ICU Questionnaire (Family Member)

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.

Please print this report and bring it to the attention of the clinical team looking after your loved one (the patient). The answers to the questions in this report will help the clinical team better understand how to provide better care to you and your family member.

Since your family member cannot effectively communicate, you have an opportunity to represent them and make sure they receive the best care possible. We have prepared this questionnaire to help you in your role as their advocate or representative, so that together we can make the best decisions on behalf of your family member. To begin, we need your help getting to know your family member as a person, not just as a patient.

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.

Quality of Life is the degree of satisfaction, comfort and enjoyment in life, and what makes life worth living.

This section looks at the value of independence in the patient's quality of life. Consider whether the patient's quality of life would be acceptable if he/she found herself in the following circumstance, with no reasonable chance of improvement.

When considering the health of your loved one BEFORE they came to hospital, please answer the following questions:

Religious, Spiritual and/or Cultural Beliefs

Religious, spiritual, and/or cultural beliefs may play an important role in end of life decision making for some people. For others, these beliefs are not important at this time.

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

This concludes the questionnaire.

A copy of the MY ICU Guide questionnaire will be sent to your email. Please print the report and discuss with the ICU Team.