End-of-life dreams and visions, often of loved ones, are part of the natural dying experience. There are clear distinctions between these and delirium
End-of-life dreams and visions (ELDVs) are well documented through history and across cultures. Between January 2011 and July 2012, 66 patients in a hospice inpatient unit were interviewed daily about the content, frequency and level of comfort or distress of their dreams and visions. Most participants reported at least one ELVD and almost half of the ELVDs occurred during sleep. Nearly all patients reported that their experience felt real. As participants approached death, comforting dreams and visions became more prevalent. ELDVs may be a source of meaning and comfort.
Citation: Grant P et al (2014) The significance of end-of-life dreams and visions. Nursing Times; 110, 28: 22-24.
Authors: Pei Grant is director of research; Scott Wright and Rachel Depner are clinical research assistants; Debra Luczkiewicz is hospice physician; all at the Center for Hospice and Palliative Care, Cheektowaga, New York.
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Since ancient times, people have recorded dreams and visions experienced by individuals at the end of their lives. Often during these dreams, the dying individual experiences deceased family, friends or religious figures (Fenwick and Brayne, 2011; Kellehear et al, 2011; Houran and Lange, 1997). These experiences may involve visual, auditory and/or kinesthetic experiences (Lawrence and Repede, 2012), with visions occurring during a wakeful state or dreams occurring during sleep.
These end-of-life dreams and visions (ELDVs) are often deeply comforting and profoundly meaningful for patients and their families (Fenwick et al, 2007; Brayne et al, 2006; Lawlor et al, 2000; Barbato et al, 1999). These experiences can occur months, weeks, days or hours before death (Mazzarino-Willett, 2010) and typically reduce fear of dying, making transition from life to death easier for those experiencing them (Lawrence and Repede, 2012; Wills-Brandon, 2000).
Although recognition is growing that ELDVs are psychologically and existentially significant, their value has long been under appreciated by the scientific and medical communities. ELDVs are often dismissed as drug-induced hallucinations, dementia or delirium by medical staff with limited understanding of the dying process (Betty, 2006). However, there is a growing body of evidence that describes the prevalence and therapeutic value of these experiences. It is estimated that 50-60% of conscious dying patients experience ELDVs (Mazzarino-Willett, 2010). It is likely this figure is even higher, as research has shown that patients, families and clinicians knowingly under report these experiences for fear of judgement, ridicule and embarrassment (Barbato et al, 1999).
The body of research on this topic is limited, and most studies have explored the meaning of patient dreams and visions from the perspective of their hospice clinicians or families (Lawrence and Repede, 2012; Kellehear, 2011; Fenwick et al, 2008; Brayne et al, 2008; 2006). Palliative care workers believe that ELDVs are part of the dying process. Bereaved family members and clinical staff report ELDVs provide personal or spiritual solace for patients at the end of life, helping them to reconcile past life events and accept death. ELDVs can occur in wakeful or sleep states and typically manifest with clear consciousness, possessing a level of clarity, detail and organisation when reported. Clinicians have reported that while hallucinations frequently elicit anxiety or perplexity, ELDVs evoke peacefulness, comfort and a sense of wonder.
While previous studies on the topic of ELDVs are valuable and contribute to the understanding and importance of these end-of-life experiences, they still have not been able to show what these experiences mean to the patients themselves. This study sought to examine hospice patients’ dreams and visions from first-hand accounts.
The aims of this study were to:
- Document hospice patients’ ELDV experiences over time using a daily survey;
- Examine the content and subjective significance of ELDVs;
- Relate the prevalence, content and significance of end-of-life experiences over time until death.
The study was performed at the Center for Hospice and Palliative Care Hospice inpatient unit in New York between January 2011 and July 2012. Daily interviews were conducted with the 66 patients who participated in the study.
Closed-ended questions were asked regarding the presence or absence of dreams and visions, whether these experiences occurred during sleep or wakefulness, content and frequency, degree of realism, and comfort versus discomfort.
Participants’ self-reported dream themes of going or preparing to go somewhere were recorded.
A total of 453 interviews were conducted. Of the 66 patients interviewed, 59 were included in the analysis, 88% of whom reported experiencing at least one dream or vision. Almost half of the dreams or visions (45.3%) occurred while asleep, 15.7% occurred while awake and 39.1% occurred while both asleep and awake. Nearly 99% of ELDVs were reported by participants to seem or feel real.
Most commonly, dreams included deceased friends and relatives (46%) and living friends or relatives (17%). ELDVs including a theme of going or preparing to go somewhere were common (39%). Dreams and visions featuring the deceased (friends, relatives, and animals/pets) were far more comforting than those of the living, the living and deceased together, and other people and experiences. As participants approached death, comforting dreams/visions of the deceased became more common. Table 1 shows examples of ELDVs.
This study is the first to examine patient dreams and vision from the patient’s perspective. The relationship between frequency and content as patients approached death was also studied.
Most participants (87%) reported experiencing at least one dream or vision - nearly twice the figure reported in a previous study (Kellehear, 2011). The fact that they were interviewed first hand about their dreams and visions may account for the higher reporting rates, as previous studies reported secondhand information from family members or clinical care-givers (Lawrence and Repede, 2012; Kellehear,2011; Brayne et al, 2008; Fenwick et al, Brayne et al, 2008; 2006).
Whether the experience occurred while awake (19%) or asleep (46%) or both (35%), the dreams and visions felt real to the participants. Many of their dreams and visions were of past meaningful experiences (28%) and reunions with deceased loved ones (72%) who often provided reassurance or guidance. Others reported dreams of preparing to go somewhere (59%). As seen with previous research with American patients, there was a noted absence of dreams featuring religious figures (Fenwick et al, 2010; Osis and Haraldsson, 1997).
Findings showed that as participants approached death, comforting dreams/visions of the deceased became more prevalent. These results agree with other studies that reported participants who experienced ELDVs had peaceful and calm deaths (Lawrence and Repede, 2012). This suggests that ELDVs may be prognostically significant based on changes in dream/vision content and increased frequency as death nears.
It was found that participants’ pre-death dreams were frequently so intense that the dream crossed from the sleep state to waking reality. This realism is consistent with prior research suggesting that, during stages of transition or crisis, dreams become more vivid, intense and memorable (Barrett, 1996).
Also, despite very little spoken dialogue within the dreams and visions, the circumstances and significance of the experiences were still conveyed. The main quality of pre-death dreams and visions was a sense of personal meaningfulness, which frequently carried emotional significance for the participant. This was also true of ELDVs that were not comforting.
Without understanding that ELDVs are a normal, mostly comforting and a valid end-of-life experience, clinicians may avoid discussion of patient dreams and visions and may discount them as hallucinations caused by medications, fever or confusional states (Betty, 2006). Delirium is characterised by disorganised thinking, altered sensorium, agitation, anxiety or fearfulness (Macleod, 2006; Breitbart et al, 2002).
In the midst of experiencing fluctuating delirium, participants were still able to draw personal meaning and comfort from their ELDVs. In contrast to delirium, ELDVs typically occur in patients who have clear consciousness and heightened acuity and awareness of their surroundings (Brayne et al, 2006; Osis and Haraldsson, 1997). ELDVs are also memorable and recalled with clarity (Mazzarino-Willett 2010; Kellehear et al, 2008) and differ most from hallucinations or delirium by the responses they evoke, including inner peace, acceptance and the sense of impending death (Barbato, 2009; Brayne et al, 2008; Mazzarino-Willett, 2010). These distinctions are critical, as medication of ELDVs mistakenly perceived as delirium may remove the dying patient from comforting experiences inherent to the dying process. This approach may further cause isolation, suffering and impairment in the dying person’s ability to experience and communicate meaning at the end of life (Fenwick and Brayne, 2011; Mazzarino-Willett, 2010).
Many physicians avoid addressing death or its psychological and spiritual implications with their patients, and this widespread inattention may worsen suffering and impede the dying process (Granda-Cameron and Houldin, 2012; Kaldjian, 2009; Curtis et al, 2004;). In the evolution from coping with illness to dying, the concept of “hope” transitions from a predication on cure to notions of personal meaning (Chochinov, 2012). Palliative care workers have reported their belief that ELDVs signify patients’ attempts to find meaning, to process or reconcile past life events and therefore come to terms with their death (Fenwick and Brayne, 2011; Brayne et al, 2008; 2006; Fenwick et al, 2007; Betty, 2006; Barbato et al, 1999). Despite the value of such experiences, patients, families and clinicians report their reluctance to discuss ELDVs openly for fear of ridicule and doubts concerning medical legitimacy (Fenwick and Brayne, 2011; Brayne, 2008; 2006; Fenwick et al, 2007; Barbato et al, 1999).
The study had some limitations. Many participants were already experiencing ELDVs at the time of enrolment, which made it difficult to analyse the time course of this phenomenon. Some experienced dementia or delirium as well as ELDVs; however, only three dream events were reported by participants with dementia.
Future studies should control more fully for delirium, use a more comprehensive questionnaire and interview patients who are not as near to death to capture the phenomena as they emerge or change.
The results of this study suggest that fear of death often diminishes as a direct result of ELDVs, and what arises is a new insight into mortality (Bulkley and Bulkeley, 2006).
The emotional impact is frequently positive, comforting and, paradoxically, life affirming. The person is physically dying, but their emotional and spiritual identity remains present as manifested by dreams and visions. In this way, ELDVs do not deny death but transcend the dying experience and present a therapeutic opportunity for clinicians to assist patients and their families in the transition from life to death, providing comfort and closure.
- End-of-life dreams and visions are meaningful and significant to patients and their families
- Previous research has been limited to family and clinician reports
- People are uncomfortable discussing ELDVs with clinical caregivers for fear of judgement and ridicule
- ELDVs are common and convey a sense of realism. Dreams of deceased loved ones, family, friends and pets, provide the most comfort
- Dream content and frequency changes as the proximity to death increases
Barbato M (2009) Reflections of a Setting Sun: Healing Experiences Around Death. Kiama, New South Wales: Michael Barbato.
Barbato M et al (1999) Parapsychological phenomena near the time of death. Journal of Palliative Care; 15: 2, 30-37.
Barrett D (1996) Trauma and Dreams. Cambridge, MA: Harvard University Press.
Betty LS (2006) Are they hallucinations or are they real? The spirituality of deathbed and near-death visions. Omega: Journal of Death and Dying; 53: 1-2, 37-49.
Brayne S et al (2008) End-of-life experiences and the dying process in a Gloucestershire nursing home as reported by nurses and care assistants. American Journal of Hospice and Palliative Medicine; 25: 3, 195-206.
Brayne S et al (2006) Deathbed phenomena and their effect on a palliative care team: a pilot study. American Journal of Hospice and Palliative Medicine; 23: 1, 17-24.
Breitbart W et al (2002) The delirium experience: delirium recall and delirium-related distress in hospitalized patients with cancer, their spouses/caregivers, and their nurses. Psychosomatics; 43: 3, 183-194.
Bulkley P, Bulkeley K (2006) Dreaming Beyond Death: a Guide to Pre-Death Dreams and Visions. Boston, MA Beacon Press.
Chochinov HM (2012) Dignity Therapy: Final Words for Final Days. New York, NY: OUP USA.
Curtis JR et al (2004) Patient-physician communication about end-of-life care for patients with severe COPD. European Respiratory Journal; 24: 2, 200-205.
Fenwick P, Brayne S (2011) End-of-life experiences: reaching out for compassion, communication, and connection-meaning of deathbed visions and coincidences. American Journal of Hospice and Palliative Medicine; 28: 1, 7-15.
Fenwick P et al (2010) Comfort for the dying: five year retrospective and one year prospective studies of end of life experiences. Archives of Gerontology and Geriatrics; 51: 2, 173-179.
Fenwick P et al (2007) End of life experiences and their implications for palliative care. International Journal of Environmental Studies; 64: 3, 315-323.
Granda-Cameron C, Houldin A (2012) Concept analysis of good death in terminally ill patients. American Journal of Hospice and Palliative Medicine; 29: 8, 632-639.
Houran J, Lange R (1997) Hallucinations that comfort: contextual mediation of deathbed visions. Perceptual and Motor Skills; 84: 3c, 1491-1504.
Kaldjian LC et al (2009) Review article: goals of care toward the end of life: a structured literature review. American Journal of Hospice and Palliative Medicine; 25: 6, 501-511.
Kellehear A et al (2011) Deathbed visions from the Republic of Moldova: a content analysis of family observations. Omega Journal of Death and Dying; 64: 4, 303-317.
Lawlor PG et al (2000) Occurrence, causes, and outcome of delirium in patients with advanced cancer: a prospective study. Archives of Internal Medicine; 160: 6, 786-794.
Lawrence M, Repede E (2012) The incidence of deathbed communications and their impact on the dying process. American Journal of Hospice and Palliative Medicine; 30: 7, 632-639.
Mazzarino-Willett A (2010) Deathbed phenomena: its role in peaceful death and terminal restlessness. American Journal of Hospice and Palliative Medicine; 27: 2, 127-133.
Macleod AD (2006) Delirium: the clinical concept. Palliative and Supportive Care; 4: 3, 305-312.
Osis K, Haraldsson E (1997) What They Saw… at the Hour of Death: a New Look at Evidence for Life After Death. Norwalk, CT: Hastings House.
Wills-Brandon C (2000) One Last Hug Before I Go: the Mystery and Meaning of Deathbed Visions. Deer Park, FL: HCI Books.