Appendix I – Indo-American Cancer Association

JavaScript isn't enabled in your browser, so this file can't be opened. Enable and reload.

Appendix 1 - Pre and post-course questionnaire

To be administered by the Course coordinator to IACA -TIPS trainees at the beginning and at the end of the course.
Please use the following Scale to fill the questionnaire.

1. Unfamiliar 2. Somewhat Unfamiliar 3. Neutral 4. Somewhat Familiar 5.Familiar

* Indicates required question

Name of the Centre *

Choose

Trivandrum Institute of Palliative Sciences, Thiruvananthapuram

MNJ Institute of Oncology, Hyderabad

Tata Memorial Hospital, Mumbai

Gujarat Cancer Research Institute, Ahmedabad

Cipla Palliative Care and Training Centre, Pune

CanSupport, New Delhi

Kasturba Medical College, Manipal, Karnataka

Date *

YYYY

Profession of the Trainee *

Doctor

Nurse

Required

Name of the Trainee *

Your answer

Feedback Type *

Pre Course

Post Course

Were you practicing palliative care before the course? YES/NO, if yes then answer the next question

Yes

Clear selection

How many patients with palliative care needs you were seeing per week?

Your answer

To me PALLIATIVE CARE means *

Your answer

For the following items, please indicate your familiarity with each topic: PALLIATIVE CARE

1. Unfamiliar 2. Somewhat Unfamiliar 3. Neutral 4. Somewhat Familiar 5.Familiar

Principles of supportive and palliative care *

Unfamiliar

Familiar

Members of a multi-disciplinary team and their roles *

Unfamiliar

Familiar

Existing barriers and stigma facing palliative care *

Unfamiliar

Familiar

Palliative Medicine as a speciality *

Unfamiliar

Familar

Differences between the therapeutic goals of palliative care and goals of conventional medical therapy *

Unfamiliar

Familar

ASSESSMENT TOOLS

Use of a scale to evaluate pain, fatigue, nausea, depression, anxiety, dyspnea, appetite, sleep disturbances, well-being *

Unfamiliar

Familiar

Use of a scale to evaluate delirium *

Unfamiliar

Familiar

PAIN MANAGEMENT

Different types of pain - nociceptive and neuropathic *

Unfamiliar

Familiar

Multidimensional assessment of pain - physical & emotional *

Unfamiliar

Familiar

Non-opioid and opioid medications for pain *

Unfamiliar

Familiar

Oral /transdermal routes of opioid administration and their advantages *

Unfamiliar

Familiar

Principles of maintenance and breakthrough dosing of opioids *

Unfamiliar

Familiar

Indications and method for opioid rotation and switching *

Unfamiliar

Familiar

Indications and utility of radiation, chemotherapy, nerve block, or surgery for managing pain *

Unfamiliar

Familiar

FATIGUE

Common causes of fatigue in cancer and palliative care patients *

Unfamiliar

Familiar

Underlying causes and their management with pharmacotherapy *

Unfamiliar

Familiar

Use of cognitive-behavioral therapy, physical exercise, light therapy *

Unfamiliar

Familiar

Preventing sleep disturbances *

Unfamiliar

Familiar

NAUSEA

Common causes of nausea in cancer and palliative care patients *

Unfamiliar

Familiar

Assessing a patient with chronic nausea *

Unfamiliar

Familiar

Receptors involved in nausea *

Unfamiliar

Familiar

Underlying causes and their management with pharmacotherapy *

Unfamiliar

Familiar

ANOREXIA AND CACHEXIA

Mechanism of anorexia and cachexia *

Unfamiliar

Familiar

Assessing and managing a patient with anorexia or cachexia *

Unfamiliar

Familiar

Utility of artificial nutritional support (IV, NG, PEG) *

Unfamiliar

Familiar

Challenges in managing patients with ostomies and catheters *

Unfamiliar

Familiar

CONSTIPATION

Common causes of constipation in cancer and palliative patients *

Unusual presenting symptoms of constipation e.g. delirium, pain, nausea & vomiting, anorexia *

Unfamiliar

Familiar

Assessing a patient with constipation *

Unfamiliar

Familiar

Measures for prevention of constipation *

Unfamiliar

Familiar

Managing chronic constipation *

Unfamiliar

Familiar

ANXIETYand DEPRESSION

Screening for anxiety and depression *

Unfamiliar

Familiar

Multi-disciplinary team in managing psycho-social concerns of person and family *

Unfamiliar

Familiar

Treatment of anxiety/depression in cancer and palliative patients *

Unfamiliar

Familiar

Recognizing risk factors for complicated bereavement *

Unfamiliar

Familiar

DYSPNOEA

Assessment of chronic progressive dyspnoea *

Unfamiliar

Familiar

Palliative management of subjective dyspnoea *

Unfamiliar

Familiar

Role of opioids in symptomatic management of dyspnea *

Unfamiliar

Familiar

DELIRIUM

Diagnostic criteria and common risk factors *

Unfamiliar

Familiar

Common presentations of the clinical subtypes (hyperactive, hypoactive, mixed) *

Unfamiliar

Familiar

Non-pharmacological management of a patient with delirium *

Unfamiliar

Familiar

Managing a patient with delirium *

Unfamiliar

Familiar

Counseling family members of patients with delirium *

Unfamiliar

Familiar

Episodic course of delirium *

Unfamiliar

Familiar

Role of palliative sedation in managing terminal delirium *

Unfamiliar

Familiar

COMMUNICATION TECHNIQUES

Using verbal and non-verbal communication techniques at the bedside or in a family meeting *

Unfamiliar

Familiar

Skills in conveying bad news( Components of Advance Care Planning, Living will, Medical power of Attorney, Do Not Resuscitate etc.) *

Unfamiliar

Familiar

Outcomes of delivering bad news poorly, late, or not at all *

Unfamiliar

Familiar

What information is to be shared, how much and with whom -patient, family members *

Unfamiliar

Familiar

Familiarity and utility of family meetings *

Unfamiliar

Familiar

Communicating regarding transition of care needs for a patient with advanced disease with professional colleagues *

Unfamiliar

Familiar

END OF LIFE [EOL] CONSIDERATIONS

Significance of maximizing quality of life *

Unfamiliar

Familiar

Your answer

Components of Advance Care Planning (Living Will, Medical Power of Attorney, Do Not Resuscitate orders) *

Unfamiliar

Familiar

Effects of delirium on patient mental capacity *

Unfamiliar

Familiar

Addressing emotional and spiritual needs *

Unfamiliar

Familiar

Invasive interventions in the context of end of life care (e.g. investigations, nutrition & hydration, IV antibiotics, surgery / chemo-radiation therapy *

Unfamiliar

Familiar

MEDICAL ETHICS IN ADVANCED DISEASE

Principle of non-maleficence and examples in advanced disease *

Unfamiliar

Familiar

Principle of beneficence and examples in advanced disease *

Unfamiliar

Familiar

Principle of autonomy and examples in advanced disease *

Unfamiliar

Familiar

Principle of justice and examples in advanced disease *

Unfamiliar

Familiar

HOME BASED CARE

Concept of home based care *

Unfamiliar

Familiar

Organization and team requirements in home based care programs *

Unfamiliar

Familiar

Contents in home care kit *

Unfamiliar

Familiar

Care and support interventions possible through home based care

Unfamiliar

Familiar

Clear selection

Role of community in home care program *

Unfamiliar

Familiar

Role of community in home care program *

Unfamiliar

Familiar

Logistics and costing of home based care program *

Unfamiliar

Familiar

Submit

Page 1 of 1

Clear form

Never submit passwords through Google Forms.

This content is neither created nor endorsed by Google. Report Abuse - Terms of Service - Privacy Policy

Forms