COMMENTARY

What Dreams May Come at the End of Life

Betty R. Ferrell, PhD, RN

May 23, 2014

End-of-Life Dreams and Visions: A Longitudinal Study of Hospice Patients' Experiences

Kerr CW, Donnelly JP, Wright ST, et al
J Palliat Med. 2014;17:296-303

Study Summary

Kerr and colleagues, the investigators of this interesting study, report that end-of-life dreams and visions (ELDVs) have been well documented throughout history and across cultures. The impact of predeath experiences on dying individuals and their loved ones can be profoundly meaningful.

The aim of the study was to quantify the frequency of dreams and visions experienced by patients nearing the end of life, examine the content and subjective significance of the ELDVs, and explore the relationship of these factors to the time or proximity to death. This mixed-methods study surveyed patients in a hospice inpatient unit, using semi-structured interviews.

Sixty-six patients admitted to a hospice inpatient unit between January 2011 and July 2012 provided informed consent and participated in the study. The semi-structured interviews contained closed and open-ended questions about the content, frequency, and comfort or distress of dreams and visions.

The final sample had 59 participants, most of whom reported experiencing at least 1 dream or vision. Almost one half of the dreams and visions occurred during sleep, and nearly all patients indicated that the dreams felt real.

The most common dreams and visions included deceased or living friends and relatives. Dreams and visions featuring the deceased (friends, relatives, and animals/pets) were significantly more comforting than dreams about the living, living and deceased combined, or other people and experiences. As participants approached death, comforting dreams and visions of the deceased became more prevalent.

A total of 453 interviews were conducted, with an average of 7.68 interviews with each of the 59 patients in the study. Of note, 88% of the patients reported at least 1 dream or vision, and most (99%) reported feeling that these dreams or visions were real. These experiences were rated as comforting (60%), distressing (19%), or both (21%). An interesting finding was that there was little religious content in the ELDVs, although they had common existential components.

The investigators concluded that ELDVs are commonly experienced phenomena during the dying process, characterized by a consistent sense of realism and marked emotional significance. These ELDVs may be a profound source of potential meaning and comfort for the dying, and therefore warrant clinical attention and further research.

Viewpoint

This is an excellent example of a study in the field of palliative care that has identified a common clinical phenomenon and attempted to build evidence to enhance care in that setting. ELDVs are a common topic in palliative care, experienced by 50%-60% of conscious dying patients. This is a conservative estimate, because these experiences are often underreported.[1]

The study authors address the issue of confusion between hallucinations and ELDVs. Hallucinations are often distressing, fearful experiences that produce anxiety. ELDVs are most often reported as resulting in a sense of calm or peace. Many professionals report that ELDVs assist patients in resolving conflicts, accepting death, and finding peace. Of note, the study authors acknowledge that most previous research on ELDVs has focused on the stories related by family members or staff rather than those related directly by patients.

The study provides validation for clinical experiences that have often been reported in palliative care.[2-6] A key implication discussed by the investigators is that clinicians who are unfamiliar with ELDVs might assume that they are hallucinations caused by medications or fevers. If clinicians do not realize that ELDVs offer comfort and meaning to patients, they might medicate the patient to cause sedation in an attempt to stop the visions or dreams.

Kerr and colleagues are to be commended for their rigorous research methods, which have provided insightful understanding of experiences that are important to patients yet often minimized by clinicians.

References

  1. Mazzarino-Willett A. Deathbed phenomena: its role in peaceful death and terminal restlessness. Am J Hosp Palliat Care. 2010;27:127-133. Abstract

  2. Fenwick P, Lovelace H, Brayne S. End of life experiences and their implications for palliative care. Int J Environ Stud. 2007;64:315-323.

  3. Brayne S, Farnham C, Fenwick P. Deathbed phenomena and their effect on a palliative care team: a pilot study. Am J Hosp Palliat Care. 2006;23:17-24. Abstract

  4. Fenwick P, Brayne S. End-of-life experiences: reaching out for compassion, communication, and connection-meaning of deathbed visions and coincidences. Am J Hosp Palliat Care. 2011;28:7-15. Abstract

  5. Lawrence M, Repede E. The incidence of deathbed communications and their impact on the dying process. Am J Hosp Palliat Care. 2013;30:632-639. Abstract

  6. Bulkeley K, Bulkeley P. Dreaming Beyond Death: A Guide to Pre-Death Dreams and Visions. Boston: Beacon Press; 2006.