Understanding Clinicians’ Perspectives on End-of-Life Dreams and Visions: An International Survey

Key Message

End-of-life dreams and visions (ELDVs) are common, clinically relevant experiences that may influence emotional, existential, and spiritual well-being near death. Despite frequent encounters, clinicians report limited preparedness to address ELDVs, highlighting the need for education, guidance, and interdisciplinary approaches within routine palliative care.

Introduction

End-of-life dreams and visions (ELDVs) are vivid, emotionally subjective experiences that commonly occur during the dying process. These experiences may involve deceased loved ones, spiritual figures, or comforting imagery and are frequently described by patients and families as meaningful and reassuring. Importantly, ELDVs are phenomenologically distinguishable from delirium, though the distinction can be clinically challenging. ELDVs are typically coherent, emotionally congruent, and often reported by individuals without obvious cognitive impairment. They occur due to neurocognitive changes and help with meaning-making and preparation for death. ¹

Research has confirmed the prevalence, content, and impact of ELDVs in hospice and palliative care populations. Kerr et al. ² conducted a longitudinal study revealing that up to 88% of hospice patients reported ELDVs, often describing them as a source of peace, closure, or spiritual connection. Other studies have reinforced these findings, documenting a wide range of themes, including reunion, transition, and forgiveness.^3–5 Recent analyses suggest that ELDVs may also contribute to posttraumatic growth in bereaved caregivers and health care workers, highlighting their broader psychosocial impact.^4,6–8

Despite their frequency and reported significance, ELDVs remain underrecognized and insufficiently addressed in clinical care. Although family caregivers often view ELDVs as meaningful, few institutions offer formal guidance on how to document, discuss, or support these phenomena. ⁹

Evidence suggests a persistent gap between physicians’ positive attitudes toward spirituality and their routine practice of taking spiritual histories.^10–14 Koenig ¹⁰ has noted that, although spiritual beliefs frequently influence patients’ coping and decision-making, clinicians often lack the training to address them.

There is a gap between the recognized significance of ELDVs and their integration into clinical practice. While the patient and family experiences of ELDVs are well-documented, little is known about the perspectives, preparedness, and perceived needs of health care professionals. To address this gap, we conducted a multinational cross-sectional survey of palliative care professionals to examine their knowledge, experiences, and attitudes regarding ELDVs.

This study aimed to explore (1) how frequently clinicians encounter ELDVs, (2) their capacity to differentiate ELDVs from delirium, (3) the extent of training and institutional guidance available, and (4) preferred approaches to education, documentation, and family communication related to ELDVs.

Methods

We conducted a cross-sectional, anonymous, web-based survey to explore health care professionals’ (HCPs) perspectives, beliefs, and experiences surrounding ELDVs. The study followed the Checklist for Reporting Results of internet E-Surveys to ensure methodological rigor, transparency, and completeness of reporting. The survey was created and deployed using the SurveyMonkey^® platform.

Results

Descriptive and inferential statistics for the questionnaire items

Awareness and experience

Most participants reported having encountered patients who described ELDVs at least occasionally (median = 3.0, Q1 = 2.0, Q3 = 3.5, IQR = 1.5), with 18.6% of participants indicating that they had never encountered ELDV-related reports (Fig. 1). The most frequently reported contents of these experiences involved deceased family members or friends (72.9%), followed by memories of important life events (47.4%), spiritual figures (26.7%), living persons (25.5%), and 7.7% indicating all of the above (Fig. 2).

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FIG. 1.

ELDV awareness and experience items (Section 2). Mean ratings (dots) and 95% confidence intervals (horizontal bars) for participants’ reported awareness and experiences with ELDVs. Responses were given on a 5-point Likert scale. ELDV, end-of-life dreams and vision.

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FIG. 2.

Reported ELDV content (Section 2). Percentages of participants reporting each content type of ELDVs. Bars represent the proportion of participants endorsing each category (N = 247). Percentages are based on the total sample, including those who had never encountered ELDVs (which are N = 46).

Participants also reported personal experience with patients who described ELDVs (median = 3.0, IQR = 1.0), as well as with family members or caregivers who reported such phenomena (median = 3.0, IQR = 1.0). Positive emotional or psychological effects of ELDVs on patients were observed more frequently (median = 3.0, IQR = 2.0) than negative ones (median = 2.0, IQR = 1.0). A Wilcoxon signed-rank test confirmed that this difference was statistically significant (W = 446.0, p < 0.001***).

Attitudes and beliefs

Participants generally endorsed positive attitudes toward ELDVs (Fig. 3). They largely agreed that ELDVs are a natural part of the dying process (median = 4.0, IQR = 1.0) and that patients can be emotionally and spiritually impacted by discussing them (median = 4.0, IQR = 1.0). Similarly, most participants believed that ELDVs should inform patient care (median = 4.0, IQR = 1.0) and be a standard component of end-of-life discussions (median = 4.0, IQR = 2.0).

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FIG. 3.

Attitudes towards ELDV items (Section 3). Mean ratings (dots) and 95% confidence intervals (horizontal bars) for items assessing participants’ attitudes toward ELDVs. Responses were given on a 5-point Likert scale.

Clinical challenges and differential diagnosis

Clinicians reported a range of challenges related to the evaluation and management of ELDVs (Fig. 4). The highest perceived challenges were the lack of institutional protocols (median = 4.0, IQR = 2.0) and lack of standardized diagnostic criteria (median = 4.0, IQR = 1.0), followed by lack of clinical time (median = 3.0, IQR = 2.0) and patient/family unawareness (median = 3.0, IQR = 2.0). The lowest perceived challenges, rated as moderate, were the fear of medicalizing (median = 3.0, IQR = 2.0) and difficulty distinguishing ELDVs from delirium/hallucinations (median = 3.0, IQR = 2.0). A Friedman test indicated that ratings differed across challenges, χ²(5) = 160.97, p < 0.001***. Post hoc Bonferroni-corrected tests showed institutional protocols and lack of standardized criteria were rated significantly higher than all other challenges (all p < 0.001).

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FIG. 4.

Perceived level of challenge items (Section 4). Mean ratings (dots) and 95% confidence intervals (horizontal bars) for participants’ perceived challenges in evaluating and managing ELDVs. Responses were given on a 5-point Likert scale.

Education and training

Participants expressed strong support for incorporating ELDV-related content in medical education (Fig. 5). They agreed that all medical education should include training to differentiate ELDVs from delirium or psychiatric conditions (median = 4.0, IQR = 1.0), while rejecting the notion that this should be limited to hospice or palliative care training (median = 2.0, IQR = 2.0).

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FIG. 5.

Education and training opinions items (Section 5). Mean ratings (dots) and 95% confidence intervals (horizontal bars) for participants’ opinion on ELDV education and training. Responses were given on a 5-point Likert scale.

When asked about specific training components (Fig. 6), participants most frequently endorsed structured communication-based frameworks (82.2%), toolkits (66.4%), and simulation-based training (55.9%). In total, 39.7% of participants endorsed all the above components.

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FIG. 6.

Preferred components and team members for ELDV-related training (Section 5). Left: Percentages of participants endorsing each proposed ELDV training component (N = 247). Bars show the proportion of participants selecting each option. Right: Percentages of participants indicating which professional groups should receive ELDV-related training (N = 247). Bars show the proportion of participants selecting each option.

A majority also supported educating multiple professional groups (Fig. 6), especially nurses (91.9%), physicians (91.1%), advanced practice providers (81.0%), chaplains (79.3%), social workers (77.3%), psychologists (76.9%), and medical or nursing aids (71.7%). Nearly half (49.0%) indicated that all above professions should receive training.

Finally, participants strongly agreed that educating families about ELDVs could reduce anxiety and confusion (median = 4.0, IQR = 1.0).

Institutional policy and interdisciplinary collaboration

Participants consistently supported institutional engagement with ELDVs (Fig. 7). They agreed that hospitals and hospices should implement formal policies (median = 4.0, IQR = 1.0), that ethics consultation teams should be available (median = 4.0, IQR = 1.0), and that multidisciplinary collaboration is essential (median = 4.0, IQR = 1.0). Moreover, institutional support for health care providers was strongly endorsed (median = 4.0, IQR = 1.0).

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FIG. 7.

Institutional policy and interdisciplinary collaboration items (Section 6). Mean ratings (dots) and 95% confidence intervals (horizontal bars) for participants’ agreement with statements regarding institutional policies and interdisciplinary collaboration on ELDVs. Responses were given on a 5-point Likert scale.

Research, advocacy, and public awareness

Participants attributed high importance to further research and public engagement regarding ELDVs (Fig. 8). Most rated as ‘very important’ the need to differentiate ELDVs from pathological conditions (median = 4.0, IQR = 1.0), identify best-practice cases, and study pharmacological influences. Participants also supported public awareness campaigns and national guidelines on ELDV recognition and management (all medians = 4.0).

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FIG. 8.

Research, advocacy, and public awareness items (Section 7). Mean ratings (dots) and 95% confidence intervals (horizontal bars) for participants’ evaluations of research, advocacy, and policy priorities related to ELDVs. Responses were given on a 5-point Likert scale.

Discussion

Our study suggests that clinicians encounter ELDVs at least occasionally, consistent with prior work among palliative care professionals. Nyblom et al. ¹⁶ found that most palliative care physicians encountered patients who described vivid and meaningful dreams or visions that involved their deceased family and friends. ¹⁶ Our participants reported a higher frequency of positive emotional effects associated with ELDVs. This pattern was consistent with the positive themes of ELDVs described by patients like comforting, preparing to go, and unfinished business. ¹ Clinician acknowledgment can invite meaning-making and facilitate emotional reconciliation. ¹³ In contrast, not acknowledging ELDVs is a missed opportunity for holistic, person-centered care and may inadvertently intensify isolation during the dying process.^17–20 When clinicians respond supportively, prior studies suggest patients may feel more peaceful and dignified, and caregivers may experience less burden.^2,19,20

We found that despite frequent exposure of clinicians to ELDVs, they felt that they lacked a structured approach to take care of such encounters. Nyblom et al. and Kerr et al. observed that many physicians recognized ELDVs but had limited training and knowledge to navigate ELDV conversations with their patients.^16,21 Hession et al. noted limited guidance within palliative care regarding ELDVs’ diagnostic criteria, documentation standards, and clinical pathways. ²² This becomes especially important in multicultural settings where there are disparities in health care and supportive care provision.^23,24

Ethical practice requires respecting their interpretations even when they might be different from biomedical theories or individual convictions.^25,26 Furthermore, the principle of beneficence highlights that physicians should recognize the potential psychological comfort of ELDVs.^22,27,28 Very few participants reported receiving formal ELDV education, which is similar to other research studies that have observed insufficient clinical preparation.^22,25,29 Our participants expressed their preference for communication based teaching and structured toolkits, which was similar to Grant et al.’s recommendation for reflective educational programs for clinicians. ²⁵ In our survey we found that many participants preferred a multidisciplinary approach across all professional groups. This supports findings from previous studies that shared training enhances spiritual literacy and reduces distress. Given that distinguishing ELDVs from delirium was rated as a moderate challenge, training should include specific guidance on phenomenological features that may help differentiate these experiences, while acknowledging that clinical overlap can occur.^16,21,22

Additionally, participants preferred institutional policies, clinical guidelines, and ethical support to adequately address ELDVs. Integrating ELDV-related education into palliative care curricula, communication training programs, and spiritual assessment frameworks may therefore improve clinician preparedness and confidence. Institutional policies and case-based interdisciplinary discussions may further support clinicians in navigating the complex intersection between spiritual experience, psychological meaning-making, and neurocognitive changes near the end of life.^28,29

Some participants reported family and community education to be equally effective. Prior research suggests that when clinicians respond with openness and respect, caregivers often perceive these experiences as comforting or meaningful, which may reduce anxiety and contribute to healthier bereavement processes.^30,31

Within this framework, ELDVs can be understood as potentially meaningful experiences that occur during the dying process rather than as phenomena that are inherently pathological. A supportive clinical response therefore aligns with the central goals of palliative care: Reducing distress, supporting existential well-being, and maintaining dignity during the final stages of life. In clinical practice, ELDVs may be addressed through a structured approach involving four key steps: Recognition, exploration, clinical differentiation, and interdisciplinary support.

First, clinicians acknowledge and validate the experience without prematurely medicalizing it. Second, patients are invited to describe the experience in their own terms, allowing personal, cultural, or spiritual interpretations to emerge. Third, clinicians evaluate whether the experience may also reflect delirium, medication effects, or other neurocognitive conditions, as there can be overlap with pathological states. Finally, interdisciplinary support involving chaplains, psychologists, nurses, or social workers can help patients and families integrate the experience within their broader emotional and spiritual context.

Exploratory group comparisons revealed that profession and clinical setting were the most consistent sources of variation: Hospice care providers reported greater ELDV awareness and more positive attitudes, while nurses reported more positive attitudes toward ELDVs and more strongly endorsed the introduction of formal ELDV policies in hospitals and public awareness campaigns. Participants based in North America reported higher ELDV awareness, while participants based in Asian and European regions reported greater perceived challenges. Participants based in Asia also reported stronger support for policies (in hospitals but also nationwide). These patterns suggest that training needs and implementation barriers are not uniform across professional roles and health care contexts and that future interventions may need to be tailored accordingly. A selection bias is present within our study since this was a self-administered online questionnaire. There is limited generalizability of our study because of nonuniform cultural representation. There is also some recall bias associated with the study because of reliance on self-reporting estimated frequencies. Future research should include patients and their families, study ELDVs through the dying process, and analyze how patient comfort, peace, and family bereavement are shaped by clinician responses.

Conclusion

This study highlights that even though ELDVs are common, clinicians feel unprepared to respond to them. It is a moderate challenge for clinicians to differentiate ELDVs from delirium, and clinical tools specifically designed to aid this distinction are currently lacking. There is a need for structured training and institutional protocols for the management of ELDVs for all physicians and should not be limited to hospice or palliative care training. The way ELDVs are perceived varies widely across cultures, so acknowledging cultural and spiritual variability is essential. Future studies should be done to include patients and their families and analyze how patient comfort and family bereavement are shaped by physician responses.