End-of-Life Dreams: A Comforting Gateway

(Last Updated On: March 17, 2016)

End-of-Life Dreams & Visions

End-of-life dreams and visions can heal the mind even when the body cannot be healed. Hospice care workers as well as researchers have learned that dreams and visions are very important during the last weeks and days of life.

Why should we care? Because most of us will experience these dreams when we approach the end of life. Understanding them can comfort and support us and those around us.

End-of-life dreams are not dementia. About 10% of people experience dementia at some point in their lives, typically when they are very old or very sick. For that reason, when an old person reports having waking visions or unusual dreams, their doctor may consider those as symptoms of dementia and not pay attention to the content of those dreams. Moreover, Hospice care has traditionally focused on pain relief and emotional or spiritual support. Often the dreams or visions reported by the patients are viewed more as a symptom of their condition, rather than pointing a path to palliative treatment.

A team of medical doctors, nurses and psychologists is hoping to change these attitudes, as described in two recent research articles by authors at Hospice Buffalo (Cheektowaga, NY), Daemen College (Amherst, MA) and Canisius College (Buffalo, NY). Today’s blog summarizes their work and discusses its implications for our personal lives.

End-of-Life Dreams versus Near-Death Experiences

End-of-Life Dreams & VisionsEnd-of-life dreams and visions should not be confused with near-death experiences, which are quite different.

End-of-life dreams, by definition, are ended by the patient’s death; near-death experiences, on the other hand, are reported by patients who did not die, who report the events after surviving a serious injury or illness.

There are some similarities between end-of-life dreams and near-death experiences. In both cases, we often find:
– A theme of taking a trip or crossing a boundary
– Positive emotions
– Visions of deceased loved ones
– Dream content that is influenced by the person’s culture and beliefs
– Less commonly (less than 20% of the time), an uncomfortable or even terrifying experience.

Despite these similarities, there are distinct differences between end-of-life dreams and near-death experiences. Certainly, the surrounding circumstances are not the same. In addition, near-death experiences are rare (because very few people come that close to death and still recover), while end-of-life dreams occur in more than half of conscious dying patients.

Near-death experiences are also set apart because they often include features that are uncommon in end-of-life dreams:
– The feeling of entering a tunnel
– Seeing a powerful light
– Life review: “seeing one’s life flash before one’s eyes”
– A sense of being dead
– Feeling detached from one’s physical body.

Seeing “angels,” figures dressed in white or religious figures are often reported as part of near-death experiences. These religious or quasi-religious images are relatively rare in end-of-life dreams of Americans. (This is one factor that seems to be culturally dependent: patients from India more frequently report seeing religious figures.)

End-of-Life Dreams: Frequency and Content

The Buffalo study interviewed 66 patient volunteers at Hospice Buffalo during an 18-month period ending in mid-2012. The average age of the participants was 75. Seven were omitted from the final results: six were still alive, and one had provided only one interview, well before death.

The research team estimated the health status of the patients using the Palliative Performance Scale, a zero-to-100% classification system developed by Victoria Hospice. The patients selected for the study all had a PPS score of 40% or less, meaning that they were expected to survive only 8 to 18 days, were mostly bedbound, had extensive disease, needed assistance with most or all Activities of Daily Living and had reduced or minimal food intake. In other words, these were people who were expected to pass very soon. The PPS assessment is pretty accurate: 60 of the 66 participants died during the study, an average of 21.6 days (median 15 days) after their first interview.

The researchers interviewed each patient daily, so long as the patient continued to be responsive. 52 of the 59 participants reported at least one dream or vision, in a total of 269 reports. This 88% of positive responses seems very high compared with people in general: sleep researchers estimate that 95% of all dreams are forgotten shortly after waking up and that less than half of people recall dreams more than once or twice a month.

When we refer to end-of-life dreams and visions we are including both experiences during sleep (dreams) and while awake (visions). In this group, 45% reported only dreams, 16% only visions, and 39% reported both dreams and visions. In nearly all instances, participants said that the experience felt “real.” This is different from most near-death experiences: in those cases, the event feels not at all ordinary.

The content of the end-of-life dreams and visions was quite consistent:
– 46% featured deceased friends or relatives
– 17% had living friends or relatives
– 10% had other people
– 35% had a variety of other content: deceased pets or animals, living pets or animals, religious figures, past meaningful experiences, and miscellaneous content.

In addition, 39% of reports by the patients featured a theme of going somewhere, or preparing to go somewhere, an obvious allusion to an imminent passing.

End-of-Life Dreams: Meaning to the Dreamer

End-of-Life Dreams & VisionsEnd-of-life dreams are rarely neutral in their emotional content. 60% are seen as comforting, 19% as distressing, and only 21% as neutral in meaning. Dreams and visions involving deceased relatives, friends or pets were particularly comforting; this type of dream begins 6 weeks before death and becomes more and more frequent until passing. The authors note with interest that the dead persons appearing in the dreams usually did not speak, yet their presence conveyed reassurance to the dreamer.

The patients who have these end-of-life dreams tend to be clearly conscious and aware of their surroundings. The researchers state that these dreams and visions “differ most from hallucinations or delirium by the responses they evoke, including inner peace, acceptance, and the sense of impending death.”

End-of-Life Dreams: Comfort for the Survivor

Family and friends who visit a patient in hospice care naturally hope that the patient’s final days are free of pain and of mental distress. End-of-life dreams and visions have a role to play in the comfort level of both a deceased person and their survivors.

A lot depends on how the professional caregivers respond. If a healthcare worker considers these dreams and visions as delirium, without significance, his reaction devalues them for the patient and does nothing to allay the alarm that visitors may feel.

These research studies, however, point us toward another path. Caregivers can now recognize that end-of-life dreams and visions are a predictable feature of the end of life: a source of reconciliation, reassurance and closure to the patient. With this knowledge, health workers can advise family members that the visions are normal, meaningful and comforting to their loved one. That it is valuable to listen to the patient describe the dreams and be accepting, so that the dying person does not feel isolated and shut off.

End-of-life dreams can allow caregivers to facilitate communication between patients and family members, leading to inclusion and acceptance for the patient, and reassurance and comfort for the family.

End-of-Life Dreams: Importance for Caregivers

End-of-Life Dreams & VisionsThe Buffalo researchers are well aware of the implications of their work in clinical settings. They note that patients, families and physicians are reluctant to discuss end-of-life dreams and visions: the lay persons fear ridicule, and the professionals doubt their medical legitimacy. In fact, patients themselves hesitate to bring up the subject, except sometimes to nurses.

The Buffalo studies demonstrate that discussing end-of-life dreams deserves to be part of standard protocol for hospice settings, a key ingredient in providing emotional and psychological support to the patient. As the researchers say,

…families and practitioners should engage in conversations about the dreams and visions to further promote this sense of comfort as well as to validate the experiences. End-of-life experiences are part of a healing process that should not be ignored by the health care personnel. …discussion about dreams and visions allows patients to share and presents a therapeutic opportunity for the clinicians to assist patient[s] and their families in the transition from life to death.

End-of-Life Dreams as Human Adaptation

End-of-life dreams are a nice example of a natural phenomenon that’s not easy to explain via evolution. After all, even though a person who is about to die gains comfort from these experiences, having these visions does not help him pass along his genes to the next generation.

As a scientist, I see several plausible explanations for such dreams:
– Those who see a grand design in human life, as a matter of religious or philosophical faith, can see end-of-life dreams as an appropriate, even necessary part of that design;
– Those who stand in awe of the brain’s amazing complexity may consider end-of-life dreams as a hard-to-comprehend natural function of this incredible organ: studies of dying mice seem to point in this direction; or
– End-of-life dreams may have survival value for the species by comforting the patient’s relatives, who are the primary caregivers in many human societies: these dreams could give them the courage to persevere through life’s struggles and sustain the human race.

Do you know relatives or friends who described end-of-life dreams or visions prior to their death? How did they seem to feel about the experience?

Research References:
Kerr et al, End-of-Life Dreams and Visions: A Longitudinal Study of Hospice Patients’ Experiences
Nosek et al, End-of-Life Dreams and Visions: A Qualitative Perspective From Hospice Patients

Drawing Credits: (all on openclipart.org)
– “Alien Brain Reader” by j4p4n
– “imagine” by presquesage
– “Old-mans-Face” by StefanvonHalenbach
– “Nurse” by chlopaya


End-of-Life Dreams: A Comforting Gateway — 3 Comments

  1. My thanks to both Charles and Bob for their helpful comments. The discussion of dreams as part of the memory-sorting process seems consistent with my earlier blog about sleep (http://artchester.net/2013/11/sleep/), which did not consider dreams. I think the sleep researchers i quoted (and Nick Greaves, whose interests are broader than this) would embrace the image of sleep-work as a stage play.

    Charles’ friend’s technique for dream interpretation is fascinating in its own right. Charles, I wish that your friend would consider writing a guest blog here, about what she has learned from that work – suitably anonymized of course. If she has already published it somewhere, I would love to see the article.

    Thanks for contributing!


  2. Charles South’s reply is, as always, thoughtful and interesting. His statements about “dual agents” (conscious and unconscious) in the mind sharing limited communication, immediately bring to mind Daniel Kahneman’s book, “Thinking, Fast and Slow”, in which the interactions of these “two systems” (in his words) are explored in depth. I found it interesting that the extensive index of this book doesn’t have an entry for dream(s) or dreaming.

    Next time I wake up, I’ll think more carefully about the “props” left over from the “stage play”. Nice analogy.

  3. Over the course of my life I’ve gradually come to accept certain theories about what dreams are, and what the role of the “unconscious (or subconscious) mind” is. I view the latter as something like an alter ego, our “other half” and “dreams” as the interface between the two. In this theory, each of us consists of these dual agents, much like a horse and rider. Communication between the two is difficult because they don’t speak the same “language” but there is a limited amount of direction the conscious can give the subconscious (generally through visualization of a desired result), and a limited amount of feedback the subconscious can return to the conscious (through dreams).

    It’s only a theory, but the whole end-of-life aspect of dreaming seems to fit well with that theory. In my theory, once we go to sleep the subconscious goes rummaging through the day’s experiences and decides what is worth integrating into long-term memory and what is not worth keeping. During the process, various images and feelings are triggered during the dreaming process that are inspired by whatever we’ve recently experienced or been feeling, but the subconscious operates at a very different level so these “symbols” appear in very different forms in dreams than we consciously experienced them.

    The image I have of this process is like a stage play where props are left when the director (that’s you) and the cast members (people you interact with during the day) go home (you go to sleep) and the janitorial service (your subconscious) comes out to tidy up. During the process, that crew moves the props (short term memories) around or puts them away (into long-term memory storage) or throws them away (the trash that isn’t worth keeping), so you, the Director (conscious mind) are ready for the next day’s performance. You aren’t usually aware of this process because you’re not there (you’re asleep) but if you come back unexpectedly (wake up) you’ll catch the service at work until they melt away into the wings of the stage and out of view.

    A friend of mine likes to interpret dreams, having learned about that through a psychiatrist she saw when she was much younger, and who used that as an analysis technique. When I told my friend about some of my dreams, I was fascinated to see how she extracted “meaning” from them that had nothing to do with my conscious memory of the dream sequence. As conscious entities we insist on seeing the chronology and concrete meanings of the dream as if we observed that flow in real life, but the technique my friend uses to pry apart the meaning of the dream assumes that every “prop” on the “stage” of your dream has independent meaning, and the interactions between props are the core of the dream. Your own observation point in the dream is irrelevant and whatever you’re “experiencing” in the dream is a red herring you should ignore. Instead, my friend would grab some element of the dream and begin prying apart what that aspect “felt” or “wanted” .. much like peeling an onion, and treating the element as a semi-sentient agent who had a story to tell. It was remarkable how she was able to isolate some feeling or worry that underlay the dream, and was related in an indirect way to my life at the time. Often, by directing my conscious mind to something I had been ignoring, it allowed me to seek solutions in real life once I was aware of the problem (that is, after all, one of the primary purposes of the conscious mind … to use logic to deal with reality).

    Looked at in this way, end-of-life dreams may be simply your own reaction to the impending event that you can perhaps logically accept (your own death) but struggle with emotionally. In your own search for peace, you instinctively look for something to reduce the fear, and the easiest to isolate are images of past memories that may be pleasant, or indicate a positive outcome. Whether those images come from your own life (memories of dear friends or relatives who may have passed on already) or whether from others (religious themes, etc) the intent is the same if your subconscious mind is at work trying to process whatever is going on with your life right then, and help you find peace with your life.

    As for remembering these dreams better than average … I would argue anyone approaching the end-of-life for a medical reason is unlikely to sleep well, because of pain or worry or having others check on you during the night. All of us know that waking up in the middle of the dream makes it much more likely we will remember some aspects of it in the morning, compared to the dream “completing” and then being dismissed and forgotten.