Appendix II
Sample Item from Questionnaire
For this condition, how would you rate the potential impact of the following six outcome
categories for patients < 15?
Condition = Respiratory Distress: Patients with shortness of
breath or evidence of
respiratory difficulty who
continue to have spontaneous
breathing. May include
asthma, COPD, CHF.
Excludes respiratory arrest.
- Impact on Survival: Low, Medium or High?
- Impact on Impaired Physiology: Low, Medium or High?
- Impact on Limit Disability: Low, Medium or High?
- Impact on Impaired Alleviate Discomfort: Low, Medium or High?
- Impact on Impaired Satisfaction: Low, Medium or High?
- Impact on Impaired Cost Effectiveness: Low, Medium or High?
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