XT. End-of-Life Interview

XT. End-of-Life Interview Module of SHARE 2017

item label type description
XT104 Question IWER:note sex of decedent (ask if unsure)
XT001 Question [{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.
XT006 Question IWER:Code proxy respondent's sex.
XT002 Question 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?
XT003 Question IWER:Specify other relative
XT004 Question IWER:Specify other non-relative
XT005 Question 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?
XT007 Question Can you tell me your year of birth?
XT101 Question 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}]?
XT102 Question In which month and year was [{Name of the deceased}] born?MONTH:YEAR:
XT103 Question In which month and year were [{Name of the deceased}] born?MONTH: ______YEAR:
XT008 Question We would lik e to k now more about the circumstances of [{Name of the deceased}] 's death. In what month and year did [he/she] pass away?MONTH:YEAR:
XT009 Question In what month and YEAR did [he/she] pass away?MONTH: ______YEAR:
XT010 Question How old was [{Name of the deceased}] when [he/she] passed away?
XT109 Question Was [{Name of the deceased}] married at the time of [his/her] death?
XT039 Question How many children did [ {Name of the deceased}] have that were still alive at the time of [ his/ her] death?Please count all natural children, fostered, adopted and stepchildren
XT011 Question What was the main cause of [his/her] death?
XT012 Question IWER:Specify other cause of death
XT013 Question How long had [{Name of the deceased}] been ill before [he/she] died?
XT014 Question Did [he/she] die ... IWER: {ReadOut} PLACE OF DYING
XT750 Question Was that in the Intensive Care Unit? IN INTENSIVE CARE UNIT
XT751 Question Was that in a palliative care or inpatient hospice unit?
XT767 Question Was there at least one (certified) nurse in the assistance or supervision staff? At LEAST A NURSE
XT752 Question Was that an inpatient hospice unit? INPATIENT HOSPICE
XT753 Question Was the residential housing provided by hospice? RESIDENTIAL PROVIDED BY HOSPICE
XT615 Question 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?
XT016 Question During the last year of [his/her] life, for how long altogether did [{Name of the deceased}] stay at hospitals, hospices or nursing homes?
XT756 Question The next couple of questions are about the care [{Name of the deceased}] received in the last month of [his/her] life. Please answer these questions based on your experience and the deceased s experience while [he/she] was receiving care. Some o
XT757 Question In the last four weeks of [his/her] life, did [{Name of the deceased}] have any hospice or palliative care?
XT754 Question What was the reason that [he/she] did not have hospice or palliative care?
XT758 Question In [his/her] last month of life, did [{Name of the deceased}] have pain or take medicine for pain? MEDICINE FOR PAIN
XT759 Question Did the deceased receive too much, too little, or just the right amount of medication for [his/her] pain? MEDICATION AMOUNT
XT760 Question In [his/her] last month of life, did [{Name of the deceased}] have trouble breathing? TROUBLE BREATHING
XT761 Question How much help in dealing with [his/her] breathing did the deceased receive - too little, or just the right amount? HOW MUCH HELP BREATHING
XT762 Question In [his/her] last month of life, did [{Name of the deceased}] have any feelings of anxiety or sadness? ANXIETY SADNESS
XT763 Question How much help in dealing with these feelings did the deceased receive - too little, or just the right amount? HOW MUCH HELP ANXIETY OR SADNESS
XT764 Question How often were the deceased's personal care needs - such as bathing, dressing, and changing bedding - taken care of as well as they should have been?
XT765 Question During [his/her] last month of life, how often overall was the staff who took care of [him/her] kind, caring, and respectful?
XT766 Question Overall, how would you rate the care the deceased received in [his/her] last month of life? IWER:
XT017 Question We would now like to ask you some questions about any expenses which [{Name of the deceased}] incurred as a result of the medical care [he/she] received in the last 12 months before [he/she] died.
XT018 Question Did [ {Name of the deceased}] have any [ care from a general practitioner/ care from specialist physicians/ hospital stays/ care in a nursing home/ hospice stays/ medication/ aids and appliances/ help with personal care due to disability/ help with domestic tasks due to disability] (in the last 12 months of [ his/ her] life)?
XT119 Question About how much did [ he/ she] pay out of pocket for [ care from a general practitioner/ care from specialistphysicians/ hospital stays/ care in a nursing home/ hospice stays/ medication/ aids and appliances/ help with personal care due to disability/ help with domestic tasks due to disability] (in the last 12 months of [ his/ her] life)? [ By out of pocket we mean that the costs were not covered or reimbursed by the health insurance/national health system/third party.]
XT105 Question We would like 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?
XT106 Question During the last year of [his/her] life, did [{Name of the deceased}] have any difficulty remembering what year it was? (Please name only difficulties that lasted at least three months?)
XT107 Question During the last year of [his/her] life, did [{Name of the deceased}] have any difficulty recognizing family members or good friends? (Please name only difficulties that lasted at least three months?)
XT020 Question 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 months of [his/her] life? Please name only difficulties that lasted at least three
XT022 Question 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?
XT023 Question Who, including yourself, has helped mainly with these activities? Please name at most three persons.
XT024 Question Overall, during the last twelve months of [his/her] life, for how long did the deceased receive help?
XT025 Question And about how many hours of help were necessary during a typical day?
XT620 Question Because of a physical, mental, emotional or memory problem, did {FL_XT620_1} have difficulty doing any ofthe following activities during the last twelve months of [ his] life? Please name only difficulties that lasted at least three months. INTRODUCTION DIFFICULTIES
XT622 Question Thinking about the activities that [ {Name of the deceased}] had problems with during the last twelve months of[ his/ her] life, has anyone helped regularly with these activities? ANYONE HELPED WITH ADLII
XT623 Question Who, including yourself, has mainly helped with these activities? Please name up to three persons.WHO HAS HELPED WITH ADLII
XT624 Question Overall, during the last twelve months of [ his/ her] life, for how long did [ {Name of the deceased}] receivehelp?
XT625 Question And about how many hours of help did [ {Name of the deceased}] receive during a typical day?HOURS OF HELP NECESSARY DURING TYPICAL DAY
XT026a Question 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.
XT026b Question Some people mak e a will to determine who receives what parts of the estate.Did [{Name of the deceased}] have a will?
XT027 Question Who were the beneficiaries of the estate, including yourself?
XT030 Question Did the deceased own [his/her] home or apartment - either in total or a share of it?
XT031 Question After any outstanding mortgages, what was the value of the home or apartment or the share of it owned by the deceased?
XT032 Question Who inherited the deceased's home or apartment, including yourself?IWER:Code relationship to deceased.
XT053 Question IWER:First names of children who inherited home
XT033 Question Did the deceased own any life insurance policies?
XT034 Question Approximately what was the total value of all life insurance policies owned by [ {Name of the deceased}]?
XT035 Question Who were the beneficiaries of the life insurance polices, including yourself.
XT054 Question IWER:Specify other relative
XT055 Question IWER:Specify other non-relative
XT056 Question IWER:First names of children who were beneficiaries
XT036 Question 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.
XT637 Question 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]?
XT638 Question 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] owned by [{Name of the deceased}] at the time of [his/her] death?
XT040a Question How would you say that the total estate was divided among the children of [ {Name of the deceased}]?IWER: {ReadOut} TOTAL ESTATE DIVIDED AMONG THE CHILDREN
XT040b Question Would you say that some children received more than others to make up for previous gifts?
XT040c Question Would you say that some children received more than others to give them financial support?
XT040d Question 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?
XT040e Question Would you say that some children received more than others because of other reasons?
XT041 Question Finally, we would lik e to k now about the deceased's funeral. Was the funeral accompanied by a religious ceremony?
XT108 Question 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 Question 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
XT043 Question IWER:Please state mode of interviewFace-to-face
XT044 Question IWER: Your interviewer id.
Start of XT. End-of-Life Interview
 
XT104

IWER:note sex of decedent (ask if unsure)

IWER:NOTE SEX OF DECEDENT (ASK IF UNSURE)
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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.
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XT006

IWER:Code proxy respondent's sex.

IWER:CODE PROXY RESPONDENT'S SEX.
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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?
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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? = A7 »
 
   
 
XT003

IWER:Specify other relative

IWER:SPECIFY OTHER RELATIVE
   
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? = A8 »
 
   
 
XT004

IWER:Specify other non-relative

IWER:SPECIFY OTHER NON-RELATIVE
   
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?
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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? != A1 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?
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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}]?
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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}]? = A5 »
 
   
 
XT102

In which month and year was [{Name of the deceased}] born?MONTH:YEAR:

IN WHICH MONTH AND YEAR WAS [{NAME OF THE DECEASED}] BORN?MONTH:YEAR:
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XT103

In which month and year were [{Name of the deceased}] born?MONTH: ^XT102_DecMonthBirthYEAR:

IN WHICH MONTH AND YEAR WERE [{NAME OF THE DECEASED}] BORN?MONTH: ______YEAR:
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XT008

We would lik e to k now more about the circumstances of [{Name of the deceased}] 's death. In what month and year did [he/she] pass away?MONTH:YEAR:

WE WOULD LIK E TO K NOW MORE ABOUT THE CIRCUMSTANCES OF [{NAME OF THE DECEASED}] 'S DEATH. IN WHAT MONTH AND YEAR DID [HE/SHE] PASS AWAY?MONTH:YEAR:
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XT009

In what month and YEAR did [he/she] pass away?MONTH: ^XT008_MonthDiedYEAR:

IN WHAT MONTH AND YEAR DID [HE/SHE] PASS AWAY?MONTH: ______YEAR:
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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?
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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?
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XT039

How many children did [ {Name of the deceased}] have that were still alive at the time of [ his/ her] death?Please count all natural children, fostered, adopted and stepchildren

NUMBER OF CHILDREN THE DECEASED HAD AT THE END
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XT011

What was the main cause of [his/her] death?

WHAT WAS THE MAIN CAUSE OF [HIS/HER] DEATH?
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If What was the main cause of [his/her] death? = A97 »
 
   
 
XT012

IWER:Specify other cause of death

IWER:SPECIFY OTHER CAUSE OF DEATH
   
If What was the main cause of [his/her] death? != A8 »
 
   
 
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?
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XT014

Did [he/she] die ... IWER: {ReadOut} PLACE OF DYING

DID [HE/SHE] DIE ...
IWER:
{READOUT}
PLACE OF DYING
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If Did [he/she] die ... IWER: {ReadOut} PLACE OF DYING = A3. in a hospital »
 
     
   
XT750

Was that in the Intensive Care Unit? IN INTENSIVE CARE UNIT

WAS THAT IN THE INTENSIVE CARE UNIT?
IN INTENSIVE CARE UNIT
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If Was that in the Intensive Care Unit? IN INTENSIVE CARE UNIT = A5. No »
 
       
     
XT751

Was that in a palliative care or inpatient hospice unit?

WAS THAT IN A PALLIATIVE CARE OR INPATIENT HOSPICE UNIT?
PALLIATIVE CARE OR INPATIENT HOSPICE
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Else
 
     
   
If Did [he/she] die ... IWER: {ReadOut} PLACE OF DYING = A5. in a residential home, sheltered housing, or old people's home »
 
       
     
XT767

Was there at least one (certified) nurse in the assistance or supervision staff? At LEAST A NURSE

WAS THERE AT LEAST ONE (CERTIFIED) NURSE IN THE ASSISTANCE OR SUPERVISION STAFF?
AT LEAST A NURSE
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XT753

Was the residential housing provided by hospice? RESIDENTIAL PROVIDED BY HOSPICE

WAS THE RESIDENTIAL HOUSING PROVIDED BY HOSPICE?
RESIDENTIAL PROVIDED BY HOSPICE
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XT615

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?
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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? > 0 »
 
     
   
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?
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XT756

The next couple of questions are about the care [{Name of the deceased}] received in the last month of [his/her] life. Please answer these questions based on your experience and the deceased s experience while [he/she] was receiving care. Some o

THE NEXT COUPLE OF QUESTIONS ARE ABOUT THE CARE [{NAME OF THE DECEASED}] RECEIVED IN THE LAST MONTH OF [HIS/HER] LIFE. PLEASE ANSWER THESE QUESTIONS BASED ON YOUR
EXPERIENCE AND THE DECEASED S EXPERIENCE WHILE [HE/SHE] WAS RECEIVING CARE. SOME OF THE QUESTIONS ASK ABOUT THE STAFF. BY STAFF, WE MEAN DOCTORS, NURSES, SOCIAL
WORKERS, CHAPLAINS, NURSING ASSISTANTS, THERAPISTS, AND OTHER PERSONNEL.
CARE INTRO
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If NOT ((((XT014 = A6) or (XT751 = A1)) or (XT752 = A1)) or (XT753 = A1))
 
     
   
XT757

In the last four weeks of [his/her] life, did [{Name of the deceased}] have any hospice or palliative care?

IN THE LAST FOUR WEEKS OF [HIS/HER] LIFE, DID [{NAME OF THE DECEASED}] HAVE ANY HOSPICE OR PALLIATIVE CARE?
IWER:
BY HOSPICE CARE WE MEAN PALLIATIVE CARE FOR TERMINALLY ILL OR SERIOUSLY ILL PATIENTS, DELIVERED AT HOME OR IN AN INSTITUTION. ACCORDING TO THE WHO DEFINITION, "PALLIATIVE CARE IS
AN APPROACH THAT IMPROVES THE QUALITY OF LIFE OF PATIENTS AND THEIR FAMILIES FACING THE PROBLEM ASSOCIATED WITH LIFE-THREATENING ILLNESS, THROUGH THE PREVENTION AND RELIEF OF
SUFFERING BY MEANS OF EARLY IDENTIFICATION AND IMPECCABLE ASSESSMENT AND TREATMENT OF PAIN AND OTHER PROBLEMS, PHYSICAL, PSYCHOSOCIAL AND SPIRITUAL
HOSPICE OR PALLIATIVE CARE
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If In the last four weeks of [his/her] life, did [{Name of the deceased}] have any hospice or palliative care? = A5. No »
 
       
     
XT754

What was the reason that [he/she] did not have hospice or palliative care?

WHAT WAS THE REASON THAT [HE/SHE] DID NOT HAVE HOSPICE OR PALLIATIVE CARE?
IWER:
{READOUT}
REASON NOT HOSPICE
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XT758

In [his/her] last month of life, did [{Name of the deceased}] have pain or take medicine for pain? MEDICINE FOR PAIN

IN [HIS/HER] LAST MONTH OF LIFE, DID [{NAME OF THE DECEASED}] HAVE PAIN OR TAKE MEDICINE FOR PAIN?
MEDICINE FOR PAIN
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If In [his/her] last month of life, did [{Name of the deceased}] have pain or take medicine for pain? MEDICINE FOR PAIN = A1. Yes »
 
     
   
XT759

Did the deceased receive too much, too little, or just the right amount of medication for [his/her] pain? MEDICATION AMOUNT

DID THE DECEASED RECEIVE TOO MUCH, TOO LITTLE, OR JUST THE RIGHT AMOUNT OF MEDICATION FOR [HIS/HER] PAIN?
MEDICATION AMOUNT
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XT760

In [his/her] last month of life, did [{Name of the deceased}] have trouble breathing? TROUBLE BREATHING

IN [HIS/HER] LAST MONTH OF LIFE, DID [{NAME OF THE DECEASED}] HAVE TROUBLE BREATHING?
TROUBLE BREATHING
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If In [his/her] last month of life, did [{Name of the deceased}] have trouble breathing? TROUBLE BREATHING = A1. Yes »
 
     
   
XT761

How much help in dealing with [his/her] breathing did the deceased receive - too little, or just the right amount? HOW MUCH HELP BREATHING

HOW MUCH HELP IN DEALING WITH [HIS/HER] BREATHING DID THE DECEASED RECEIVE - TOO LITTLE, OR JUST THE RIGHT AMOUNT?
HOW MUCH HELP BREATHING
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XT762

In [his/her] last month of life, did [{Name of the deceased}] have any feelings of anxiety or sadness? ANXIETY SADNESS

IN [HIS/HER] LAST MONTH OF LIFE, DID [{NAME OF THE DECEASED}] HAVE ANY FEELINGS OF ANXIETY OR SADNESS?
ANXIETY SADNESS
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If In [his/her] last month of life, did [{Name of the deceased}] have any feelings of anxiety or sadness? ANXIETY SADNESS = A1. Yes »
 
     
   
XT763

How much help in dealing with these feelings did the deceased receive - too little, or just the right amount? HOW MUCH HELP ANXIETY OR SADNESS

HOW MUCH HELP IN DEALING WITH THESE FEELINGS DID THE DECEASED RECEIVE - TOO LITTLE, OR JUST THE RIGHT AMOUNT?
HOW MUCH HELP ANXIETY OR SADNESS
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XT764

How often were the deceased's personal care needs - such as bathing, dressing, and changing bedding - taken care of as well as they should have been?

HOW OFTEN WERE THE DECEASED'S PERSONAL CARE NEEDS - SUCH AS BATHING, DRESSING, AND CHANGING BEDDING - TAKEN CARE OF AS WELL AS THEY SHOULD HAVE BEEN?
IWER:
{READOUT}.
PERSONAL CARE NEEDS MET
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XT765

During [his/her] last month of life, how often overall was the staff who took care of [him/her] kind, caring, and respectful?

DURING [HIS/HER] LAST MONTH OF LIFE, HOW OFTEN OVERALL WAS THE STAFF WHO TOOK CARE OF [HIM/HER] KIND, CARING, AND RESPECTFUL?
IWER:
{READOUT}.
STAFF CARING AND RESPECTFULL
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XT766

Overall, how would you rate the care the deceased received in [his/her] last month of life? IWER:

OVERALL, HOW WOULD YOU RATE THE CARE THE DECEASED RECEIVED IN [HIS/HER] LAST MONTH OF LIFE?
IWER:
{READOUT}.
RATE CARE
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XT017

We would now like to ask you some questions about any expenses which [{Name of the deceased}] incurred as a result of the medical care [he/she] received in the last 12 months before [he/she] died.

WE WOULD NOW LIKE TO ASK YOU SOME QUESTIONS ABOUT ANY EXPENSES WHICH [{NAME OF THE DECEASED}] INCURRED AS A RESULT OF THE MEDICAL CARE [HE/SHE] RECEIVED IN THE
LAST 12 MONTHS BEFORE [HE/SHE] DIED.
FOR EACH OF THE TYPES OF CARE I WILL NOW LIST, PLEASE INDICATE WHETHER [{NAME OF THE DECEASED}] RECEIVED THE CARE AND, IF SO, GIVE YOUR BEST ESTIMATE OF THE COSTS INCURRED
FROM THAT CARE.
PLEASE INCLUDE ONLY COSTS NOT PAID OR REIMBURSED BY THE HEALTH INSURANCE OR THE EMPLOYER.
INTRODUCTION EXPENSES MEDICAL CARE
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XT018

Did [ {Name of the deceased}] have any [ care from a general practitioner/ care from specialist physicians/ hospital stays/ care in a nursing home/ hospice stays/ medication/ aids and appliances/ help with personal care due to disability/ help with domestic tasks due to disability] (in the last 12 months of [ his/ her] life)?

HAD TYPE OF MEDICAL CARE IN THE LAST TWELVE MONTHS
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If Did [ {Name of the deceased}] have any [ care from a general practitioner/ care from specialist physicians/ hospital stays/ care in a nursing home/ hospice stays/ medication/ aids and appliances/ help with personal care due to disability/ help with domestic tasks due to disability] (in the last 12 months of [ his/ her] life)? = A1 Yes 5 No  »
 
   
 
XT119

About how much did [ he/ she] pay out of pocket for [ care from a general practitioner/ care from specialistphysicians/ hospital stays/ care in a nursing home/ hospice stays/ medication/ aids and appliances/ help with personal care due to disability/ help with domestic tasks due to disability] (in the last 12 months of [ his/ her] life)? [ By out of pocket we mean that the costs were not covered or reimbursed by the health insurance/national health system/third party.]

COSTS OF TYPE OF MEDICAL CARE IN THE LAST TWELVE MONTHS
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XT105

We would like 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 LIKE 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?
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XT106

During the last year of [his/her] life, did [{Name of the deceased}] have any difficulty remembering what 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 REMEMBERING WHAT YEAR IT WAS? (PLEASE NAME ONLY DIFFICULTIES THAT LASTED AT LEAST THREE MONTHS?)
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XT107

During the last year of [his/her] life, did [{Name of the deceased}] have any difficulty recognizing family 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 RECOGNIZING FAMILY MEMBERS OR GOOD FRIENDS? (PLEASE NAME ONLY DIFFICULTIES THAT LASTED AT LEAST THREE MONTHS?)
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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 months of [his/her] life? Please name only difficulties that lasted at least three

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
MONTHS OF [HIS/HER] LIFE? PLEASE NAME ONLY DIFFICULTIES THAT LASTED AT LEAST THREE MONTHS.
IWER:
{READOUT}.
{CODEALL}
INTRODUCTION DIFFICULTIES DOING ACTIVITIES
expand
 
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 months of [his/her] life? Please name only difficulties that lasted at least three > 0 »
 
   
 
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?
expand
   
 
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? = A1 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.
expand
     
   
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?
expand
     
   
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?
expand
     
 
XT620

Because of a physical, mental, emotional or memory problem, did {FL_XT620_1} have difficulty doing any ofthe following activities during the last twelve months of [ his] life? Please name only difficulties that lasted at least three months. INTRODUCTION DIFFICULTIES

INTRODUCTION DIFFICULTIES
expand
   
 
If Because of a physical, mental, emotional or memory problem, did {FL_XT620_1} have difficulty doing any ofthe following activities during the last twelve months of [ his] life? Please name only difficulties that lasted at least three months. INTRODUCTION DIFFICULTIES > 0 »
 
     
   
XT622

Thinking about the activities that [ {Name of the deceased}] had problems with during the last twelve months of[ his/ her] life, has anyone helped regularly with these activities? ANYONE HELPED WITH ADLII

THINKING ABOUT THE ACTIVITIES THAT [ {NAME OF THE DECEASED}] HAD PROBLEMS WITH DURING THE LAST TWELVE MONTHS OF[ HIS/ HER] LIFE, HAS ANYONE HELPED REGULARLY WITH THESE ACTIVITIES? ANYONE HELPED WITH ADLII
expand
     
   
If Thinking about the activities that [ {Name of the deceased}] had problems with during the last twelve months of[ his/ her] life, has anyone helped regularly with these activities? ANYONE HELPED WITH ADLII = A1 Yes 5 No  »
 
       
     
XT623

Who, including yourself, has mainly helped with these activities? Please name up to three persons.WHO HAS HELPED WITH ADLII

WHO, INCLUDING YOURSELF, HAS MAINLY HELPED WITH THESE ACTIVITIES? PLEASE NAME UP TO THREE PERSONS.WHO HAS HELPED WITH ADLII
expand
       
     
XT624

Overall, during the last twelve months of [ his/ her] life, for how long did [ {Name of the deceased}] receivehelp?

OVERALL, DURING THE LAST TWELVE MONTHS OF [ HIS/ HER] LIFE, FOR HOW LONG DID [ {NAME OF THE DECEASED}] RECEIVEHELP?
expand
       
     
XT625

And about how many hours of help did [ {Name of the deceased}] receive during a typical day?HOURS OF HELP NECESSARY DURING TYPICAL DAY

AND ABOUT HOW MANY HOURS OF HELP DID [ {NAME OF THE DECEASED}] RECEIVE DURING A TYPICAL DAY?HOURS OF HELP NECESSARY DURING TYPICAL DAY
expand
       
 
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.

INTRODUCTION TO ASSETS
expand
   
 
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?
expand
   
 
XT027

Who were the beneficiaries of the estate, including yourself?

WHO WERE THE BENEFICIARIES OF THE ESTATE, INCLUDING YOURSELF?
expand
   
 
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?
expand
   
 
If Did the deceased own [his/her] home or apartment - either in total or a share of it? = A1 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?
expand
     
   
XT032

Who inherited the deceased's home or apartment, including yourself?IWER:Code relationship to deceased.

WHO INHERITED THE DECEASED'S HOME OR APARTMENT, INCLUDING YOURSELF?IWER:CODE RELATIONSHIP TO DECEASED.
expand
     
   
If A3 includes XT032 »
 
       
     
XT053

IWER:First names of children who inherited home

IWER:FIRST NAMES OF CHILDREN WHO INHERITED HOME
       
 
XT033

Did the deceased own any life insurance policies?

DID THE DECEASED OWN ANY LIFE INSURANCE POLICIES?
expand
   
 
If Did the deceased own any life insurance policies? = A1 Yes 5 No  »
 
     
   
XT034

Approximately what was the total value of all life insurance policies owned by [ {Name of the deceased}]?

VALUE OF ALL LIFE INSURANCE POLICIES
expand
     
   
XT035

Who were the beneficiaries of the life insurance polices, including yourself.

WHO WERE THE BENEFICIARIES OF THE LIFE INSURANCE POLICES, INCLUDING YOURSELF.
expand
     
   
If A6 includes XT035 »
 
       
     
XT054

IWER:Specify other relative

IWER:SPECIFY OTHER RELATIVE
       
   
If A7 includes XT035
 
       
     
XT055

IWER:Specify other non-relative

IWER:SPECIFY OTHER NON-RELATIVE
       
   
If A3 includes XT035 »
 
       
     
XT056

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.

INTRODUCTION TYPES OF ASSETS
expand
   
 
XT637

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]?
expand
   
 
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]? = A1 Yes 5 No  »
 
     
   
XT638

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] owned by [{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] OWNED BY [{NAME OF THE DECEASED}] AT THE TIME OF [HIS/HER] DEATH?
expand
     
 
If How many children did [ {Name of the deceased}] have that were still alive at the time of [ his/ her] death?Please count all natural children, fostered, adopted and stepchildren > 1 »
 
     
   
XT040A

How would you say that the total estate was divided among the children of [ {Name of the deceased}]?IWER: {ReadOut} TOTAL ESTATE DIVIDED AMONG THE CHILDREN

TOTAL ESTATE DIVIDED AMONG THE CHILDREN
expand
     
 
If How would you say that the total estate was divided among the children of [ {Name of the deceased}]?IWER: {ReadOut} TOTAL ESTATE DIVIDED AMONG THE CHILDREN = A1. Some children received more than others »
 
     
   
XT040B

Would you say that some children received more than others to make up for previous gifts?

WOULD YOU SAY THAT SOME CHILDREN RECEIVED MORE THAN OTHERS TO MAKE UP FOR PREVIOUS GIFTS?
expand
     
   
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?
expand
     
   
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?
expand
     
   
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?
expand
     
 
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?
expand
   
 
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?

ANYTHING ELSE TO SAY ABOUT THE DECEASED
   
 
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
expand
   
 
XT043

IWER:Please state mode of interviewFace-to-face

INTERVIEW MODE
expand
   
 
XT044

IWER: Your interviewer id.

INTERVIEWER ID
   
End of XT. End-of-Life Interview
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


========================================================================
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


========================================================================
XT006
IWER:Code proxy respondent's sex.

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)


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) = A7 »

|  ========================================================================
XT003
IWER:Specify other relative

IWER:SPECIFY OTHER RELATIVE

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) = A8 »

|  ========================================================================
XT004
IWER:Specify other non-relative

IWER:SPECIFY OTHER NON-RELATIVE

========================================================================
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


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) != A1 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..2001

========================================================================
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


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) = A5 »

|  ========================================================================
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


|  ========================================================================
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..2010

========================================================================
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


========================================================================
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
9. 2014
10. 2015
11. 2016
12. 2017


========================================================================
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

========================================================================
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


========================================================================
========================================================================
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)


If What was the main cause of [his/her] death? (XT011) = A97 »

|  ========================================================================
XT012
IWER:Specify other cause of death

IWER:SPECIFY OTHER CAUSE OF DEATH

If What was the main cause of [his/her] death? (XT011) != A8 »

|  ========================================================================
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


|  ========================================================================
XT014
Did [@ he/@ she] die ... IWER: {ReadOut} PLACE OF DYING

DID [@ HE/@ SHE] DIE ...
IWER:
{READOUT}
PLACE OF DYING
- - - - - - - - - - - - - - - - - - - - - - - - -
1. at______ own home
2. at another person's home
3. in a hospital
4. in a nursing home
5. in a residential home, sheltered housing, or old people's home
6. in a hospice
7. in transit to a medical facility
97. at some other place

If Did [@ he/@ she] die ... IWER: {ReadOut} PLACE OF DYING (XT014) = A3. in a hospital »

| |  ========================================================================
| | 
XT750
Was that in the Intensive Care Unit? IN INTENSIVE CARE UNIT

WAS THAT IN THE INTENSIVE CARE UNIT?
IN INTENSIVE CARE UNIT
- - - - - - - - - - - - - - - - - - - - - - - - -
1. Yes
5. No

| |  If Was that in the Intensive Care Unit? IN INTENSIVE CARE UNIT (XT750) = A5. No »

| | |  ========================================================================
| | | 
XT751
Was that in a palliative care or inpatient hospice unit?

WAS THAT IN A PALLIATIVE CARE OR INPATIENT HOSPICE UNIT?
PALLIATIVE CARE OR INPATIENT HOSPICE
- - - - - - - - - - - - - - - - - - - - - - - - -
1. Yes
5. No

Else

| |  If Did [@ he/@ she] die ... IWER: {ReadOut} PLACE OF DYING (XT014) = A5. in a residential home, sheltered housing, or old people's home »

| | |  ========================================================================
| | | 
XT767
Was there at least one (certified) nurse in the assistance or supervision staff? At LEAST A NURSE

WAS THERE AT LEAST ONE (CERTIFIED) NURSE IN THE ASSISTANCE OR SUPERVISION STAFF?
AT LEAST A NURSE
- - - - - - - - - - - - - - - - - - - - - - - - -
1. Yes
5. No

| | |  ========================================================================
| | | 
XT753
Was the residential housing provided by hospice? RESIDENTIAL PROVIDED BY HOSPICE

WAS THE RESIDENTIAL HOUSING PROVIDED BY HOSPICE?
RESIDENTIAL PROVIDED BY HOSPICE
- - - - - - - - - - - - - - - - - - - - - - - - -
1. Yes
5. No

|  ========================================================================
XT615
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?
- - - - - - - - - - - - - - - - - - - - - - - - -
0..999

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? (XT615) > 0 »

| |  ========================================================================
| | 
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


|  ========================================================================
XT756
The next couple of questions are about the care [@ {Name of the deceased}] received in the last month of [@ his/@ her] life. Please answer these questions based on your experience and the deceased s experience while [@ he/@ she] was receiving care. Some o

THE NEXT COUPLE OF QUESTIONS ARE ABOUT THE CARE [@ {NAME OF THE DECEASED}] RECEIVED IN THE LAST MONTH OF [@ HIS/@ HER] LIFE. PLEASE ANSWER THESE QUESTIONS BASED ON YOUR
EXPERIENCE AND THE DECEASED S EXPERIENCE WHILE [@ HE/@ SHE] WAS RECEIVING CARE. SOME OF THE QUESTIONS ASK ABOUT THE STAFF. BY STAFF, WE MEAN DOCTORS, NURSES, SOCIAL
WORKERS, CHAPLAINS, NURSING ASSISTANTS, THERAPISTS, AND OTHER PERSONNEL.
CARE INTRO
- - - - - - - - - - - - - - - - - - - - - - - - -
1. Continue

If NOT ((XT014 = A6) or (XT751 = A1)) or (XT752 = A1)) or (XT753 = A1))

| |  ========================================================================
| | 
XT757
In the last four weeks of [@ his/@ her] life, did [@ {Name of the deceased}] have any hospice or palliative care?

IN THE LAST FOUR WEEKS OF [@ HIS/@ HER] LIFE, DID [@ {NAME OF THE DECEASED}] HAVE ANY HOSPICE OR PALLIATIVE CARE?
IWER:
BY HOSPICE CARE WE MEAN PALLIATIVE CARE FOR TERMINALLY ILL OR SERIOUSLY ILL PATIENTS, DELIVERED AT HOME OR IN AN INSTITUTION. ACCORDING TO THE WHO DEFINITION, "PALLIATIVE CARE IS
AN APPROACH THAT IMPROVES THE QUALITY OF LIFE OF PATIENTS AND THEIR FAMILIES FACING THE PROBLEM ASSOCIATED WITH LIFE-THREATENING ILLNESS, THROUGH THE PREVENTION AND RELIEF OF
SUFFERING BY MEANS OF EARLY IDENTIFICATION AND IMPECCABLE ASSESSMENT AND TREATMENT OF PAIN AND OTHER PROBLEMS, PHYSICAL, PSYCHOSOCIAL AND SPIRITUAL
HOSPICE OR PALLIATIVE CARE
- - - - - - - - - - - - - - - - - - - - - - - - -
1. Yes
5. No

| |  If In the last four weeks of [@ his/@ her] life, did [@ {Name of the deceased}] have any hospice or palliative care? (XT757) = A5. No »

| | |  ========================================================================
| | | 
XT754
What was the reason that [@ he/@ she] did not have hospice or palliative care?

WHAT WAS THE REASON THAT [@ HE/@ SHE] DID NOT HAVE HOSPICE OR PALLIATIVE CARE?
IWER:
{READOUT}
REASON NOT HOSPICE
- - - - - - - - - - - - - - - - - - - - - - - - -
1. Was not needed or wanted
2. Was needed or wanted but not available
3. Was needed or wanted but too expensive

|  ========================================================================
XT758
In [@ his/@ her] last month of life, did [@ {Name of the deceased}] have pain or take medicine for pain? MEDICINE FOR PAIN

IN [@ HIS/@ HER] LAST MONTH OF LIFE, DID [@ {NAME OF THE DECEASED}] HAVE PAIN OR TAKE MEDICINE FOR PAIN?
MEDICINE FOR PAIN
- - - - - - - - - - - - - - - - - - - - - - - - -
1. Yes
5. No

If In [@ his/@ her] last month of life, did [@ {Name of the deceased}] have pain or take medicine for pain? MEDICINE FOR PAIN (XT758) = A1. Yes »

| |  ========================================================================
| | 
XT759
Did the deceased receive too much, too little, or just the right amount of medication for [@ his/@ her] pain? MEDICATION AMOUNT

DID THE DECEASED RECEIVE TOO MUCH, TOO LITTLE, OR JUST THE RIGHT AMOUNT OF MEDICATION FOR [@ HIS/@ HER] PAIN?
MEDICATION AMOUNT
- - - - - - - - - - - - - - - - - - - - - - - - -
1. Too much
2. Too little
3. Right amount

|  ========================================================================
XT760
In [@ his/@ her] last month of life, did [@ {Name of the deceased}] have trouble breathing? TROUBLE BREATHING

IN [@ HIS/@ HER] LAST MONTH OF LIFE, DID [@ {NAME OF THE DECEASED}] HAVE TROUBLE BREATHING?
TROUBLE BREATHING
- - - - - - - - - - - - - - - - - - - - - - - - -
1. Yes
5. No

If In [@ his/@ her] last month of life, did [@ {Name of the deceased}] have trouble breathing? TROUBLE BREATHING (XT760) = A1. Yes »

| |  ========================================================================
| | 
XT761
How much help in dealing with [@ his/@ her] breathing did the deceased receive - too little, or just the right amount? HOW MUCH HELP BREATHING

HOW MUCH HELP IN DEALING WITH [@ HIS/@ HER] BREATHING DID THE DECEASED RECEIVE - TOO LITTLE, OR JUST THE RIGHT AMOUNT?
HOW MUCH HELP BREATHING
- - - - - - - - - - - - - - - - - - - - - - - - -
1. Too little
2. Right amount

|  ========================================================================
XT762
In [@ his/@ her] last month of life, did [@ {Name of the deceased}] have any feelings of anxiety or sadness? ANXIETY SADNESS

IN [@ HIS/@ HER] LAST MONTH OF LIFE, DID [@ {NAME OF THE DECEASED}] HAVE ANY FEELINGS OF ANXIETY OR SADNESS?
ANXIETY SADNESS
- - - - - - - - - - - - - - - - - - - - - - - - -
1. Yes
5. No

If In [@ his/@ her] last month of life, did [@ {Name of the deceased}] have any feelings of anxiety or sadness? ANXIETY SADNESS (XT762) = A1. Yes »

| |  ========================================================================
| | 
XT763
How much help in dealing with these feelings did the deceased receive - too little, or just the right amount? HOW MUCH HELP ANXIETY OR SADNESS

HOW MUCH HELP IN DEALING WITH THESE FEELINGS DID THE DECEASED RECEIVE - TOO LITTLE, OR JUST THE RIGHT AMOUNT?
HOW MUCH HELP ANXIETY OR SADNESS
- - - - - - - - - - - - - - - - - - - - - - - - -
1. Too little
2. Right amount

|  ========================================================================
XT764
How often were the deceased's personal care needs - such as bathing, dressing, and changing bedding - taken care of as well as they should have been?

HOW OFTEN WERE THE DECEASED'S PERSONAL CARE NEEDS - SUCH AS BATHING, DRESSING, AND CHANGING BEDDING - TAKEN CARE OF AS WELL AS THEY SHOULD HAVE BEEN?
IWER:
{READOUT}.
PERSONAL CARE NEEDS MET
- - - - - - - - - - - - - - - - - - - - - - - - -
1. Always
2. Usually
3. Sometimes
4. Never
5. Help was not needed or wanted for personal care

|  ========================================================================
XT765
During [@ his/@ her] last month of life, how often overall was the staff who took care of [@ him/@ her] kind, caring, and respectful?

DURING [@ HIS/@ HER] LAST MONTH OF LIFE, HOW OFTEN OVERALL WAS THE STAFF WHO TOOK CARE OF [@ HIM/@ HER] KIND, CARING, AND RESPECTFUL?
IWER:
{READOUT}.
STAFF CARING AND RESPECTFULL
- - - - - - - - - - - - - - - - - - - - - - - - -
1. Always
2. Usually
3. Sometimes
4. Never

|  ========================================================================
XT766
Overall, how would you rate the care the deceased received in [@ his/@ her] last month of life? IWER:

OVERALL, HOW WOULD YOU RATE THE CARE THE DECEASED RECEIVED IN [@ HIS/@ HER] LAST MONTH OF LIFE?
IWER:
{READOUT}.
RATE CARE
- - - - - - - - - - - - - - - - - - - - - - - - -
1. Excellent
2. Very good
3. Good
4. Fair
5. Poor

========================================================================
XT017
We would now like to ask you some questions about any expenses which [@ {Name of the deceased}] incurred as a result of the medical care [@ he/@ she] received in the last 12 months before [@ he/@ she] died.

WE WOULD NOW LIKE TO ASK YOU SOME QUESTIONS ABOUT ANY EXPENSES WHICH [@ {NAME OF THE DECEASED}] INCURRED AS A RESULT OF THE MEDICAL CARE [@ HE/@ SHE] RECEIVED IN THE
LAST 12 MONTHS BEFORE [@ HE/@ SHE] DIED.
FOR EACH OF THE TYPES OF CARE I WILL NOW LIST, PLEASE INDICATE WHETHER [@ {NAME OF THE DECEASED}] RECEIVED THE CARE AND, IF SO, GIVE YOUR BEST ESTIMATE OF THE COSTS INCURRED
FROM THAT CARE.
@BPLEASE INCLUDE ONLY COSTS NOT PAID OR REIMBURSED BY THE HEALTH INSURANCE OR THE EMPLOYER.@B
INTRODUCTION EXPENSES MEDICAL CARE
- - - - - - - - - - - - - - - - - - - - - - - - -
1. Continue

========================================================================
If Did [ {Name of the deceased}] have any [ care from a general practitioner/ care from specialist physicians/ hospital stays/ care in a nursing home/ hospice stays/ medication/ aids and appliances/ help with personal care due to disability/ help with domestic tasks due to disability] (in the last 12 months of [ his/ her] life)? (XT018) = A1 Yes 5 No  »

|  ========================================================================
========================================================================
XT105
We would like 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 LIKE 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 remembering what 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 REMEMBERING WHAT 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 recognizing family 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 RECOGNIZING FAMILY 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 months of [@ his/@ her] life? Please name only difficulties that lasted at least three

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
MONTHS OF [@ HIS/@ HER] LIFE? PLEASE NAME ONLY DIFFICULTIES THAT LASTED AT LEAST THREE MONTHS.
IWER:
{READOUT}.
{CODEALL}
INTRODUCTION DIFFICULTIES DOING ACTIVITIES
- - - - - - - - - - - - - - - - - - - - - - - - -
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 months of [@ his/@ her] life? Please name only difficulties that lasted at least three (XT020) > 0 »

|  ========================================================================
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


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) = A1 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
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


| |  ========================================================================
| | 
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

|  ========================================================================
XT620
Because of a physical, mental, emotional or memory problem, did {FL_XT620_1} have difficulty doing any ofthe following activities during the last twelve months of [ his] life? Please name only difficulties that lasted at least three months. INTRODUCTION DIFFICULTIES

INTRODUCTION DIFFICULTIES
- - - - - - - - - - - - - - - - - - - - - - - - -
1 Preparing a hot meal
2 Shopping for groceries
3 Making telephone calls
4 Taking medication
5 Using a map to figure out how to get around in a strange place
6 Doing work around the house or garden
7 Managing money, such as paying bills and keeping track of expenses
8 Leaving the house independently and accessing transportation services
9 Doing personal laundry
10 Continence over urination or defecation
96 None of these


If Because of a physical, mental, emotional or memory problem, did {FL_XT620_1} have difficulty doing any ofthe following activities during the last twelve months of [ his] life? Please name only difficulties that lasted at least three months. INTRODUCTION DIFFICULTIES (XT620) > 0 »

| |  ========================================================================
| | 
XT622
Thinking about the activities that [ {Name of the deceased}] had problems with during the last twelve months of[ his/ her] life, has anyone helped regularly with these activities? ANYONE HELPED WITH ADLII

THINKING ABOUT THE ACTIVITIES THAT [ {NAME OF THE DECEASED}] HAD PROBLEMS WITH DURING THE LAST TWELVE MONTHS OF[ HIS/ HER] LIFE, HAS ANYONE HELPED REGULARLY WITH THESE ACTIVITIES? ANYONE HELPED WITH ADLII
- - - - - - - - - - - - - - - - - - - - - - - - -
1 Yes
5 No


| |  If Thinking about the activities that [ {Name of the deceased}] had problems with during the last twelve months of[ his/ her] life, has anyone helped regularly with these activities? ANYONE HELPED WITH ADLII (XT622) = A1 Yes 5 No  »

| | |  ========================================================================
| | | 
XT623
Who, including yourself, has mainly helped with these activities? Please name up to three persons.WHO HAS HELPED WITH ADLII

WHO, INCLUDING YOURSELF, HAS MAINLY HELPED WITH THESE ACTIVITIES? PLEASE NAME UP TO THREE PERSONS.WHO HAS HELPED WITH ADLII
- - - - - - - - - - - - - - - - - - - - - - - - -
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
15 Friend or neighbor of the deceased
16 Other person


| | |  ========================================================================
| | | 
XT624
Overall, during the last twelve months of [ his/ her] life, for how long did [ {Name of the deceased}] receivehelp?

OVERALL, DURING THE LAST TWELVE MONTHS OF [ HIS/ HER] LIFE, FOR HOW LONG DID [ {NAME OF THE DECEASED}] RECEIVEHELP?
- - - - - - - - - - - - - - - - - - - - - - - - -
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


| | |  ========================================================================
| | | 
XT625
And about how many hours of help did [ {Name of the deceased}] receive during a typical day?HOURS OF HELP NECESSARY DURING TYPICAL DAY

AND ABOUT HOW MANY HOURS OF HELP DID [ {NAME OF THE DECEASED}] RECEIVE DURING A TYPICAL DAY?HOURS OF HELP NECESSARY DURING TYPICAL DAY
- - - - - - - - - - - - - - - - - - - - - - - - -
0..24

|  ========================================================================
|  ========================================================================
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


|  ========================================================================
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 of the deceased
7. Other non-relatives
8. Church, foundation or charitable organization
9. Deceased did not leave anything at all (SPONTANEOUS)
10. Not decided yet (SPONTANEOUS)

|  ========================================================================
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


If Did the deceased own [his/her] home or apartment - either in total or a share of it? (XT030) = A1 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?
- - - - - - - - - - - - - - - - - - - - - - - - -
-50000000..50000000

| |  ========================================================================
| | 
XT032
Who inherited the deceased's home or apartment, including yourself?IWER:Code relationship to deceased.

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 A3 IN XT032 »

| | |  ========================================================================
| | | 
XT053
IWER:First names of children who inherited home

IWER:FIRST NAMES OF CHILDREN WHO INHERITED HOME

|  ========================================================================
XT033
Did the deceased own any life insurance policies?

DID THE DECEASED OWN ANY LIFE INSURANCE POLICIES?
- - - - - - - - - - - - - - - - - - - - - - - - -
1 Yes
5 No


If Did the deceased own any life insurance policies? (XT033) = A1 Yes 5 No  »

| |  ========================================================================
| | 
XT034
Approximately what was the total value of all life insurance policies owned by [ {Name of the deceased}]?

VALUE OF ALL LIFE INSURANCE POLICIES
- - - - - - - - - - - - - - - - - - - - - - - - -
0..100000000000000000

| |  ========================================================================
| | 
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)


| |  If A6 IN XT035 »

| | |  ========================================================================
| | | 
XT054
IWER:Specify other relative

IWER:SPECIFY OTHER RELATIVE

| |  If A7 IN XT035

| | |  ========================================================================
| | | 
XT055
IWER:Specify other non-relative

IWER:SPECIFY OTHER NON-RELATIVE

| |  If A3 IN XT035 »

| | |  ========================================================================
| | | 
XT056
IWER:First names of children who were beneficiaries

IWER:FIRST NAMES OF CHILDREN WHO WERE BENEFICIARIES

|  ========================================================================
|  ========================================================================
XT637
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


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]? (XT637) = A1 Yes 5 No  »

| |  ========================================================================
| | 
XT638
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] owned by [{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] OWNED BY [{NAME OF THE DECEASED}] AT THE TIME OF [HIS/HER] DEATH?
- - - - - - - - - - - - - - - - - - - - - - - - -
-50000000..50000000

If How many children did [ {Name of the deceased}] have that were still alive at the time of [ his/ her] death?Please count all natural children, fostered, adopted and stepchildren (XT039) > 1 »

| |  ========================================================================
| | 
XT040A
How would you say that the total estate was divided among the children of [ {Name of the deceased}]?IWER: {ReadOut} TOTAL ESTATE DIVIDED AMONG THE CHILDREN

TOTAL ESTATE DIVIDED AMONG THE CHILDREN
- - - - - - - - - - - - - - - - - - - - - - - - -
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
5. Estate @bnot@b divided yet (SPONTANEOUS ONLY)

If How would you say that the total estate was divided among the children of [ {Name of the deceased}]?IWER: {ReadOut} TOTAL ESTATE DIVIDED AMONG THE CHILDREN (XT040A) = A1. Some children received more than others »

| |  ========================================================================
| | 
XT040B
Would you say that some children received more than others to make up for previous gifts?

WOULD YOU SAY THAT SOME CHILDREN RECEIVED MORE THAN OTHERS TO MAKE 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


| |  ========================================================================
| | 
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


| |  ========================================================================
| | 
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


|  ========================================================================
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


|  ========================================================================
|  ========================================================================
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


|  ========================================================================
XT043
IWER:Please state mode of interviewFace-to-face

INTERVIEW MODE
- - - - - - - - - - - - - - - - - - - - - - - - -
1 Face-to-face
2 Telephone


|  ========================================================================
XT044
End of XT. End-of-Life Interview