How to Write a Death Plan: Worksheet
By Ashley T Benem, Death Midwife, LMP, Minister
The Plan:
A Death Plan fills in the gaps of information not covered by a living will, last will and testament, Advanced Care
Directive or funeral plan. It is designed to tie those plans together in a cohesive way for families and loved
ones to follow with ease.
Form checklist
Durable power of attorney for Finances
Durable power of attorney for Health Care
Advanced Directives (Living Will)
Dementia & Alzheimer’s Provision
Last Will and Testament
POLST
Funeral & burial contracts/arrangements
Guiding questions/prompts
When you are ill, what do you want/need? What do
you NOT want?
When you are very stressed, what relaxes you and
brings you comfort?
When you are stressed, where do you hold or feel
tension in your body?
Pre Death
Post Death
Place
Home, hospice, hospital, skilled nursing facility:
rest home, assisted living, convolecesant center,
rehab
Method
natural course, VSED: Voluntary stopping eating &
drinking, Death with Dignity
Who will attend: Who do you want there?
Family, friends, clergy, Death Midwife, medical
caregivers, pets
Who will support: Physical, emotional, mental, spiritual
Family, friends, clergy, Death Midwife, medical
caregivers, pets
Environment
In what room or space, temperature, lighting, scents,
music, noise levels, furnishings, bedding, Focal points:
personal items, pictures, flowers, secular objects
Interventions
Medical, comfort measures, spiritual
Preparing the body
Cleaning, dressing, laying in honor, esthetics (makeup,
hair), embalming, organ or body donation
Medication
Comfort care, regular regimen
Pain control
What level (1-10) and how lucid/conscious
Transportation
By who, to where, when, in what
Vigil
Where, how long
Ceremony/Ritual
Spiritual, ethnic, customary; when, where, facilitated
by who, for who
Funeral/memorial
When, where, how many attendees (who), facilitated
by
Deposition of the body
Buried or cremated; in what, where, by who,
attendees
Obituary
Planning for flexibility: PLAN A: Best case scenario PLAN B: Limiting circumstances PLAN C: accident, unexpected
Include a dated, signed or notarized copy with 1) Advanced Directives, 2) Medical charts, 3) support team, 4) with You.
A Sacred Passing: Death Midwifery Services PO Box 5284 Bellingham, WA 98227-5284 (360)927-5040 www.asacredpassing.com