1. Hospice Buffalo
End of Life Dreams and Visions
NSG 499 Independent Research Project
Catie Glawatz and Sarah Dow
In coordination with the Palliative Care Institute (PCI)
Under the direction of Kelly Clem

2. Purpose
To promote End of Life Dream and Vision
awareness and educate on appropriate
evidence based practices in hopes to assist
healthcare providers support patients through
the dying process

3. Practice Problem
ELDV’s
Delirium
Hallucinations Confusion
Patients making significant changes towards
end of life tend to experience
dreams, visions, hallucinations, delirium, etc.
-Healthcare providers tend to treat patient experiences
with designated medications
-Evidence suggests that some patients experience end of
life dreams and visions that promote comfort and support
through the dying process
Therefore, healthcare providers need to distinguish
between patients who experience distress and comfort to
medicate and treat appropriately.

4. Clinical Question
P
I
C
O
Within the Hospice/Palliative Care Patient
population,
Do End of Life Dream and Vision (ELDV)
Conversations
As opposed to no ELDV conversations
Promote comfort and support among
patients and their families?

5. Evidence-Search Process
Search History
Data Base Key Words Inclusion
Criteria
Number of
Citations
Retrieved
Exclusion
Criteria
Number of
Citations
Used
CINAHL “End of Life”
“Dreams”
“Visions” Scholarly
Journal
Articles,
Peer
Reviewed
3
Published
after 2011 (5
years old)
Account for
duplicates
Level IV
Evidence
3
Palliative
Care
Institute
Consult
None 11 3

6. Data Extraction
Table of Evidence
Article Sample Design Intervention Findings/Conclusions Level of Evidence Strengths
End-of-Life
Experiences and the
Dying Process in a
Glouestershire
Nursing Home as
Reported by Nurses
and Care Assistants
10 staff members
(5 RN’s, 5 PCA’s)
working at a Nursing
Home facility
All had at least 3
years of experience
5 year retrospective
study to explore End
of Life Events
(ELE’s)
Quantitative and
Qualitative Data
Questionnaire and
semi-structured
interview portions
None End of Life experiences
(ELE’s) are reported by
doctors and nurses
Common ELE’s include
visions and dreams that
provide comfort and support
to patients
Participants report that more
training is necessary to foster
communication between
professionals and patients
who experience ELE’s
Retrospective
Study
Level IV
Only study that
interviewed
healthcare team
members
“All interviewees
agreed that they
lacked specific
training that focused
on ELE’s”
Significance of End-
of-Life Dreams and
Visions Experienced
by the Terminally ill
in Rural and Urban
India
60 terminally ill
patients with
Palliative
Performance Scale of
>40%
Prospective, Cohort
based with mixed
methods research
design
Participants
answered various
closed and open
ended questions
about occurrence of
ELDVs if any.
Qualitative Data
None Most participants were able to
recall the ELDVs vividly and
in detail.
Most participants reported the
ELDVs to be distressing at
first but after better after
discussing them with the
team.
Prospective,
cohort based,
with mixed-
methods
research design
Level IV
This is our only study
which takes place
outside of the US,
suggesting that
ELDV’s transcend
cultural boundaries

7. Data Extraction
Table of Evidence Continued
Article Sample Design Intervention Findings/Conclusions Level of Evidence Strengths
*End-of-Life Dreams
and
Visions: A
Longitudinal Study of
Hospice Patients'
Experiences
Center for Hospice
and Palliative Care
Inpatient Unit In
Cheektowaga NY
59 participants
Palliative
Performance Scale of
>40%
Mixed methods
survey using a semi-
structured interview
consisting of open
and closed ended
questions regarding
content, frequency,
and comfort/distress
of dreams and
visions
Qualitative and
Quantitative Data
None Most participants (88.1%)
reported experiencing at least
one ELDV during the study
Most common dream/vision
included deceased family
members or relatives
As participants approached
death, comforting
dreams/visions of the
deceased became more
prevalent
Mixed Methods
Survey
Level IV
One of the first
studies to ask
patients directly
about ELDV’s
Study was conducted
in WNY with a
current practicing
physician
Suggests a need for
the distinction
between ELDV’s and
delirium symptoms
The Incidence of
Deathbed
Communications and
Their Impact on the
Dying Process.
60 Patient Charts
over a 3 month period
Nurses were asked
to document
Deathbed
Communications
(DBC’s) in patient
charts
Qualitative and
Quantitative Data
A general
presentation for
staff about
DBC’s
Chart audits as a method of
gathering incidences of DBC’s
within the last 30 days of
death proved not as beneficial
as anticipated. Charts were
not descriptive enough for
accurate evaluation
89% of hospice nurses stated
that patients have calm
peaceful deaths associated
with DBC, making the search
for valid documentation and
intervention significant
Cohort Study
Level IV
Only study to
suggest a way to
chart patient DBC
experiences

8. Data Extraction
Table of Evidence Continued
Article Sample Design Intervention Findings/Conclusions Level of Evidence Strengths
*End-of-Life
Dreams and Visions:
A Qualitative
Perspective From
Hospice Patients
Center for Hospice
and Palliative Care
Inpatient Unit In
Cheektowaga NY
59 participants
Palliative
Performance
Scale of >40%
Mixed methods survey
using a semi-structured
interview consisting of
open and closed ended
questions regarding
content, frequency, and
comfort/distress of
dreams and visions
Quantitative and
Qualitative Data
None ELDV’s were sorted into 6 major
categories:
● Comforting Presence
● Preparing to Go
● Watching or Engaging
with The Dead
● Loved Ones Waiting
● Distressing
Experiences
● Unfinished Business
ELDV’s appear distinct from
hallucinations in terms of the
feelings they evoke (comfort vs.
distress) as well as the clarity,
detail, and organization in which
they are are reported
Mixed Methods
Survey
Level IV
One of the first
studies to ask
patients directly
about ELDV’s
Study was conducted
in WNY with a
current practicing
physician
Suggests a need for
the distinction
between ELDV’s and
delirium symptoms
Meaning-centered
dream work with
hospice patients: A
pilot study
7 Hospice Patients
Palliative
Performance
Scale of >30%
Meaning-centered
variation of the
cognitive experimental
model of dream work
was tested
Total of 12 dream work
sessions were
conducted with 7
hospice patients
Qualitative Data
Dream Work
sessions with
Hospice
Patients
Patients were
consulted
through three
stages :
exploration,
insight and
action
Six major domains emerging
from transcripts were:
● Dream Exploration
● Insight from Dreams
● Actions Taken
● End of Life Concerns
● Sources of Meaning in
Life
● Perceptions of Dream
Work Process
Case Control
Level IV
Only study to use a
specific therapy tool
(Dream Work Model)
to assess patient’s
ELDV’s

9. Summary of Evidence
Distinction
between
ELDV’s and
Delirium
Importance
of ELDV’s in
regards to
Psychosocial
and
Spiritual care
Interventions
Recognize a
need for
educational
programs
regarding
ELDV’s

10. Practice Recommendations
Implement Evaluate Sustain
Training sessions to
educate healthcare staff on
ELDV’s in hopes to
encourage communication
between patients, family
members and staff
Patient mood and affect
-Patients nearing end of life
who experience ELDV’s
report feelings of comfort
and support
Foster an environment of
open communication
between staff members to
promote appropriate ELDV
interventions
The following recommendations are based on analysis of the best evidence to assess the need to
evaluate for ELDV’s within the Hospice patient population:

11. Future Implications/Research Initiatives
Our literature review consisted of Level IV evidence
In order to provide healthcare professionals with additional
recommendations, Level III or higher evidence must be conducted
(RCT’s)
Hospice Buffalo is currently in the works of filming a documentary
about ELDV’s… stay tuned!

12. Looking for
Information...

13. References
Brayne, S., Lovelace, H., & Fenwick, P. (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.
doi:10.1177/1049909108315302
Dam, A. (2016). Significance of end-of-life dreams and visions experienced by the terminally ill in rural and Urban India. Indian Journal of
Palliative Care Indian J Palliat Care, 22(2), 130. doi:10.4103/0973-1075.179600
Kerr, C. W., Donnelly, J. P., Wright, S. T., Kuszczak, S. M., Banas, A., Grant, P. C., & Luczkiewicz, D. L. (2014). End-of-Life Dreams and
Visions: A Longitudinal Study of Hospice Patients' Experiences. Journal of Palliative Medicine, 17(3), 296-303.
doi:10.1089/jpm.2013.0371
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. doi:10.1177/1049909112467529
Nosek, C. L., Kerr, C. W., Woodworth, J., Wright, S. T., Grant, P. C., Kuszczak, S. M., . . . Depner, R. M. (2014). End-of-Life
Dreams and Visions: A Qualitative Perspective From Hospice Patients. American Journal of Hospice and Palliative Medicine,
32(3), 269-274. doi:10.1177/1049909113517291
Wright, S. T., Grant, P. C., Depner, R. M., Donnelly, J. P., & Kerr, C. W. (2014). Meaning-centered dream work with hospice patients: A
pilot study. Palliative and Supportive Care Pall Supp Care, 13(05), 1193-1211. doi:10.1017/s1478951514001072