Death and Dying has often been called the last taboo and we need your help and ideas. If we don't talk about what we want at the end of life, we will not be able to make improvements that really matter to you. Only a third of people have discussed their end of life wishes with anyone. We would really appreciate it, if you could take the time to answer the following questions. You will then be entered into a free prize draw to win a Tastes of Lincolnshire Hamper worth £50

Q1.	All of these are important, however which are the most important to you? (1 being most important, 5 being least important)
		1		2		3		4		5
	Help people talk about dying so that they, and their families, are prepared
	Make sure family and carers are central and critical partners in end of life care
	Make sure that people will be in the company of others who care about them when they die
	Provide end of life care that is available to patients locally during the day and night
	Help people be cared for and die in their preferred place of choice where possible

Q2.	Have you ever discussed with someone what your wishes would be at the end of life in any of these areas?
		Yes in detail		Only a bit		No not at all
	Medical needs
	Spiritual and religious needs
	Privacy and peace
	Dying with dignity (eg respectful care and support)
	Where you would prefer to die
	Pain relief

Q3.	If you ticked no to any of the above, please tick below why you have not discussed this issue with anyone (tick all that apply)
	I don't feel comfortable talking about death		I'm too young to discuss death		Other people do not want to talk to me about my death
	Death feels a long way off		There is no one available to me to talk about death

	Other, please specify

Q4.	How confident are you in planning the following:
		Very confident		Fairly confident		Not very confident		Not confident at all
	Getting the right sort of end of life care and support from family and friends
	Getting the right sort of end of life care and support from professionals
	Your finances
	Your funeral arrangements

Q5.	Thinking about yourself when the time comes, where would you prefer to die? (please tick one only)
	At home		In a hospital		Don't know
	In an hospice		In a nursing home
	In a care home		Don't mind

	Somewhere else, please specify

Q6.	When the time comes for your death, please tell us what would be the most and least important thing for your end of life care by ranking the options below (1 being most important, 6 being least important)
		1		2		3		4		5		6
	To be pain free/to be without pain
	To retain my dignity eg respectful care and support
	To be with my family/friends
	To be peaceful/calm
	To be sure I am not a burden on other people
	For people to listen and be respectful of my wishes

Q7.	Are there any other issues important to you?

About You

Please take a moment to complete the information below, we will not use it to identify you, only to help us analyse the data more effectively

Q8.	Are you?
	Male		Female

Q9.	What is your age group?
	Under 18		51-60		91 plus
	18-30		61-70		Prefer to say
	31-40		71-80
	41-50		81-90

Q10.	What is your religion/belief system, evenif you are not currently practicing?
	Christian (including C of E, Catholic, Protestant and all other Christian denominations)		Muslim		Agnostic
	Buddhist		Sikh		Prefer not to say
	Hindu		Humanist
	Jewish		Atheist

	Any other religion/belief, please specify

Q11.	Do you consider yourself to have a diability?
	Yes (go to Q12)		No

Q12.	If 'yes' please tick any of the boxes that apply to you
	Visual Impairment		Mental Impairment		Physical Impairment
	Learning Disability		Hearing Impairment

If you would like to be entered into the free prize draw, please complete your details below

	Name

	Address

	Telephone number

	Email address

Closing date: 4 January 2011

All data provided will remain confidential and will only be used for the purpose of service improvement and will be processed in accordance with relevant legislation, in particular the Data Protection Act 1998