Please circle the number from 1-5 that best describes your confidence level:
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1 Study ID# Family Member Self-Efficacy in Decision-Making Scale (conscious patient) In some families, one person makes health care decisions with a sick loved one. In other families, several family members or friends make decisions with the sick loved one. When answering the questions below, please keep in mind your particular situation. Please circle the number from 1-5 that best describes your confidence level: If my loved one prefers to have help in making health care decisions, I am confident that I will be able to help: 1) make decisions about his/her health care. 2) make decisions that are in his/her best interest. 3) make decisions about how he/she will receive food and fluid. 4) make decisions about whether to stop trying to eat if he/she wants to stop. 5) make decisions about his/her receiving resuscitation. 6) make decisions about where he/she will be cared for at the end of life. 7) make decisions about continuing to fight his/her disease. 8) make decisions that will help him/her avoid suffering. 9) make decisions that promote his/her comfort.
2 Family Member Self-Efficacy in Decision-Making Scale (conscious patient) 10) make decisions that are consistent with his/her faith beliefs or ultimate concerns. 11) make decisions that will respect his/her dignity. 12) make decisions that will avoid burdening our family. 13) handle the news if the doctor says that his/her death is near. Study ID#
3 Family Member Self-Efficacy in Decision-Making Scale (unconscious patient) Please circle the number from 1-5 that best describes your confidence level If my loved one becomes too ill to make health care decisions, I am confident that I will be able to: 1) make decisions about his/her health care. 2) make decisions that he/she would make for himself/herself. 3) make decisions that are in keeping with his/her values. 4) make decisions about how he/she will receive food and fluid. 5) make decisions about whether to stop urging him/her to eat. 6) make decisions about treatments to manage his/her pain. 7) make decisions about his/her receiving resuscitation. 8) make decisions about where he/she will be cared for at the end of life. 9) make decisions about continuing to fight his/her disease. 10) make decisions that will help him/her avoid suffering.
4 Family Member Self-Efficacy in Decision-Making Scale (unconscious patient) 11) make decisions that promote his/her comfort. 12) make decisions that will respect his/her dignity. 13) talk to other family members about his/her health care. Scoring Directions:
5 1) To obtain a total scale score for the conscious version of the scale and a total scale score for the unconscious version of the scale, sum the scores of the items in each scale. Total Score for the Conscious Version Total Score for the Unconscious Version 2) To compare the scores on the conscious and unconscious versions of the scale, sum the overlapping 9 items on each scale (listed below): Total score for the overlapping 9 items on the Conscious Version Total score for the overlapping 9 items on the Unconscious Version 1) make decisions about his/her health care. 2) make decisions about how he/she will receive food and fluid. 3) make decisions about whether to stop trying to eat if he/she wants to stop. 4) make decisions about his/her receiving resuscitation. 5) make decisions about where he/she will be cared for at the end of life. 6) make decisions about continuing to fight his/her disease. 7) make decisions that will help him/her avoid suffering. 8) make decisions that promote his/her comfort.
6 9) make decisions that will respect his/her dignity. Reference Nolan M.T., Hughes M.T., Kub, J., Terry P.B., Astrow A.B., Thompson R.E., et al. (2009). Development and validation of the family decision making self-efficacy scale, Palliative and Supportive Care.7:
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