End of Life Curriculum Post-Rotation Survey
Name: Optional Gender: Male / Female
PGY level: 2 3 date:
After receiving lectures and simulation cases on end of life care in pediatric patients during your PICU rotation. Please rate your educational experience in relation to each statement using the following scale:
1 2 3 4 5
Strongly disagree No opinion strongly agree
Patient care/Medical Knowledge:
1) I am able to provide adequate pain control for terminally ill children
1 2 3 4 5
2) I am able to provide symptomatic relief of other symptoms (nausea, vomiting, fatigue)in terminally ill children
1 2 3 4 5
3) I am able to identify the signs and symptoms of pain and anxiety in a dying children
1 2 3 4 5
4) I am knowledgeable of non-pharmacologic methods of controlling pain
1 2 3 4 5
5) I am knowledgeable of other services that are available to care for the dying patient & family
1 2 3 4 5
6) I am capable of declaring death, discussing autopsy, completing a death certificate and discussing organ donation
1 2 3 4 5

Interpersonal Communication Skills
1) I am able to discuss with families the transition from curative to palliative care in terminally ill children
1 2 3 4 5
2) I am able to conduct a collaborative family conference to discuss “ bad news” or newly diagnosed life threatening disease
1 2 3 4 5
3) I am competent to discuss code status with families of terminally ill children
1 2 3 4 5
4) I am competent to discuss withdrawal of care with families of terminally ill children with futility of care
1 2 3 4 5
5) I am comfortable to include the terminally ill child in discussion of difficult diagnosis, treatment options and palliative care
1 2 3 4 5
Professionalism
1) I am aware that there is a broad range of cultural and religious attitudes and practices regarding death
1 2 3 4 5
2) I am capable of offering and providing spiritual support to the family and dying child
1 2 3 4 5
3) The outward expression of grief is acceptable behavior for a physician caring for terminally ill children
1 2 3 4 5
4) I am comfortable of speaking with families of dying children or of a child who has died
1 2 3 4 5

5) I can recognize the limitations of care and able to refer dying patient to hospice or palliative care services
1 2 3 4 5
Practice Based Learning
1) I can reflect and examine my practice with regards to the concept of dying children and their family and improve my practice by using other resources available
1 2 3 4 5
2) In caring for a dying child and family; I am able to process and cope with grief appropriately
1 2 3 4 5
System Based practice
1) I am aware of the existence of hospital resources and can use these allocated resources to help the dying child and family
1 2 3 4 5
For the following questions, please rate your experience with this curriculum
1) The standardized patient scenarios were very realistic
1 2 3 4 5
2) The standardized patients were well trained and realistic in portraying the roles
1 2 3 4 5
3) The questions asked by the standardized patient were appropriate for the case portrayed
1 2 3 4 5
4) Simulation scenarios are very realistic
1 2 3 4 5
5) The feedback given by the faculty and standardized patient were provided in a positive and helpful manner
1 2 3 4 5

6) Debriefing session served its purpose
1 2 3 4 5
7) If you were to use this case again, is there any additional data that you would like to be included or available? Yes _____ No____. If yes, please specify