Domains of Well-Being Physical Well Being and Symptoms Pain Fatigue Weakness Nausea Shortness of breath Loss of appetite Difficulty sleeping Difficulty with activities of daily living (getting to the bathroom, bathing, dressing, eating) Psychological Well-being and Symptoms Loss of control Anxiety Depression Happiness Social Well-being and Symptoms Roles and relationships Family distress Isolation Social support Spiritual Well-being and Symptoms Making sense of the acute or chronic illness Suffering Maintaining hope Inner strength Adapted from Ferrell, B., & Coyle, N. (2006). Textbook of Palliative Nursing, 2 nd edition.
WISH 6 My Wish For the Kind of Spiritual and Religious Care I Want (Please cross out anything you do not agree with. You may want to have a conversation with a rabbi/chaplain/priest/minister that you trust as you convey your wishes). My religious/spiritual tradition is: I belong to the following house of worship: The clergy member who knows me best is: Whether or not I appear to be conscious, I wish to have the opportunity to (circle all that apply): o Say goodbye to others o Invite people to say goodbye to me either in person or by other means o Have someone/chaplain/ loved one help me write goodbye cards I wish that my surroundings be filled with the following (circle all that apply) o Art, Light/Natural Sunlight/Time Outdoors o Type of Music o In addition, I would like to be surrounded by: I wish that my autonomy, dignity and sanctity not be compromised in my final days. o I want to be treated with the understanding that I am created in God s image o I wish to be treated as a living human being as long as I am alive (for example: do not talk about me in the third person, do not talk about my funeral) o I wish for people to know that they may speak about my imminent death in my presence. I wish to have the following liturgical prayers/rituals observed in my final days and/or at the time of my death: (circle all that apply) o Pastor/religious clergy visit with me (I only want a clergy person of my own faith) o I would like the chaplain and/or my clergy to be attentive to my family o Specific readings/prayers from my religious/faith tradition, including: o Money (Tzedakah) donated to the following causes or organizations: o Rituals including: Communion every day
Sacrament of the Sick (performed by priest to the gravely ill and before operations) Vidui (traditional Jewish prayer said before time of death) Sh ma Tahara (ritual washing) performed on my body Shomrim (ritual guards) to remain with my body after I die until I am buried In addition: I wish for people to know how grateful I am for the following relationships with (circle all that apply): o God o Family o Friends I wish for those who love me to know that I feel great gratitude for the following in my life: I wish for those who care about me to know that the highest values in my life are: To honor these values is to continue to honor me. In addition to the above, the following religious/spiritual values and observances are important to me: Created by Rabbi Sandi Intraub in collaboration with Hebrew SeniorLife Chaplaincy & Religious Services
Sample of Person-Centered Questions for Discussing End of Life Concerns What are your worries? What are you most concerned about at this time? What are your biggest fears? What are your most important hopes? What do you hope for your family? Who is important to you? Who provides support to you? Who do you share things with if you are troubled? What gives you joy in your life? What would you like your children or grandchildren to remember about you?
THE FIVE PRACTICES OF CULTURE CHANGE I. RESPECTING THE VOICES OF OUR RESIDENTS Our traditions teach us that human life is sacred We treat all people with dignity and respect We know that elders are a source of wisdom and a resource to be cherished We value every resident and his or her unique life story Have I honored a resident today? II. RE-ESTABLISHING RELATIONSHIPS We understand that relationships are the heart of life We are committed to knowing each person We put the person before the task We feel connected to our residents and we care about their well being Have I had special time with a resident today? *The Five Practices of Culture Change are inspired by the Pioneer Network Values and Principles Copyright Hebrew SeniorLife 2014
III. RE-EMPHASIZING INDIVIDUAL CHOICE We believe that all people have the right to determine their own future We advocate for our residents' individual choices We celebrate each individual s unique needs and desires We encourage everyone to reach his or her desired potential. Have I listened to and responded to a resident s wish today? IV. RE-IMAGINING HOME We want our residents to enjoy the comforts, happiness and security of home We create communities that rekindle the human spirit We understand and appreciate that we are guests in our residents home We recognize that quality of care and quality of life are inseparable Have I helped a resident feel more at home today? V. RE-EMPOWERING STAFF We believe that every staff member can and does make a difference We know that the voices of our front line staff are essential in making decisions and driving change We continue to improve our communication skills in order to build strong and successful teams We value our employees and show them our appreciation for they are our greatest asset Have I made a difference in someone s life today?