1. Nebraska Hospice and Palliative Care Partnership Community Survey on End of Life 2006 N=324

2. COMFORT ITEMS

3. How comfortable are you with talking about death?

4. How comfortable would you be writing your own will if you thought your death would occur soon?

5. How comfortable are you with thinking about life after death?

6. LIKELIHOOD ITEMS

7. How likely are you to attend funerals or memorial services?

8. How likely are you to read books, newspaper articles or other information that deal with the subject of death and dying?

9. How likely are you to watch television programs or movies that deal with the subject of death and dying?

10. How likely are you to avoid medical checkups because you are afraid the doctor will find something serious?

11. How likely are you to speak freely with loved ones about death and dying?

12. How likely are you to visit or telephone a friend or relative who has recently lost a loved one in order to see how they are doing?

13. How likely are you to preplan the funeral or memorial service of someone you’re caring for?

14. AFRAID ITEMS

15. How afraid are you of dying from a long-term illness?

16. How afraid are you of dying suddenly?

17. How afraid are you of dying alone?

18. How afraid are you of dying in an institution such as a nursing home or hospital?

19. How afraid are you of dying painfully?

20. VALUE ITEMS

21. There is a special value in getting old.

22. Dying is an important part of life.

23. If someone could tell me that I likely have six months or less to live, I would want to know.

24. Caring for people who are dying is a rewarding experience.

25. If I knew I was dying, I would want medical intervention to keep me alive as long as possible.

26. CONCERN ITEMS

27. How concerned are you that your (or your spouse/partner’s) money won’t last?

28. How concerned are you that your family’s money won’t last?

29. How concerned are you that you will be a burden to your family or friends?

30. Which of the following problems would be worse than death?

31. ADVANCE PLANNING ITEMS

32. Health Care Power of Attorney

33. Living Will

34. Last will and testament

35. Funeral or burial pre-plan

36. With whom have you talked about your wishes for care at the end of life?

37. Who would you want to initiate a conversation with you regarding end-of-life issues?

38. Who would you trust to provide information on end-of-life issues?

39. IMPORTANCE ITEMS

40. How important is having family / friends visiting you?

41. How important is being able to stay in your home?

42. How important are honest answers from your doctor?

43. How important is comfort from religious / spiritual services or persons?

44. How important is knowing medicine would be available to you?

45. How important is planning your own funeral or memorial service?

46. How important is being able to complete your own will?

47. How important is fulfilling personal goals/pleasures?

48. How important is reviewing your life history with your family?

49. How important is having health care professionals visit you at your home?

50. How important is getting your finances in order?

51. How important is understanding your treatment options?

52. How important is giving to others in time, gifts, or wisdom?

53. How important is being physically comfortable?

54. How important is being free from pain?

55. How important is having things settled with the family?

56. How important is being at peace spiritually?

57. How important is not being a burden to loved ones?

58. How important is knowing how to say goodbye?

59. How Important is having a sense of your own worth?

60. How important is being off machines that extend life such as life support?

61. If you could choose the ONE way you die, what would your choice be?

62. If you were terminally ill and could choose where to die, where would you MOST want to die?

63. PAIN MANAGEMENT ITEMS

64. I am afraid my doctor may not believe I am in pain or may not treat my pain.

65. I would only take pain medicines when the pain is severe.

66. I would take the lowest amount of medicine possible to save larger doses for later when the pain is worse.

67. I am afraid I will become addicted to the pain medicine over time.

68. I am afraid I would be given too much pain medicine.

69. SUPPORT ITEMS

70. What type of support would you want if you were dying?

71. Listen when I want to talk

72. Provide transportation

73. Help with chores

74. Do fun things with me

75. Know what I want when I die

76. Help care for other family members

77. Encourage me when I am down

78. Understand what I’m going through

79. Know about my illness

80. HOSPICE ITEMS

81. Have you heard of hospice services?

82. How did you learn about hospice?

83. If dying, would you want hospice support?

84. Where would you want to receive hospice support?

85. To the best of your knowledge, does Medicare pay for hospice services?

86. For which of the following chronic illnesses do you think hospice services would be helpful?

87. Would you be interested to hear more about hospice services?

88. DEMOGRAPICS REGARDING SPIRITUALITY

89. How religious/spiritual do you consider yourself?

90. Are you affiliated with an organized faith community?

91. How often do you attend religious or spiritual services?

92. How often do you find strength in your religion or spirituality?

93. GENERAL DEMOGRAPHICS

94. Are you a caregiver?

95. Do you have a serious, chronic illness?

96. Does a member of your household have a serious, chronic illness?

97. If respondent has chronic illness, which best describes it?

98. Gender

99. Age of Respondents

100. Marital Status

101. Highest level of education completed

102. Current employment status

103. Race/Ethnicity

104. Are you Hispanic or Latino?

105. Household income

106. Do you live alone?

107. Are you a member of AARP?

108. Are you a United States Veteran?

109. How would you rate your own general health?