© 1998 Irene Higginson
Published here with permission.

The POS (The Palliative Care Outcome Scale)
STAFF QUESTIONNAIRE

Patient Name: Unique No:
Care Setting: Date of Birth:
Date: Assessment No:

Please answer the following questions by ticking the box next to the answer which you think most accurately describes how the patient has been feeling. Thank you.

1. Over the past 3 days, has the patient been affected by pain?
¨ 0 Not at all, no effect
¨ 1 Slightly - but not bothered to be rid of it
¨ 2 Moderately - pain limits some activity
¨ 3 Severely - activities or concentration markedly affected
¨ 4 Overwhelmingly - unable to think of anything else
2. Over the past 3 days, have any other symptoms e.g. nausea, coughing or constipation seemed to be affecting how they feel?
¨ 0 No, not at all
¨ 1 Slightly
¨ 2 Moderately
¨ 3 Severely
¨ 4 Overwhelmingly
3. Over the past 3 days, have they been feeling anxious or worried about their illness or treatment?
¨ 0 No, not at all
¨ 1 Occasionally
¨ 2 Sometimes - affects their concentration now and then
¨ 3 Most of the time - often affects their concentration
¨ 4 Patient does not seem to think of anything else - completely preoccupied by worry and anxiety
4. Over the past 3 days, have any of their family or friends been anxious or worried about the patient?
¨ 0 No, not at all
¨ 1 Occasionally
¨ 2 Sometimes - it seems to affect their concentration
¨ 3 Most of the time
¨ 4 Yes, they always seem preoccupied with worry
5. Over the past 3 days, how much information has been given to the patient and their family or friends?
¨ 0 Full information - patient feels free to ask
¨ 1 Information given but not always understood by patient
¨ 2 Information given to patient on request - patient would have liked more
¨ 3 Very little given and some questions have been avoided
¨ 4 None at all
6. Over the past 3 days, has the patient been able to share how they are feeling with family or friends?
¨ 0 Yes, as much as they wanted to
¨ 1 Most of the time
¨ 2 Sometimes
¨ 3 Occasionally
¨ 4 No, not at all with anyone
7. Over the past 3 days, do you think they have felt that life was worth living?
¨ 0 Yes, all the time
¨ 1 Most of the time
¨ 2 Sometimes
¨ 3 Occasionally
¨ 4 No, not at all
8. Over the past 3 days, do you think they have felt good about themselves?
¨ 0 Yes, all the time
¨ 1 Most of the time
¨ 2 Sometimes
¨ 3 Occasionally
¨ 4 No, not at all
9. Over the past 3 days, how much time do you feel has been wasted on appointments relating to the healthcare of this patient, e.g. waiting around for transport or repeating tests?
¨ 0 None at all
¨ 2 Up to half a day wasted
¨ 4 More than half a day wasted
10. Over the past 3 days, have any practical matters resulting from their illness, either financial or personal been addressed?
¨ 0 Practical problems have been addressed and their affairs are as up to date as they would wish
¨ 2 Practical problems are in the process of being addressed
¨ 4 Practical problems exist which were not addressed
¨ 0 The patient has had no practical problem
11. If any, what have been the patient's main problems in the last 3 days?
1.
2.

 

12. What is the patient's ECOG scale performance status?

(0-fully active; 1-restricted; 2-ambulatory; 3-limited self care; 4-completely disabled)  ______

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