Personal Grief and Loss Awareness Activity As a result of experiences with loss and grief, each of us develops ?our own unique style of dealing with these issues. Understanding

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.