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. Author manuscript; available in PMC: 2020 May 1.
Published in final edited form as: J Pain Symptom Manage. 2019 Jan 24;57(5):980–988.e9. doi: 10.1016/j.jpainsymman.2019.01.008

Appendix 3.

Final 17-item ACP Engagement Survey- Surrogate Decision-Maker

Item Theoretical
Construct		 Domain (Factor)
1. How well informed are you about who can be a medical decision maker? Knowledge Serving as surrogate decision-maker
2. How well informed are you about what makes someone a good medical decision maker? Knowledge Serving as surrogate decision-maker
3. How well informed are you about the types of decisions that you may have to make for your loved one in the future? Knowledge Serving as surrogate decision-maker
4. How much have you thought about your role as your loved one’s medical decision-maker? Contemplation Serving as surrogate decision-maker
5. As of today, how confident are you that you could serve as your loved one’s medical decision maker? Self-efficacy Serving as surrogate decision-maker
6. As of today, how confident are you that you could talk with your loved one about the care he/she would want if he/she were very sick or near the end of life? Self-efficacy Serving as surrogate decision-maker
7. As of today, how confident are you that you could be part of a discussion with your loved one’s DOCTOR about the care your loved one would want if he/she were very sick or near the end of life? Self-efficacy Serving as surrogate decision-maker
8. How much have you thought about talking with your loved one about whether or not there are certain health situations that would make your loved one’s life not worth living? Contemplation Contemplation
9. How much have you thought about being part of a discussion with your loved one’s DOCTORS about whether or not there are certain health situations that would make your loved one’s life not worth living? Contemplation Contemplation
10. How much have you thought about talking with your loved one about the care he/she would want if they were very sick or near the end of life? Contemplation Contemplation
11. How much have you thought about being part of a discussion with your loved one’s DOCTORS about the care he/she would want if they were very sick or near the end of life? Contemplation Contemplation
12. How ready are you to formally discuss with your loved one your role as their medical decision maker? Readiness Readiness
13. How ready are you to talk to your loved one about the kind of medical care he/she would want if they were very sick or near the end of life? Readiness Readiness
14. How ready are you to talk to your loved one about whether or not there are certain health situations that would make your loved one’s life not worth living? Readiness Readiness
15. How ready are you to be part of a discussion with your loved one’s DOCTOR about whether or not there are certain health situations that would make your loved one’s life not worth living? Readiness Readiness
16. How ready are you to be part of a discussion with your loved one’s DOCTOR about the kind of medical care your loved one would want if he/she were very sick or near the end of life? Readiness Readiness
17. How ready are you to ask your loved one’s DOCTOR questions to help you make a good medical decision for your loved one if your loved one was unable to speak for themselves? Readiness Readiness