Appendix: Survey
Part 1: Background Information
Please provide the following background information
- 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
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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
- 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)
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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 opinion1 / 2 / 3 / 4 / 5
Thanks for taking the time to complete this survey!
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