XT. End-of-Life Interview
XT. End-of-Life Interview Module of SHARE 2013
Start of XT. End-of-Life Interview
========================================================================
XT104
IWER:note sex of decedent (ask if unsure)
IWER:NOTE SEX OF DECEDENT (ASK IF UNSURE)
- - - - - - - - - - - - - - - - - - - - - - - - -
1 Male
2 Female
IWER:NOTE SEX OF DECEDENT (ASK IF UNSURE)
- - - - - - - - - - - - - - - - - - - - - - - - -
1 Male
2 Female
========================================================================
XT001
[{Name of the deceased}] has participated in the SHARE study before [his/her] death. [His/Her] contribution was very valuable. We would find it extremely helpful to havesome information about the final year of [{Name of the deceased}]'s life. All the information collected is strictly confidential, and will be held anonymously.
[{NAME OF THE DECEASED}] HAS PARTICIPATED IN THE SHARE STUDY BEFORE [HIS/HER] DEATH. [HIS/HER] CONTRIBUTION WAS VERY VALUABLE. WE WOULD FIND IT EXTREMELY HELPFUL TO HAVESOME INFORMATION ABOUT THE FINAL YEAR OF [{NAME OF THE DECEASED}]'S LIFE. ALL THE INFORMATION COLLECTED IS STRICTLY CONFIDENTIAL, AND WILL BE HELD ANONYMOUSLY.
- - - - - - - - - - - - - - - - - - - - - - - - -
1 Continue
[{NAME OF THE DECEASED}] HAS PARTICIPATED IN THE SHARE STUDY BEFORE [HIS/HER] DEATH. [HIS/HER] CONTRIBUTION WAS VERY VALUABLE. WE WOULD FIND IT EXTREMELY HELPFUL TO HAVESOME INFORMATION ABOUT THE FINAL YEAR OF [{NAME OF THE DECEASED}]'S LIFE. ALL THE INFORMATION COLLECTED IS STRICTLY CONFIDENTIAL, AND WILL BE HELD ANONYMOUSLY.
- - - - - - - - - - - - - - - - - - - - - - - - -
1 Continue
========================================================================
XT006
IWER:Code proxy respondent's sex.
IWER:CODE PROXY RESPONDENT'S SEX.
- - - - - - - - - - - - - - - - - - - - - - - - -
1 Male
2 Female
IWER:CODE PROXY RESPONDENT'S SEX.
- - - - - - - - - - - - - - - - - - - - - - - - -
1 Male
2 Female
========================================================================
XT002
Before we start ask ing questions about the last year of life of [{Name of the deceased}], would you please tell me what was your relationship to the deceased?
BEFORE WE START ASK ING QUESTIONS ABOUT THE LAST YEAR OF LIFE OF [{NAME OF THE DECEASED}], WOULD YOU PLEASE TELL ME WHAT WAS YOUR RELATIONSHIP TO THE DECEASED?
- - - - - - - - - - - - - - - - - - - - - - - - -
1 Husband or wife or partner
2 Son or Daughter
3 Son- or Daughter-in-law
4 Son or Daughter of husband, wife or partner
5 Grandchild
6 Sibling
7 Other relative (specify)
8 Other non-relative (specify)
BEFORE WE START ASK ING QUESTIONS ABOUT THE LAST YEAR OF LIFE OF [{NAME OF THE DECEASED}], WOULD YOU PLEASE TELL ME WHAT WAS YOUR RELATIONSHIP TO THE DECEASED?
- - - - - - - - - - - - - - - - - - - - - - - - -
1 Husband or wife or partner
2 Son or Daughter
3 Son- or Daughter-in-law
4 Son or Daughter of husband, wife or partner
5 Grandchild
6 Sibling
7 Other relative (specify)
8 Other non-relative (specify)
If Before we start ask ing questions about the last year of life of [{Name of the deceased}], would you please tell me what was your relationship to the deceased? (XT002) = 7 »
| ========================================================================
If Before we start ask ing questions about the last year of life of [{Name of the deceased}], would you please tell me what was your relationship to the deceased? (XT002) = 8 »
| ========================================================================
========================================================================
XT005
During the last twelve months of [his/her] life, how often did you have contact with [{Name of the deceased}], either personally, by phone, mail, email, or any other electronicmeans?
DURING THE LAST TWELVE MONTHS OF [HIS/HER] LIFE, HOW OFTEN DID YOU HAVE CONTACT WITH [{NAME OF THE DECEASED}], EITHER PERSONALLY, BY PHONE, MAIL, EMAIL, OR ANY OTHER ELECTRONICMEANS?
- - - - - - - - - - - - - - - - - - - - - - - - -
1 Daily
2 Several times a week
3 About once a week
4 About every two weeks
5 About once a month
6 Less than once a month
7 Never
DURING THE LAST TWELVE MONTHS OF [HIS/HER] LIFE, HOW OFTEN DID YOU HAVE CONTACT WITH [{NAME OF THE DECEASED}], EITHER PERSONALLY, BY PHONE, MAIL, EMAIL, OR ANY OTHER ELECTRONICMEANS?
- - - - - - - - - - - - - - - - - - - - - - - - -
1 Daily
2 Several times a week
3 About once a week
4 About every two weeks
5 About once a month
6 Less than once a month
7 Never
If Before we start ask ing questions about the last year of life of [{Name of the deceased}], would you please tell me what was your relationship to the deceased? (XT002) <> 1 Husband or wife or partner
2 Son or Daughter
3 Son- or Daughter-in-law
4 Son or Daughter of husband, wife or partner
5 Grandchild
6 Sibling
7 Other relative (specify)
8 Other non-relative (specify)
»
| ========================================================================
|
XT007
Can you tell me your year of birth?
CAN YOU TELL ME YOUR YEAR OF BIRTH?
- - - - - - - - - - - - - - - - - - - - - - - - -
1900..1992
CAN YOU TELL ME YOUR YEAR OF BIRTH?
- - - - - - - - - - - - - - - - - - - - - - - - -
1900..1992
========================================================================
XT101
Let us now talk about the deceased. Just to mak e sure that we have the correct information about [{Name of the deceased}], can I just confirm that [he/she] was born in[{Month and Year birth of deceased}]?
LET US NOW TALK ABOUT THE DECEASED. JUST TO MAK E SURE THAT WE HAVE THE CORRECT INFORMATION ABOUT [{NAME OF THE DECEASED}], CAN I JUST CONFIRM THAT [HE/SHE] WAS BORN IN[{MONTH AND YEAR BIRTH OF DECEASED}]?
- - - - - - - - - - - - - - - - - - - - - - - - -
1 Yes
5 No
LET US NOW TALK ABOUT THE DECEASED. JUST TO MAK E SURE THAT WE HAVE THE CORRECT INFORMATION ABOUT [{NAME OF THE DECEASED}], CAN I JUST CONFIRM THAT [HE/SHE] WAS BORN IN[{MONTH AND YEAR BIRTH OF DECEASED}]?
- - - - - - - - - - - - - - - - - - - - - - - - -
1 Yes
5 No
If Let us now talk about the deceased. Just to mak e sure that we have the correct information about [{Name of the deceased}], can I just confirm that [he/she] was born in[{Month and Year birth of deceased}]? (XT101) = 5 »
| ========================================================================
|
XT102
In which month and year was [{Name of the deceased}] born?@bMONTH@b:YEAR:
IN WHICH MONTH AND YEAR WAS [{NAME OF THE DECEASED}] BORN?@BMONTH@B:YEAR:
- - - - - - - - - - - - - - - - - - - - - - - - -
1 January
2 February
3 March
4 April
5 May
6 June
7 July
8 August
9 September
10 October
11 November
12 December
IN WHICH MONTH AND YEAR WAS [{NAME OF THE DECEASED}] BORN?@BMONTH@B:YEAR:
- - - - - - - - - - - - - - - - - - - - - - - - -
1 January
2 February
3 March
4 April
5 May
6 June
7 July
8 August
9 September
10 October
11 November
12 December
| ========================================================================
|
XT103
In which month and year were [{Name of the deceased}] born?MONTH: ^XT102_DecMonthBirth@bYEAR@b:
IN WHICH MONTH AND YEAR WERE [{NAME OF THE DECEASED}] BORN?MONTH: ______@BYEAR@B:
- - - - - - - - - - - - - - - - - - - - - - - - -
1900..2008
IN WHICH MONTH AND YEAR WERE [{NAME OF THE DECEASED}] BORN?MONTH: ______@BYEAR@B:
- - - - - - - - - - - - - - - - - - - - - - - - -
1900..2008
========================================================================
XT008
We would lik e to k now more about the circumstances of [{Name of the deceased}] 's death. In what @bmonth@b and year did [he/she] pass away?@bMONTH@b:YEAR:
WE WOULD LIK E TO K NOW MORE ABOUT THE CIRCUMSTANCES OF [{NAME OF THE DECEASED}] 'S DEATH. IN WHAT @BMONTH@B AND YEAR DID [HE/SHE] PASS AWAY?@BMONTH@B:YEAR:
- - - - - - - - - - - - - - - - - - - - - - - - -
1 January
2 February
3 March
4 April
5 May
6 June
7 July
8 August
9 September
10 October
11 November
12 December
WE WOULD LIK E TO K NOW MORE ABOUT THE CIRCUMSTANCES OF [{NAME OF THE DECEASED}] 'S DEATH. IN WHAT @BMONTH@B AND YEAR DID [HE/SHE] PASS AWAY?@BMONTH@B:YEAR:
- - - - - - - - - - - - - - - - - - - - - - - - -
1 January
2 February
3 March
4 April
5 May
6 June
7 July
8 August
9 September
10 October
11 November
12 December
========================================================================
XT009
In what month and @bYEAR@b did [he/she] pass away?MONTH: ^XT008_MonthDied@bYEAR@b:
IN WHAT MONTH AND @BYEAR@B DID [HE/SHE] PASS AWAY?MONTH: ______@BYEAR@B:
- - - - - - - - - - - - - - - - - - - - - - - - -
1 2006
2 2007
3 2008
4 2009
5 2010
6 2011
7 2012
8 2013
IN WHAT MONTH AND @BYEAR@B DID [HE/SHE] PASS AWAY?MONTH: ______@BYEAR@B:
- - - - - - - - - - - - - - - - - - - - - - - - -
1 2006
2 2007
3 2008
4 2009
5 2010
6 2011
7 2012
8 2013
========================================================================
XT010
How old was [{Name of the deceased}] when [he/she] passed away?
HOW OLD WAS [{NAME OF THE DECEASED}] WHEN [HE/SHE] PASSED AWAY?
- - - - - - - - - - - - - - - - - - - - - - - - -
20..120
HOW OLD WAS [{NAME OF THE DECEASED}] WHEN [HE/SHE] PASSED AWAY?
- - - - - - - - - - - - - - - - - - - - - - - - -
20..120
========================================================================
XT109
Was [{Name of the deceased}] married at the time of [his/her] death?
WAS [{NAME OF THE DECEASED}] MARRIED AT THE TIME OF [HIS/HER] DEATH?
- - - - - - - - - - - - - - - - - - - - - - - - -
1 Yes
5 No
WAS [{NAME OF THE DECEASED}] MARRIED AT THE TIME OF [HIS/HER] DEATH?
- - - - - - - - - - - - - - - - - - - - - - - - -
1 Yes
5 No
========================================================================
XT039
How many children did [{Name of the deceased}] have that were still alive at the time of [his/her] death? Please include foster and adopted children.
HOW MANY CHILDREN DID [{NAME OF THE DECEASED}] HAVE THAT WERE STILL ALIVE AT THE TIME OF [HIS/HER] DEATH? PLEASE INCLUDE FOSTER AND ADOPTED CHILDREN.
HOW MANY CHILDREN DID [{NAME OF THE DECEASED}] HAVE THAT WERE STILL ALIVE AT THE TIME OF [HIS/HER] DEATH? PLEASE INCLUDE FOSTER AND ADOPTED CHILDREN.
========================================================================
XT011
What was the main cause of [his/her] death?
WHAT WAS THE MAIN CAUSE OF [HIS/HER] DEATH?
- - - - - - - - - - - - - - - - - - - - - - - - -
1 Cancer
2 A heart attack
3 A stroke
4 Other cardiovascular related illness such as heart failure, arrhythmia
5 Respiratory disease
6 Disease of the digestive system such as gastrointestinal ulcer, inflammatory bowel disease
7 Severe infectious disease such as pneumonia, septicemia or flu
8 Accident
97 Other (Please specify)
WHAT WAS THE MAIN CAUSE OF [HIS/HER] DEATH?
- - - - - - - - - - - - - - - - - - - - - - - - -
1 Cancer
2 A heart attack
3 A stroke
4 Other cardiovascular related illness such as heart failure, arrhythmia
5 Respiratory disease
6 Disease of the digestive system such as gastrointestinal ulcer, inflammatory bowel disease
7 Severe infectious disease such as pneumonia, septicemia or flu
8 Accident
97 Other (Please specify)
If What was the main cause of [his/her] death? (XT011) = 97 »
| ========================================================================
If What was the main cause of [his/her] death? (XT011) = 8 »
| ========================================================================
|
XT013
How long had [{Name of the deceased}] been ill before [he/she] died?
HOW LONG HAD [{NAME OF THE DECEASED}] BEEN ILL BEFORE [HE/SHE] DIED?
- - - - - - - - - - - - - - - - - - - - - - - - -
1 Less than one month
2 One month or more but less than 6 months
3 6 months or more but less than a year
4 One year or more
HOW LONG HAD [{NAME OF THE DECEASED}] BEEN ILL BEFORE [HE/SHE] DIED?
- - - - - - - - - - - - - - - - - - - - - - - - -
1 Less than one month
2 One month or more but less than 6 months
3 6 months or more but less than a year
4 One year or more
| ========================================================================
|
XT014
Did [he/she] die ...
DID [HE/SHE] DIE ...
- - - - - - - - - - - - - - - - - - - - - - - - -
1 at______
2 at another person
3 in a hospital
4 in a nursing home
5 in a residential home or sheltered housing
6 in a hospice
97 at some other place (Please specify)
DID [HE/SHE] DIE ...
- - - - - - - - - - - - - - - - - - - - - - - - -
1 at______
2 at another person
3 in a hospital
4 in a nursing home
5 in a residential home or sheltered housing
6 in a hospice
97 at some other place (Please specify)
|
If Did [he/she] die ... (XT014) = 97 »
| | ========================================================================
| ========================================================================
|
XT015
In the last year before [he/she] died, on how many different occasions did [{Name of the deceased}] stay in a hospital, hospice or nursing home?
IN THE LAST YEAR BEFORE [HE/SHE] DIED, ON HOW MANY DIFFERENT OCCASIONS DID [{NAME OF THE DECEASED}] STAY IN A HOSPITAL, HOSPICE OR NURSING HOME?
- - - - - - - - - - - - - - - - - - - - - - - - -
1 Not at all
2 1 to 2 times
3 3 to 5 times
4 More than 5 times
IN THE LAST YEAR BEFORE [HE/SHE] DIED, ON HOW MANY DIFFERENT OCCASIONS DID [{NAME OF THE DECEASED}] STAY IN A HOSPITAL, HOSPICE OR NURSING HOME?
- - - - - - - - - - - - - - - - - - - - - - - - -
1 Not at all
2 1 to 2 times
3 3 to 5 times
4 More than 5 times
|
If In the last year before [he/she] died, on how many different occasions did [{Name of the deceased}] stay in a hospital, hospice or nursing home? (XT015) > 1 Not at all
2 1 to 2 times
3 3 to 5 times
4 More than 5 times
»
| | ========================================================================
| |
XT016
During the last year of [his/her] life, for how long altogether did [{Name of the deceased}] stay at hospitals, hospices or nursing homes?
DURING THE LAST YEAR OF [HIS/HER] LIFE, FOR HOW LONG ALTOGETHER DID [{NAME OF THE DECEASED}] STAY AT HOSPITALS, HOSPICES OR NURSING HOMES?
- - - - - - - - - - - - - - - - - - - - - - - - -
1 Less than one week
2 One week or more but less than one month
3 One month or more but less than 3 months
4 3 months or more but less than 6 months
5 6 months or more but less than a year
6 A full year
DURING THE LAST YEAR OF [HIS/HER] LIFE, FOR HOW LONG ALTOGETHER DID [{NAME OF THE DECEASED}] STAY AT HOSPITALS, HOSPICES OR NURSING HOMES?
- - - - - - - - - - - - - - - - - - - - - - - - -
1 Less than one week
2 One week or more but less than one month
3 One month or more but less than 3 months
4 3 months or more but less than 6 months
5 6 months or more but less than a year
6 A full year
========================================================================
XT107
During the last year of [his/her] life, did [{Name of the deceased}] have any difficulty recognizingfamily members or good friends? (Please name only difficulties that lasted at least three months?)
DURING THE LAST YEAR OF [HIS/HER] LIFE, DID [{NAME OF THE DECEASED}] HAVE ANY DIFFICULTY RECOGNIZINGFAMILY MEMBERS OR GOOD FRIENDS? (PLEASE NAME ONLY DIFFICULTIES THAT LASTED AT LEAST THREE MONTHS?)
- - - - - - - - - - - - - - - - - - - - - - - - -
1 Yes
5 No
DURING THE LAST YEAR OF [HIS/HER] LIFE, DID [{NAME OF THE DECEASED}] HAVE ANY DIFFICULTY RECOGNIZINGFAMILY MEMBERS OR GOOD FRIENDS? (PLEASE NAME ONLY DIFFICULTIES THAT LASTED AT LEAST THREE MONTHS?)
- - - - - - - - - - - - - - - - - - - - - - - - -
1 Yes
5 No
As CNT goes from 1 to 8 » »
|
If (CNT < 3) or (CNT > 5)) or (We would lik e to k now more about the difficulties people have in their last year of life because of a physical, mental, emotional or memory problems. During the last year of[his/her] life, did [{Name of the deceased}] have any difficulty remembering where [he/she] was? Please name only difficulties that lasted at least three months? (XT105) <> 1 Yes
5 No
) »
| | ========================================================================
| |
XT018
Has [{Name of the deceased}] had any [care from a general practitioner/care from specialist physicians/hospital stays/care in a nursing home/hospicestays/medication/aids and appliances/home care or home help due to disability] (in the last 12 months of [his/her] life)?
HAS [{NAME OF THE DECEASED}] HAD ANY [CARE FROM A GENERAL PRACTITIONER/CARE FROM SPECIALIST PHYSICIANS/HOSPITAL STAYS/CARE IN A NURSING HOME/HOSPICESTAYS/MEDICATION/AIDS AND APPLIANCES/HOME CARE OR HOME HELP DUE TO DISABILITY] (IN THE LAST 12 MONTHS OF [HIS/HER] LIFE)?
- - - - - - - - - - - - - - - - - - - - - - - - -
1 Yes
5 No
HAS [{NAME OF THE DECEASED}] HAD ANY [CARE FROM A GENERAL PRACTITIONER/CARE FROM SPECIALIST PHYSICIANS/HOSPITAL STAYS/CARE IN A NURSING HOME/HOSPICESTAYS/MEDICATION/AIDS AND APPLIANCES/HOME CARE OR HOME HELP DUE TO DISABILITY] (IN THE LAST 12 MONTHS OF [HIS/HER] LIFE)?
- - - - - - - - - - - - - - - - - - - - - - - - -
1 Yes
5 No
| |
If Has [{Name of the deceased}] had any [care from a general practitioner/care from specialist physicians/hospital stays/care in a nursing home/hospicestays/medication/aids and appliances/home care or home help due to disability] (in the last 12 months of [his/her] life)? (XT018) = 1 Yes
5 No
»
| | | ========================================================================
| | |
XT019
About how much did [his/her] [care from a general practitioner/care from specialist physicians/hospital stays/care in a nursing home/hospice stays/medication/aidsand appliances/home care or home help due to disability] cost (in the last 12 months of [his/her] life)?
ABOUT HOW MUCH DID [HIS/HER] [CARE FROM A GENERAL PRACTITIONER/CARE FROM SPECIALIST PHYSICIANS/HOSPITAL STAYS/CARE IN A NURSING HOME/HOSPICE STAYS/MEDICATION/AIDSAND APPLIANCES/HOME CARE OR HOME HELP DUE TO DISABILITY] COST (IN THE LAST 12 MONTHS OF [HIS/HER] LIFE)?
- - - - - - - - - - - - - - - - - - - - - - - - -
0..980000
ABOUT HOW MUCH DID [HIS/HER] [CARE FROM A GENERAL PRACTITIONER/CARE FROM SPECIALIST PHYSICIANS/HOSPITAL STAYS/CARE IN A NURSING HOME/HOSPICE STAYS/MEDICATION/AIDSAND APPLIANCES/HOME CARE OR HOME HELP DUE TO DISABILITY] COST (IN THE LAST 12 MONTHS OF [HIS/HER] LIFE)?
- - - - - - - - - - - - - - - - - - - - - - - - -
0..980000
========================================================================
XT105
We would lik e to k now more about the difficulties people have in their last year of life because of a physical, mental, emotional or memory problems. During the last year of[his/her] life, did [{Name of the deceased}] have any difficulty remembering where [he/she] was? Please name only difficulties that lasted at least three months?
WE WOULD LIK E TO K NOW MORE ABOUT THE DIFFICULTIES PEOPLE HAVE IN THEIR LAST YEAR OF LIFE BECAUSE OF A PHYSICAL, MENTAL, EMOTIONAL OR MEMORY PROBLEMS. DURING THE LAST YEAR OF[HIS/HER] LIFE, DID [{NAME OF THE DECEASED}] HAVE ANY DIFFICULTY REMEMBERING WHERE [HE/SHE] WAS? PLEASE NAME ONLY DIFFICULTIES THAT LASTED AT LEAST THREE MONTHS?
- - - - - - - - - - - - - - - - - - - - - - - - -
1 Yes
5 No
WE WOULD LIK E TO K NOW MORE ABOUT THE DIFFICULTIES PEOPLE HAVE IN THEIR LAST YEAR OF LIFE BECAUSE OF A PHYSICAL, MENTAL, EMOTIONAL OR MEMORY PROBLEMS. DURING THE LAST YEAR OF[HIS/HER] LIFE, DID [{NAME OF THE DECEASED}] HAVE ANY DIFFICULTY REMEMBERING WHERE [HE/SHE] WAS? PLEASE NAME ONLY DIFFICULTIES THAT LASTED AT LEAST THREE MONTHS?
- - - - - - - - - - - - - - - - - - - - - - - - -
1 Yes
5 No
========================================================================
XT106
During the last year of [his/her] life, did [{Name of the deceased}] have any difficulty rememberingwhat year it was? (Please name only difficulties that lasted at least three months?)
DURING THE LAST YEAR OF [HIS/HER] LIFE, DID [{NAME OF THE DECEASED}] HAVE ANY DIFFICULTY REMEMBERINGWHAT YEAR IT WAS? (PLEASE NAME ONLY DIFFICULTIES THAT LASTED AT LEAST THREE MONTHS?)
- - - - - - - - - - - - - - - - - - - - - - - - -
1 Yes
5 No
DURING THE LAST YEAR OF [HIS/HER] LIFE, DID [{NAME OF THE DECEASED}] HAVE ANY DIFFICULTY REMEMBERINGWHAT YEAR IT WAS? (PLEASE NAME ONLY DIFFICULTIES THAT LASTED AT LEAST THREE MONTHS?)
- - - - - - - - - - - - - - - - - - - - - - - - -
1 Yes
5 No
========================================================================
XT107
During the last year of [his/her] life, did [{Name of the deceased}] have any difficulty recognizingfamily members or good friends? (Please name only difficulties that lasted at least three months?)
DURING THE LAST YEAR OF [HIS/HER] LIFE, DID [{NAME OF THE DECEASED}] HAVE ANY DIFFICULTY RECOGNIZINGFAMILY MEMBERS OR GOOD FRIENDS? (PLEASE NAME ONLY DIFFICULTIES THAT LASTED AT LEAST THREE MONTHS?)
- - - - - - - - - - - - - - - - - - - - - - - - -
1 Yes
5 No
DURING THE LAST YEAR OF [HIS/HER] LIFE, DID [{NAME OF THE DECEASED}] HAVE ANY DIFFICULTY RECOGNIZINGFAMILY MEMBERS OR GOOD FRIENDS? (PLEASE NAME ONLY DIFFICULTIES THAT LASTED AT LEAST THREE MONTHS?)
- - - - - - - - - - - - - - - - - - - - - - - - -
1 Yes
5 No
========================================================================
XT020
Because of a physical, mental, emotional or memory problem, did [{Name of the deceased}] have difficulty doing any of the following activities during the last twelve monthsof [his/her] life? Please name only difficulties that lasted at least three months.
BECAUSE OF A PHYSICAL, MENTAL, EMOTIONAL OR MEMORY PROBLEM, DID [{NAME OF THE DECEASED}] HAVE DIFFICULTY DOING ANY OF THE FOLLOWING ACTIVITIES DURING THE LAST TWELVE MONTHSOF [HIS/HER] LIFE? PLEASE NAME ONLY DIFFICULTIES THAT LASTED AT LEAST THREE MONTHS.
- - - - - - - - - - - - - - - - - - - - - - - - -
1 Dressing, including putting on shoes and socks
2 Walking across a room
3 Bathing or showering
4 Eating, such as cutting up your food
5 Getting in or out of bed
6 Using the toilet, including getting up or down
96 None of these
BECAUSE OF A PHYSICAL, MENTAL, EMOTIONAL OR MEMORY PROBLEM, DID [{NAME OF THE DECEASED}] HAVE DIFFICULTY DOING ANY OF THE FOLLOWING ACTIVITIES DURING THE LAST TWELVE MONTHSOF [HIS/HER] LIFE? PLEASE NAME ONLY DIFFICULTIES THAT LASTED AT LEAST THREE MONTHS.
- - - - - - - - - - - - - - - - - - - - - - - - -
1 Dressing, including putting on shoes and socks
2 Walking across a room
3 Bathing or showering
4 Eating, such as cutting up your food
5 Getting in or out of bed
6 Using the toilet, including getting up or down
96 None of these
If (Because of a physical, mental, emotional or memory problem, did [{Name of the deceased}] have difficulty doing any of the following activities during the last twelve monthsof [his/her] life? Please name only difficulties that lasted at least three months. (XT020) > 0) and NOT (96 IN XT020) »
| ========================================================================
|
XT022
Think ing about the activities that the deceased had problems with during the last twelve months of [his/her] life, has anyone helped regularly with these activities?
THINK ING ABOUT THE ACTIVITIES THAT THE DECEASED HAD PROBLEMS WITH DURING THE LAST TWELVE MONTHS OF [HIS/HER] LIFE, HAS ANYONE HELPED REGULARLY WITH THESE ACTIVITIES?
- - - - - - - - - - - - - - - - - - - - - - - - -
1 Yes
5 No
THINK ING ABOUT THE ACTIVITIES THAT THE DECEASED HAD PROBLEMS WITH DURING THE LAST TWELVE MONTHS OF [HIS/HER] LIFE, HAS ANYONE HELPED REGULARLY WITH THESE ACTIVITIES?
- - - - - - - - - - - - - - - - - - - - - - - - -
1 Yes
5 No
|
If Think ing about the activities that the deceased had problems with during the last twelve months of [his/her] life, has anyone helped regularly with these activities? (XT022) = 1 Yes
5 No
»
| | ========================================================================
| |
XT023
Who, including yourself, has helped mainly with these activities? Please name at most three persons.
WHO, INCLUDING YOURSELF, HAS HELPED MAINLY WITH THESE ACTIVITIES? PLEASE NAME AT MOST THREE PERSONS.
- - - - - - - - - - - - - - - - - - - - - - - - -
1 Yourself (proxy respondent)
2 Husband or wife or partner of the deceased
3 Mother or father of the deceased
4 Son of the deceased
5 Son-in-law of the deceased
6 Daughter of the deceased
7 Daughter-in-law of the deceased
8 Grandson of the deceased
9 Granddaughter of the deceased
10 Sister of the deceased
11 Brother of the deceased
12 Other relative
13 Unpaid volunteer
14 Professional helper (e.g. nurse)
15 Friend or neighbor of the deceased
16 Other person
WHO, INCLUDING YOURSELF, HAS HELPED MAINLY WITH THESE ACTIVITIES? PLEASE NAME AT MOST THREE PERSONS.
- - - - - - - - - - - - - - - - - - - - - - - - -
1 Yourself (proxy respondent)
2 Husband or wife or partner of the deceased
3 Mother or father of the deceased
4 Son of the deceased
5 Son-in-law of the deceased
6 Daughter of the deceased
7 Daughter-in-law of the deceased
8 Grandson of the deceased
9 Granddaughter of the deceased
10 Sister of the deceased
11 Brother of the deceased
12 Other relative
13 Unpaid volunteer
14 Professional helper (e.g. nurse)
15 Friend or neighbor of the deceased
16 Other person
| | ========================================================================
| |
XT024
Overall, during the last twelve months of [his/her] life, for how long did the deceased receive help?
OVERALL, DURING THE LAST TWELVE MONTHS OF [HIS/HER] LIFE, FOR HOW LONG DID THE DECEASED RECEIVE HELP?
- - - - - - - - - - - - - - - - - - - - - - - - -
1 Less than one month
2 One month or more but less than 3 months
3 3 months or more but less than 6 months
4 6 months or more but less than a year
5 A full year
OVERALL, DURING THE LAST TWELVE MONTHS OF [HIS/HER] LIFE, FOR HOW LONG DID THE DECEASED RECEIVE HELP?
- - - - - - - - - - - - - - - - - - - - - - - - -
1 Less than one month
2 One month or more but less than 3 months
3 3 months or more but less than 6 months
4 6 months or more but less than a year
5 A full year
| | ========================================================================
| |
XT025
And about how many hours of help were necessary during a typical day?
AND ABOUT HOW MANY HOURS OF HELP WERE NECESSARY DURING A TYPICAL DAY?
- - - - - - - - - - - - - - - - - - - - - - - - -
0..24
AND ABOUT HOW MANY HOURS OF HELP WERE NECESSARY DURING A TYPICAL DAY?
- - - - - - - - - - - - - - - - - - - - - - - - -
0..24
========================================================================
XT026A
The next questions are about the assets and life insurance policies the deceased may have owned and what happened to those assets after [{Name of the deceased}] died.I appreciate that this may upset or distress you, but we would find it very helpful to have some information about the financial issues surrounding death. Before I continue,though, I'd lik e to assure you again that everything you have already told me and anything else you tell me will be k ept completely confidential.
THE NEXT QUESTIONS ARE ABOUT THE ASSETS AND LIFE INSURANCE POLICIES THE DECEASED MAY HAVE OWNED AND WHAT HAPPENED TO THOSE ASSETS AFTER [{NAME OF THE DECEASED}] DIED.I APPRECIATE THAT THIS MAY UPSET OR DISTRESS YOU, BUT WE WOULD FIND IT VERY HELPFUL TO HAVE SOME INFORMATION ABOUT THE FINANCIAL ISSUES SURROUNDING DEATH. BEFORE I CONTINUE,THOUGH, I'D LIK E TO ASSURE YOU AGAIN THAT EVERYTHING YOU HAVE ALREADY TOLD ME AND ANYTHING ELSE YOU TELL ME WILL BE K EPT COMPLETELY CONFIDENTIAL.
- - - - - - - - - - - - - - - - - - - - - - - - -
1 Continue
THE NEXT QUESTIONS ARE ABOUT THE ASSETS AND LIFE INSURANCE POLICIES THE DECEASED MAY HAVE OWNED AND WHAT HAPPENED TO THOSE ASSETS AFTER [{NAME OF THE DECEASED}] DIED.I APPRECIATE THAT THIS MAY UPSET OR DISTRESS YOU, BUT WE WOULD FIND IT VERY HELPFUL TO HAVE SOME INFORMATION ABOUT THE FINANCIAL ISSUES SURROUNDING DEATH. BEFORE I CONTINUE,THOUGH, I'D LIK E TO ASSURE YOU AGAIN THAT EVERYTHING YOU HAVE ALREADY TOLD ME AND ANYTHING ELSE YOU TELL ME WILL BE K EPT COMPLETELY CONFIDENTIAL.
- - - - - - - - - - - - - - - - - - - - - - - - -
1 Continue
========================================================================
XT026B
Some people mak e a will to determine who receives what parts of the estate.Did [{Name of the deceased}] have a will?
SOME PEOPLE MAK E A WILL TO DETERMINE WHO RECEIVES WHAT PARTS OF THE ESTATE.DID [{NAME OF THE DECEASED}] HAVE A WILL?
- - - - - - - - - - - - - - - - - - - - - - - - -
1 Yes
5 No
SOME PEOPLE MAK E A WILL TO DETERMINE WHO RECEIVES WHAT PARTS OF THE ESTATE.DID [{NAME OF THE DECEASED}] HAVE A WILL?
- - - - - - - - - - - - - - - - - - - - - - - - -
1 Yes
5 No
========================================================================
XT027
Who were the beneficiaries of the estate, including yourself?
WHO WERE THE BENEFICIARIES OF THE ESTATE, INCLUDING YOURSELF?
- - - - - - - - - - - - - - - - - - - - - - - - -
1 Yourself (proxy)
2 Husband or wife or partner of the deceased
3 Children of the deceased
4 Grandchildren of the deceased
5 Siblings of the deceased
6 Other relatives (specify) of the deceased
7 Other non-relatives (specify)
8 Church, foundation or charitable organization
9 Deceased did not leave anything at all (SPONTANEOUS)
WHO WERE THE BENEFICIARIES OF THE ESTATE, INCLUDING YOURSELF?
- - - - - - - - - - - - - - - - - - - - - - - - -
1 Yourself (proxy)
2 Husband or wife or partner of the deceased
3 Children of the deceased
4 Grandchildren of the deceased
5 Siblings of the deceased
6 Other relatives (specify) of the deceased
7 Other non-relatives (specify)
8 Church, foundation or charitable organization
9 Deceased did not leave anything at all (SPONTANEOUS)
If 6 IN XT027 »
| ========================================================================
If 7 IN XT027 »
| ========================================================================
========================================================================
XT030
Did the deceased own [his/her] home or apartment - either in total or a share of it?
DID THE DECEASED OWN [HIS/HER] HOME OR APARTMENT - EITHER IN TOTAL OR A SHARE OF IT?
- - - - - - - - - - - - - - - - - - - - - - - - -
1 Yes
5 No
DID THE DECEASED OWN [HIS/HER] HOME OR APARTMENT - EITHER IN TOTAL OR A SHARE OF IT?
- - - - - - - - - - - - - - - - - - - - - - - - -
1 Yes
5 No
If Did the deceased own [his/her] home or apartment - either in total or a share of it? (XT030) = 1 Yes
5 No
»
| ========================================================================
|
XT031
After any outstanding mortgages, what was the value of the home or apartment or the share of it owned by the deceased?
AFTER ANY OUTSTANDING MORTGAGES, WHAT WAS THE VALUE OF THE HOME OR APARTMENT OR THE SHARE OF IT OWNED BY THE DECEASED?
- - - - - - - - - - - - - - - - - - - - - - - - -
1 Yourself (proxy respondent)
2 Husband or wife or partner
3 Sons or daughters (ASK FOR FIRST NAMES)
4 Grandchildren
5 Siblings
6 Other relatives (specify)
7 Other non-relatives (specify)
AFTER ANY OUTSTANDING MORTGAGES, WHAT WAS THE VALUE OF THE HOME OR APARTMENT OR THE SHARE OF IT OWNED BY THE DECEASED?
- - - - - - - - - - - - - - - - - - - - - - - - -
1 Yourself (proxy respondent)
2 Husband or wife or partner
3 Sons or daughters (ASK FOR FIRST NAMES)
4 Grandchildren
5 Siblings
6 Other relatives (specify)
7 Other non-relatives (specify)
| ========================================================================
|
XT032
Who inherited the deceased's home or apartment, including yourself?
WHO INHERITED THE DECEASED'S HOME OR APARTMENT, INCLUDING YOURSELF?
IWER:CODE RELATIONSHIP TO DECEASED.
- - - - - - - - - - - - - - - - - - - - - - - - -
1 Yourself (proxy respondent)
2 Husband or wife or partner
3 Sons or daughters (ASK FOR FIRST NAMES)
4 Grandchildren
5 Siblings
6 Other relatives (specify)
7 Other non-relatives (specify)
WHO INHERITED THE DECEASED'S HOME OR APARTMENT, INCLUDING YOURSELF?
IWER:CODE RELATIONSHIP TO DECEASED.
- - - - - - - - - - - - - - - - - - - - - - - - -
1 Yourself (proxy respondent)
2 Husband or wife or partner
3 Sons or daughters (ASK FOR FIRST NAMES)
4 Grandchildren
5 Siblings
6 Other relatives (specify)
7 Other non-relatives (specify)
|
If 6 IN XT032 »
| | ========================================================================
|
If 7 IN XT032 »
| | ========================================================================
|
If 3 IN XT032 »
| | ========================================================================
| |
XT053
========================================================================
XT033
Did the deceased own any life insurance policies?
DID THE DECEASED OWN ANY LIFE INSURANCE POLICIES?
- - - - - - - - - - - - - - - - - - - - - - - - -
1 Yes
5 No
DID THE DECEASED OWN ANY LIFE INSURANCE POLICIES?
- - - - - - - - - - - - - - - - - - - - - - - - -
1 Yes
5 No
If Did the deceased own any life insurance policies? (XT033) = 1 Yes
5 No
»
| ========================================================================
|
XT034
In total, about what was the value of all life insurance policies owned by the deceased?
IN TOTAL, ABOUT WHAT WAS THE VALUE OF ALL LIFE INSURANCE POLICIES OWNED BY THE DECEASED?
- - - - - - - - - - - - - - - - - - - - - - - - -
1000..50000000
IN TOTAL, ABOUT WHAT WAS THE VALUE OF ALL LIFE INSURANCE POLICIES OWNED BY THE DECEASED?
- - - - - - - - - - - - - - - - - - - - - - - - -
1000..50000000
| ========================================================================
|
XT035
Who were the beneficiaries of the life insurance polices, including yourself.
WHO WERE THE BENEFICIARIES OF THE LIFE INSURANCE POLICES, INCLUDING YOURSELF.
- - - - - - - - - - - - - - - - - - - - - - - - -
1 Yourself (proxy respondent)
2 Husband or wife or partner
3 Sons or daughters (ASK FOR FIRST NAMES)
4 Grandchildren
5 Siblings
6 Other relatives (specify)
7 Other non-relatives (specify)
WHO WERE THE BENEFICIARIES OF THE LIFE INSURANCE POLICES, INCLUDING YOURSELF.
- - - - - - - - - - - - - - - - - - - - - - - - -
1 Yourself (proxy respondent)
2 Husband or wife or partner
3 Sons or daughters (ASK FOR FIRST NAMES)
4 Grandchildren
5 Siblings
6 Other relatives (specify)
7 Other non-relatives (specify)
|
If 6 IN XT035 »
| | ========================================================================
|
If 7 IN XT035 »
| | ========================================================================
|
If 3 IN XT035 »
| | ========================================================================
| |
XT056
IWER:First names of children who were beneficiaries
IWER:FIRST NAMES OF CHILDREN WHO WERE BENEFICIARIES
IWER:FIRST NAMES OF CHILDREN WHO WERE BENEFICIARIES
========================================================================
XT036
I will now read out a few types of assets people may have. For each item, please tell me whether the deceased owned them at the time of [his/her] death and, if so, pleasegive your best estimate of their value after any outstanding debts.
I WILL NOW READ OUT A FEW TYPES OF ASSETS PEOPLE MAY HAVE. FOR EACH ITEM, PLEASE TELL ME WHETHER THE DECEASED OWNED THEM AT THE TIME OF [HIS/HER] DEATH AND, IF SO, PLEASEGIVE YOUR BEST ESTIMATE OF THEIR VALUE AFTER ANY OUTSTANDING DEBTS.
- - - - - - - - - - - - - - - - - - - - - - - - -
1 Continue
I WILL NOW READ OUT A FEW TYPES OF ASSETS PEOPLE MAY HAVE. FOR EACH ITEM, PLEASE TELL ME WHETHER THE DECEASED OWNED THEM AT THE TIME OF [HIS/HER] DEATH AND, IF SO, PLEASEGIVE YOUR BEST ESTIMATE OF THEIR VALUE AFTER ANY OUTSTANDING DEBTS.
- - - - - - - - - - - - - - - - - - - - - - - - -
1 Continue
As CNT goes from 1 to 5 » »
| ========================================================================
|
XT037
Did [he/she] own any [businesses, including land or premises/other real estate/cars/financial assets, e.g. cash, bonds or stock s/jewelry or antiquities]?
DID [HE/SHE] OWN ANY [BUSINESSES, INCLUDING LAND OR PREMISES/OTHER REAL ESTATE/CARS/FINANCIAL ASSETS, E.G. CASH, BONDS OR STOCK S/JEWELRY OR ANTIQUITIES]?
- - - - - - - - - - - - - - - - - - - - - - - - -
1 Yes
5 No
DID [HE/SHE] OWN ANY [BUSINESSES, INCLUDING LAND OR PREMISES/OTHER REAL ESTATE/CARS/FINANCIAL ASSETS, E.G. CASH, BONDS OR STOCK S/JEWELRY OR ANTIQUITIES]?
- - - - - - - - - - - - - - - - - - - - - - - - -
1 Yes
5 No
|
If Did [he/she] own any [businesses, including land or premises/other real estate/cars/financial assets, e.g. cash, bonds or stock s/jewelry or antiquities]? (XT037) = 1 Yes
5 No
»
| | ========================================================================
| |
XT038
About what was the value of the [businesses, including land or premises/other real estate/cars/financial assets, e.g. cash, bonds or stock s/jewelry or antiquities] ownedby [{Name of the deceased}] at the time of [his/her] death?
ABOUT WHAT WAS THE VALUE OF THE [BUSINESSES, INCLUDING LAND OR PREMISES/OTHER REAL ESTATE/CARS/FINANCIAL ASSETS, E.G. CASH, BONDS OR STOCK S/JEWELRY OR ANTIQUITIES] OWNEDBY [{NAME OF THE DECEASED}] AT THE TIME OF [HIS/HER] DEATH?
- - - - - - - - - - - - - - - - - - - - - - - - -
1 Some children received more than others
2 The estate was divided about equally among all children
3 The estate was distributed exactly among the children
4 The children have not received anything
ABOUT WHAT WAS THE VALUE OF THE [BUSINESSES, INCLUDING LAND OR PREMISES/OTHER REAL ESTATE/CARS/FINANCIAL ASSETS, E.G. CASH, BONDS OR STOCK S/JEWELRY OR ANTIQUITIES] OWNEDBY [{NAME OF THE DECEASED}] AT THE TIME OF [HIS/HER] DEATH?
- - - - - - - - - - - - - - - - - - - - - - - - -
1 Some children received more than others
2 The estate was divided about equally among all children
3 The estate was distributed exactly among the children
4 The children have not received anything
If (How many children did [{Name of the deceased}] have that were still alive at the time of [his/her] death? Please include foster and adopted children. (XT039) > 1) and NOT (9 IN XT027) »
| ========================================================================
|
XT040A
XT040A
|
If XT040A = 1 »
| | ========================================================================
| |
XT040B
Would you say that some children received more than others to mak e up for previous gifts?
WOULD YOU SAY THAT SOME CHILDREN RECEIVED MORE THAN OTHERS TO MAK E UP FOR PREVIOUS GIFTS?
- - - - - - - - - - - - - - - - - - - - - - - - -
1 Yes
5 No
WOULD YOU SAY THAT SOME CHILDREN RECEIVED MORE THAN OTHERS TO MAK E UP FOR PREVIOUS GIFTS?
- - - - - - - - - - - - - - - - - - - - - - - - -
1 Yes
5 No
| | ========================================================================
| |
XT040C
Would you say that some children received more than others to give them financial support?
WOULD YOU SAY THAT SOME CHILDREN RECEIVED MORE THAN OTHERS TO GIVE THEM FINANCIAL SUPPORT?
- - - - - - - - - - - - - - - - - - - - - - - - -
1 Yes
5 No
WOULD YOU SAY THAT SOME CHILDREN RECEIVED MORE THAN OTHERS TO GIVE THEM FINANCIAL SUPPORT?
- - - - - - - - - - - - - - - - - - - - - - - - -
1 Yes
5 No
| | ========================================================================
| |
XT040D
Would you say that some children received more than others because they helped or cared for the deceased towards the end of [his/her] life?
WOULD YOU SAY THAT SOME CHILDREN RECEIVED MORE THAN OTHERS BECAUSE THEY HELPED OR CARED FOR THE DECEASED TOWARDS THE END OF [HIS/HER] LIFE?
- - - - - - - - - - - - - - - - - - - - - - - - -
1 Yes
5 No
WOULD YOU SAY THAT SOME CHILDREN RECEIVED MORE THAN OTHERS BECAUSE THEY HELPED OR CARED FOR THE DECEASED TOWARDS THE END OF [HIS/HER] LIFE?
- - - - - - - - - - - - - - - - - - - - - - - - -
1 Yes
5 No
| | ========================================================================
| |
XT040E
Would you say that some children received more than others because of other reasons?
WOULD YOU SAY THAT SOME CHILDREN RECEIVED MORE THAN OTHERS BECAUSE OF OTHER REASONS?
- - - - - - - - - - - - - - - - - - - - - - - - -
1 Yes
5 No
WOULD YOU SAY THAT SOME CHILDREN RECEIVED MORE THAN OTHERS BECAUSE OF OTHER REASONS?
- - - - - - - - - - - - - - - - - - - - - - - - -
1 Yes
5 No
| |
If Would you say that some children received more than others because of other reasons? (XT040E) = 1 Yes
5 No
»
| | | ========================================================================
========================================================================
XT041
Finally, we would lik e to k now about the deceased's funeral. Was the funeral accompanied by a religious ceremony?
FINALLY, WE WOULD LIK E TO K NOW ABOUT THE DECEASED'S FUNERAL. WAS THE FUNERAL ACCOMPANIED BY A RELIGIOUS CEREMONY?
- - - - - - - - - - - - - - - - - - - - - - - - -
1 Yes
5 No
FINALLY, WE WOULD LIK E TO K NOW ABOUT THE DECEASED'S FUNERAL. WAS THE FUNERAL ACCOMPANIED BY A RELIGIOUS CEREMONY?
- - - - - - - - - - - - - - - - - - - - - - - - -
1 Yes
5 No
========================================================================
XT108
We have ask ed you many questions about numerous aspects of [{Name of the deceased}]'s health and finances, and we want to thank you very much for your assistancewith them. Is there anything else you would lik e to add about the life circumstances of [{Name of the deceased}] in [his/her] last year of life?
WE HAVE ASK ED YOU MANY QUESTIONS ABOUT NUMEROUS ASPECTS OF [{NAME OF THE DECEASED}]'S HEALTH AND FINANCES, AND WE WANT TO THANK YOU VERY MUCH FOR YOUR ASSISTANCEWITH THEM. IS THERE ANYTHING ELSE YOU WOULD LIK E TO ADD ABOUT THE LIFE CIRCUMSTANCES OF [{NAME OF THE DECEASED}] IN [HIS/HER] LAST YEAR OF LIFE?
WE HAVE ASK ED YOU MANY QUESTIONS ABOUT NUMEROUS ASPECTS OF [{NAME OF THE DECEASED}]'S HEALTH AND FINANCES, AND WE WANT TO THANK YOU VERY MUCH FOR YOUR ASSISTANCEWITH THEM. IS THERE ANYTHING ELSE YOU WOULD LIK E TO ADD ABOUT THE LIFE CIRCUMSTANCES OF [{NAME OF THE DECEASED}] IN [HIS/HER] LAST YEAR OF LIFE?
========================================================================
XT042
This is the end of the interview. Thank you once again for all the information you have given us. It will prove extremely useful in helping us to understand how people fare atthe end of their lives
THIS IS THE END OF THE INTERVIEW. THANK YOU ONCE AGAIN FOR ALL THE INFORMATION YOU HAVE GIVEN US. IT WILL PROVE EXTREMELY USEFUL IN HELPING US TO UNDERSTAND HOW PEOPLE FARE ATTHE END OF THEIR LIVES
- - - - - - - - - - - - - - - - - - - - - - - - -
1 Continue
THIS IS THE END OF THE INTERVIEW. THANK YOU ONCE AGAIN FOR ALL THE INFORMATION YOU HAVE GIVEN US. IT WILL PROVE EXTREMELY USEFUL IN HELPING US TO UNDERSTAND HOW PEOPLE FARE ATTHE END OF THEIR LIVES
- - - - - - - - - - - - - - - - - - - - - - - - -
1 Continue
========================================================================
XT043
IWER:Please state mode of interview
IWER:PLEASE STATE MODE OF INTERVIEW
- - - - - - - - - - - - - - - - - - - - - - - - -
1 Face-to-face
2 Telephone
IWER:PLEASE STATE MODE OF INTERVIEW
- - - - - - - - - - - - - - - - - - - - - - - - -
1 Face-to-face
2 Telephone
========================================================================
End of XT. End-of-Life Interview