ICU Questionnaire (Health Care Professional)

My ICU Guide - ICU Questionnaire (Heatlh Care Professional)

Please review the text contained in the questionnaire, ask all the questions and reword answers in the space provided. Along the way, we have included several tips or suggestions on how to move this discussion forward with a family
Your Intensive Care Unit (ICU) staff realize that having a family member or friend in the ICU can be very stressful. The ICU may seem like a strange environment with lots of machines, noises and monitors. ICU patients are usually very sick. You may have a lot of questions about the care your family member may receive. The ICU team is here to help you get the information and support you need.

This questionnaire will ask questions about the patient in the ICU, their values, important decision making situations, and the experience in the ICU. It is divided into 8 pages. At the end of the questionnaire, an individualized report will be generated summarizing your responses. This information may be helpful to you and can be provided to the health care team to help them better understand the patient and family. By providing your email address, you will be able to save the questionnaire to return to later and receive an emailed copy of the report.
Interviewer Email * Required
By providing your email address, you will be able to save the questionnaire to return to later and receive an emailed copy of the report.
Interviewer: Probe as to the familiarity with the ICU and need for general orientation to the ICU. Provide ICU information leaflet if available, or refer to the Learn About the ICU section of this website.
Help Us Get To Know You
Is there anything that you would like the ICU team to know about you and your family that will help us support you through your family member’s illness the best we can?
By family, we mean two or more persons who are related in any way - biologically, legally or emotionally.
Interviewer: Probe about the size, nature, and characteristics of the family if not volunteered. For example: How does your family make decisions? Who will be the family spokesperson? What is the makeup of the family (children, relatives, friends, spouse, etc.) and are they close by?
In general, how are you feeling right now? Use the slider to best describe how DEPRESSED you feel NOW, where zero equals no depression and 10 equals the worst possible depression:
Depression = Feeling sad
In general, how are you feeling right now? Use the slider to best describe how ANXIOUS you feel NOW, where zero equals no anxiety and 10 equals the worst possible anxiety:
Anxiety = Feeling nervous
Interviewer: Based on responses, refer to the following sections of this website to provide added support to the caregiver/family member:

Looking After Yourself

When a family member is in the ICU

Save and Continue Later

Please help us understand the patient’s physical status prior to this hospital admission.
Palliative Performance Scale (PPS v.2)
INSTRUCTIONS TO INTERVIEWER
1. The PPS should be completed on initial assessment at all sites and weekly thereafter.
2. The PPS can be recorded by a staff who are familiar with the person’s functional status, such as rehabilitation, nursing or medical staff.
3. Recording of the PPS is on the consultation form at initial assessment (home care), and weekly there is a row near the bottom of the ESAS graph.  
4. PPS scores are determined by reading horizontally at each level to find a ‘best fit’ for the patient who is then assigned as the PPS% score.
5. Begin at the left column and read downwards until the appropriate ambulation level is reached, then read across to the next column and downwards again until the activity/evidence of disease is located. These steps are repeated until all five columns are covered before assigning the actual PPS for that patient. In this way, ‘leftward’ columns (columns to the left of any specific column) are ‘stronger’ determinants and generally take precedence over others.
  Example 1: A patient who spends the majority of the day sitting or lying down due to fatigue from advanced disease and requires considerable assistance to walk even for short distances but who is otherwise fully conscious level with good intake would be scored at PPS 50%.  
  Example 2: A patient who has become paralyzed and quadriplegic requiring total care would be PPS 30%. Although this patient may be placed in a wheelchair (and perhaps seem initially to be at 50%), the score is 30% because he or she would be otherwise totally bed bound due to the disease or complication if it were not for caregivers providing total care including lift/transfer. The patient may have normal intake and full conscious level.  
  Example 3: However, if the patient in example 2 was paraplegic and bed bound but still able to do some selfcare such as feed themselves, then the PPS would be higher at 40 or 50% since he or she is not ‘total care.’  
STEP-BY-STEP INSTRUCTIONS
1. We need you to pick one category in each column.
2. Click on the blue bar below to open the Palliative Performance Scale Chart.
3. For each section (Ambulation, Activity & Evidence of Disease, Self Care, Intake, Conscious Level) discuss with the family member to choose the appropriate level, and then select it from the drop-down menu below.
4. After selecting a level for each section, use the lowest PPS level recorded to select an Overall PPS Level.
© Copyright Notice. The Palliative Performance Scale version 2 (PPSv2) tool is copyright to Victoria Hospice Society and replaces the first PPS published in 1996 [J Pall Care 9(4): 2632]. It cannot be altered or used in any way other than as intended and described here. Programs may use PPSv2 with appropriate recognition.

Click here to see Palliative Performance Scale (PPS v.2) Chart

PPS Level	Ambulation	Activity & Evidence of Disease	Self-Care	Intake	Conscious Level
100%	Full	Normal activity & work / No evidence of disease	Full	Normal	Full
90%	Full	Normal activity & work / Some evidence of disease	Full	Normal	Full
80%	Full	Normal activity with effort / Some evidence of disease	Full	Normal or Reduced	Full
70%	Reduced	Unable normal job/work / Significant disease	Full	Normal or Reduced	Full
60%	Reduced	Unable hobby/house work / Significant disease	Occasional assistance necessary	Normal or Reduced	Full or Confusion
50%	Mainly Sit/Lie	Unable to do any work / Extensive disease	Considerable assistance required	Normal or Reduced	Full or Confusion
40%	Mainly in Bed	Unable to do most activity / Extensive disease	Mainly assistance	Normal or Reduced	Full or Drowsy +/- Confusion
30%	Totally Bed Bound	Unable to do any activity / Extensive disease	Requires total care	Normal or Reduced	Full or Drowsy +/- Confusion
20%	Totally Bed Bound	Unable to do any activity / Extensive disease	Requires total care	Minimal to Sips	Full or Drowsy +/- Confusion
10%	Totally Bed Bound	Unable to do any activity / Extensive disease	Requires total care	Mouth Care Only	Drowsy or Coma +/- Confusion

Ambulation
Activity & Evidence of Disease
Self-Care
Intake
Conscious Level
Overall PPS Level (use instructions provided to choose appropriate score)
The slider below represents a person’s total lifetime from birth on the far left to death on the far right. Prior to their recent illness that brought them to the ICU, please move the slider to where you saw your family member at that point in time.

Save and Continue Later

Decisional Preferences - Family Member Version
Who else would you like to be involved in making the decisions regarding the care of your family member in the ICU?
Please specify.
What is your relationship to this person?
e.g. Spouse, brother or sister, friend, etc.
Which of the following best represents the role you prefer when it comes to making the final decision about your family member's treatments in the ICU?
- I prefer to leave the medical decisions to the doctors
- I prefer that the doctors make the final decision but that they seriously consider my opinion
- I prefer that the doctor and I share responsibility for deciding about the medical decisions
- I prefer to make the final decision about the medical decisions after seriously considering the doctors’ opinion
- I prefer to make the decision by myself
- Declined
How else can we best support you at this time?
Interviewer: This concludes the portion of the questionairre that requires responses from the family. The next page requires responses from the hospital record. If the patient is 80 years of age or more (to calculate clinical prediction score). Once finished, remember to submit the data, print the report and share the report with the clinical team of the family.

Save and Continue Later

My ICU Guide - ICU Questionnaire (Heatlh Care Professional)

Help Us Get To Know You

Help Us Get To Know Your Family Member

Please help us understand the patient’s physical status prior to this hospital admission.

Palliative Performance Scale (PPS v.2)

INSTRUCTIONS TO INTERVIEWER

STEP-BY-STEP INSTRUCTIONS

Click here to see Palliative Performance Scale (PPS v.2) Chart

Informational Preferences - Family Member Version

Many patients in the ICU are unable to make their own medical decisions. In these situations, knowing if they have already communicated their wishes or written them down can be helpful in making decisions about the treatments your family member may receive.

Making Treatment Decisions in ICU

What Matters Most (Graphic Values History Tool)

The treatment team would like to know more about what matters most to each patient in regards to health care and quality of life. Before we begin, we would like to ask:

Quality of Life†

Exploring Value Trade-offs

What would he/she say is more important:

Impact of Decision on Others

Religious, Spiritual and/or Cultural Beliefs

Please choose ONE.

Considering the option you prefer (your answer to the last question), please answer the following questions:

Decisional Preferences - Family Member Version

Clinical Prediction Rule