Toggle navigation Load unfinished survey Resume later Exit and clear survey Language: English - English English - English Français - French Nederlands - Dutch default Caution: JavaScript execution is disabled in your browser or for this website. You may not be able to answer all questions in this survey. Please, verify your browser parameters. SGP - Advanced Care Planning All deaths that occurred in patients of your practice 1. Identification (This question is mandatory) GP code Only numbers may be entered in this field. (This question is mandatory) Startdate of consultation week (monday) Date format: dd.mm.yyyy Open date/time selector Format: dd.mm.yyyy 1900-01-01 2037-12-31 DD.MM.YYYY 2. Patient information (This question is mandatory) Sex patient Choose one of the following answers Male Female X (This question is mandatory) Which type of IDcard your patient possess? Choose one of the following answers Please choose... Belgian IDcard other identity card or residence permit issued in Belgium or other EU member state illegal migrant / without a valid residence permit tourist no answer (This question is mandatory) Does the patient has access to OMNIO/BIM statute, urgent medical aid, CPAS/OCMW or other financial help? Yes No (This question is mandatory) Age of the patient at death Only numbers may be entered in this field. If unknown, please fill in 999 (This question is mandatory) Where did the patient stay the longest in the last year of her/his life? Choose one of the following answers At home/relatives (incl. service flats) Nursing home Other: Cause of death: Illness or condition that directly resulted in death. Report below the logical relationship of the diseases/conditions that led to the immediate cause of death. When listing multiple diseases, list the one underlying the death last ("original cause of death"). immediate cause of death: caused by: caused by: caused by: * Here we do not mean the mode of death as e.g. heart failure, syncope etc.... but the disease, trauma or complication that caused death (e.g. dementia, respiratory infection, complications after fall, etc.). (This question is mandatory) Has a diagnosis of dementia been made by you or another physician? Choose one of the following answers Yes, severe dementia Yes, mild dementia No Unknown 3. Death of the patient (This question is mandatory) What was the place where the patient died? Choose one of the following answers At home or living with family (including service apartment) Nursing home Hospital (excl. palliative unit in a hospital) Palliative unit of a hospital I don't know Other: (This question is mandatory) What was the patient's length of stay in days at the place of death? .... days (max. 89 days, if > 90 days, enter 90) Your answer must be between 0 and 90 Only an integer value may be entered in this field. (This question is mandatory) Were you informed (verbally or in writing) of the patient's preference regarding place of death? Yes No (This question is mandatory) Were you informed (verbally or in writing) of the patient's preference regarding place of death? YES, by whom Choose one of the following answers By the patient himself By a close relative or family member of the patient Other: (This question is mandatory) Where did this patient most want to die? Choose one of the following answers At home or living with family (incl. service flat) Nursing home Hospital (excl. palliative unit in a hospital) Palliative unit of a hospital I don't know Other: (This question is mandatory) Was the patient able to make decisions during the last week before death? Choose one of the following answers Yes Sometimes yes, sometimes no No I don't know (This question is mandatory) Was the death sudden and totally unexpected? Yes No 4. Patient treatment before and around death (This question is mandatory) How often did you have (estimated average) contact with patient or relatives regarding the patient? Only numbers may be entered in these fields. In the last week before death ( ... times a week) In the 2-4th week before death ( ... times a week) 2nd-3rd month before death ( ... per month) (This question is mandatory) Have you had one or more conversations about ACP (advance care planning) with the patient or a relative? Choose one of the following answers Yes, only with the patient Yes, with the patient and a relative Yes, only with a relative No (This question is mandatory) When was the last time you had a conversation about ACP with this patient and/or relative? Choose one of the following answers At most one week before death At most 1 month before death At most 3 months before death More than 3 months before death (This question is mandatory) How many conversations about ACP did you have with this patient in total? Only numbers may be entered in this field. (This question is mandatory) How many conversations about ACP did you have with this relative in total? Only numbers may be entered in this field. (This question is mandatory) How many conversations about ACP did you have with this patient and relative in total? Only numbers may be entered in these fields. with the patient with the relative with the patient and the relative (This question is mandatory) What topics did you discuss (in these conversations) with this patient and/or relative? Yes, with the patient Yes, with the relative Yes, with the patient and relative No Values, norms in the care process that are important for the patient Yes, with the patient Yes, with the relative Yes, with the patient and relative No Important aspects of quality of life Yes, with the patient Yes, with the relative Yes, with the patient and relative No Experience(s) of serious illness or death in the close environment Yes, with the patient Yes, with the relative Yes, with the patient and relative No Fears and uncertainties about present and future health Yes, with the patient Yes, with the relative Yes, with the patient and relative No Discussion of trustee or legal representative Yes, with the patient Yes, with the relative Yes, with the patient and relative No Information preferences of the patient Yes, with the patient Yes, with the relative Yes, with the patient and relative No Agreements on care objectives Yes, with the patient Yes, with the relative Yes, with the patient and relative No Declarations of will Yes, with the patient Yes, with the relative Yes, with the patient and relative No (This question is mandatory) Had the patient completed a written living will? Choose one of the following answers Yes No I don't know (This question is mandatory) Specify which will Choose one of the following answers a negative living will a declaration of intent regarding euthanasia in the event of irreversible coma a will for burial a declaration for organ donation a will donation to science I don't know Other: (This question is mandatory) Did the patient ever express specific wishes about any medical treatment she/he wanted (or not) in the last phase of life? Choose one of the following answers Yes No I don't know (This question is mandatory) Have you ever discussed these wishes with the patient? Yes No (This question is mandatory) During the last week before death, was a medical procedure or treatment carried out that was not in accordance with his/her expressed wishes? Choose one of the following answers Yes No I don't know (This question is mandatory) Were there wishes related to any of the following medical treatments/decisions? Yes, in written form Yes, orally Yes, in written and oral form No whether or not to forgo further life-extending treatment Yes, in written form Yes, orally Yes, in written and oral form No whether or not to keep the patient continuously unconscious by means of medication until death Yes, in written form Yes, orally Yes, in written and oral form No whether or not to prescribe, dispense or administer a medicinal product with the express purpose of hastening the end of life Yes, in written form Yes, orally Yes, in written and oral form No (This question is mandatory) Did the patient ever express a wish about who should take decisions about medical procedures in her/his place in case she/he could no longer do it herself? Choose one of the following answers Yes, in written form Yes, orally No I don't know (This question is mandatory) Have you ever discussed this wish with the patient? Yes No (This question is mandatory) If the situation arose, was this person consulted? Choose one of the following answers Yes No I don't know Situation did not occur Submit Load unfinished survey Resume later Please confirm you want to clear your response? Exit and clear survey ×
