please specify) ......

Do not know

3.Which of the following best describes “anxiety”?

Please check all that apply:

Restless

Worried

Low

Miserable

Other (please specify) ......

Do not know

4.Which of the following best describes “feeling of well-being”?

Please check all that apply:

Overall physical and mental comfort

Happiness

Healthiness

The honest answer to the question “How are you?”

Other (please specify) ......

Do not know

5.Which of the following best describes “shortness of breath”?

Low SpO2 (Oxygen saturation)

Respiratory rate > 20 breaths per minute

Feeling of inability to catch ones breath

Pain with deep inspiration

Other (please specify) ......

Do not know

6.Which of the following best describes “drowsiness”?

Tiredness

Sleepiness

Exhaustion

Low Energy

Other (please specify) ......

Do not know

7.You have a patient that states his pain in the past 24 hours ranges
from 3 – 9 but it most often is around a 6.
His pain right now is 4. The appropriate ESAS pain score is:

3

4

6

9

Other (please specify) ......

Do not know

8.A patient states he/she has no desire to eat at all.
The ESAS score for appetite is best represented by which
number?

1

4

6

10

Other (please specify) ......

Do not know

9.What is an appropriate well-being ESAS score for a person with
the best feeling of well being?

0

4

6

10

Other (please specify) ......

Do not know

10.What is an appropriate depression ESAS score for a person with
complaints of depression that is pretty bad, but has been much
worse in the past?

2

6

9

Other (please specify) Do not know

11.What would be the best way to describe the “worst possible pain” to a patient?

not able to concentrate because of pain

the worst pain you had in the past

the worst pain you could imagine

Other (please specify)

Do not know

12.What would be the best way to describe “the worst possible nausea” to a patient?

can not keep any food down

even the thought of food makes one want throwing up

the worst nausea you can imagine

Other (please specify).

Do not know

13.When you use the ESAS to assess your patient's symptoms, do you ask whether the score the patient selected is mild, moderate or
severe?

No

Yes

Part 4: Training

1.What type training have you received on the ESAS?

Please check all that apply:

None

Handout

Informal one on one

Group teaching

Other (please specify)

2.Do you feel that you have been adequately oriented to and trained
in the ESAS and its appropriate use?

Yes

No

3.If you answered “No” to question 2, then what type of training
would you like to have received?

Part 5: General Comments

1.What are the benefits of using the ESAS in your clinical practice?

2.What are the challenges of using the ESAS in your clinical practice?

3.Overall how comfortable are you using the ESAS?

Not at all / Very comfortable / No opinion
1 / 2 / 3 / 4 / 5

Thanks for taking the time to complete this survey!

1