Personal Reflection

Check all answers that apply

1. What was your first experience with

death? Who died?

 Grandparent/great-grandparent

 Parent

 Brother or sister

 A child

 Other family member

 Friend or acquaintance

 Stranger or a public figure

 Animal or pet

2. When you were a child, how was death

or dying talked about in your family?

 Openly

 With some sense of discomfort

 As though it were a taboo subject

 Do not recall any discussion

3. What does death mean to you?

 The end; the final process of life

 The beginning of a life after death; a

transition, a new beginning

 A kind of endless sleep; rest and

peace

 End of this life, but survival of the

spirit

 Other (specify):

____________________________

4. What about your own death concerns

you most?

 I could no longer have any

experiences.

 I am afraid of what might happen to

my body after death.

 I am uncertain about what might

happen to me if there is a life after

death.

 I could no longer provide for my

family.

 It would cause grief to my family and

friends.

 There would be some things left

undone.

 I have no concerns about my death.

 Other (specify):

_____________________________

5. What about the process of dying

concerns you most?

 It might be long and painful

 Being a financial burden to my family

 Causing my family to suffer

 Being dependent on others to care

for me

 Losing control of my mind and body

 I am not concerned about the

process of dying.

 Other (specify):

_____________________________

6. How large a role has spirituality or

religion played in your attitude toward

death?

 A very significant role

 Influential, but not a major role

 A relatively minor role

 No role at all

7. If you were told that you had a limited

time to live, how would you want to

spend the time you had remaining?

 I would pursue personal pleasures

(travel, adventure, chocolate).

 I would prefer being alone: reading,

contemplation or praying.

 I would like to focus on loved ones.

 I would shift from my own needs to a

concern for others (family, friends).

 I would try to tie up loose ends.

 I would try to do one important thing.

 I would make few changes.

 Other (specify):

_____________________________

8. If or when you are married or have a

long-term partner, would you prefer to

outlive your spouse/partner?

 Yes, I would prefer to die second

and outlive my spouse/partner.

 No, I would rather die first and have

my spouse/partner outlive me.

 It doesn’t matter to me.

 This question doesn’t apply to me.

9. If you had a choice, what kind of death

would you prefer?

 Sudden, unexpected death

 Quiet, dignified death

 Death in the line of duty

 Death after a great achievement

 There is no “appropriate” kind of

death.

 Other (specify):

_____________________________

10. What is one thing you would want to

say to someone special before you die?

___________________________________

___________________________________

___________________________________

___________________________________

The Center for Healthcare Decisions developed this questionnaire, based in part on

Edwin Schneidman’s “You and Death: An Exercise.”

For more information, contact the Coalition for Compassionate Care of California at www.coalitionccc.org.

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