Photograph by Georgia Hilmer
What We Can Learn from End-of-Life Dreams
What We Can Learn from
End-of-Life Dreams
“A person who is dying doesn’t care what their liver function or heart function is like. They’re having a separate experience that—paradoxically—can be very positive,” says hospice physician Christopher Kerr, MD, PhD.
Kerr studied more than 1,000 hospice patients, collecting interviews about their experiences to try to understand what happens when we die. In his book, Death Is But a Dream, he tells their stories. What Kerr and his medical team observed at the bedsides of the dying was remarkable: His patients were experiencing vivid dreams and visions in the days, weeks, and months leading up to their deaths. They experienced reunions with past loved ones, symbolic dreams of travel, and visions of being welcomed to the other side. Even traumatic visions before death led to an opportunity for forgiveness or transcendence, says Kerr, resulting in a sense of peace and comfort.
Kerr believes we need a new perspective on death. That there can be great beauty in dying. And that the visions we encounter as we approach death may tell us that dying is the opposite of a loss. It’s an affirmation of life.
(For other perspectives, you can read more on death and grief and listen to GP’s podcast conversation with palliative care physician BJ Miller about processing our regrets.)
A Q&A with Christopher Kerr
I hadn’t been working in hospice care long before I realized there was a gap in our understanding of the dying process. Medically, there is more to dying than organ failure. There is the non-physical, experiental aspect to end of life that we often fail to see. We live in a world where seeing is believing—there has to be data for something to be true. So I started to conduct studies on the subjective experiences at end of life.
Proving the research depends on how you define the word “prove.” You can’t prove abstractions like love, fear, and depression. But we understand and accept that they are human experiences, that they can be measured, and that they need to be honored. So to study the patients experience of dying, we used standardized questionnaires. We asked patients about their experiences every day leading up to their death. Because the subjects had to consent to this, we ruled out patients who were suffered with confusion state. We made sure patients were cognitively intact and that their thinking was clear. In total, we gathered almost 500 separate interviews in just the first study.
The thing we hear the most from our patients is that “this is different from normal dreaming.” Their dreams feel more like virtual or lived events. Oftentimes, patients will preface their experiences by saying, “I don’t usually dream, but this is different.” To help study this, we measured realism on a zero-to-ten scale, with ten being the highest degree of realism. Far and away, the number most people chose was ten. We call them dreams because it’s our only nomenclature or reference point. If we really listen to our patients, they firmly believe their dreams actually happened. The patients are left with a profound, deep feeling, as though it’s a memory, and not a distant dream experience.
We also measured comfort. And overwhelmingly, the dream experiences we gathered were comforting. As patients got closer to death, there was an increased frequency of predeath dreams and visions, and specifically ones featuring their loved ones who had passed. When we measured comfort based on what they were seeing, seeing their deceased loved ones was associated with the highest level of comfort. It’s like a built-in mechanism: When you get closer to the end of your life, those you have loved will return in ever-increasing frequency, and that will give you the feeling of overwhelming security and love returned.
People die as they live. If you have lived a life where there’s been significant regret or pain, dying doesn’t erase the fact of having lived through those things. These events don’t deny death, either. They seem to transcend it. We’ve all been wounded for having lived. These processes often address that. We found about 17 percent of people in our study had distressing dreams. But they were very meaningful experiences, because they resulted in expressions of forgiveness and love. These experiences were often the most transformative.
“We’ve all been wounded for having lived.”
For example, one of the patients in our study was a woman whose child was in prison, and she had always questioned her worth and identity as a mother. At the end of this patient’s life, she had a vision that her deceased parents returned to her and reassured her that she was, in fact, a wonderful and devoted mother. That sort of love, forgiveness, and wholeness is what provides people with the peace they need to sleep, to let go, and to be in less fear of dying.
I don’t believe so. I see an enormous number of people who are having traumatic experiences, and their trauma is addressed before they die. We’ve studied veterans who have suffered with PTSD for sixty or seventy years. There’s one patient in particular, who is documented in my book, who struggled with survivor’s guilt. He had an end-of-life vision that the soldiers he had left behind had come to visit him. Because of this, after sixty-seven years of holding on to his trauma, he was finally allowed to forgive himself and come to some sort of peace.
About one third of patients in this study dreamed about preparing to go somewhere, packing, or being in some mode of transport—everything from canoes to airplanes. The metaphor is obvious: They are in transition. The interesting piece is that these patients don’t come out of their dreams with an explanation of what it all means, specifically. The big difference between end-of-life dreams and normal dreams is that the time for therapy is over. People don’t wake up wanting analysis. They’re just given an understanding, and they’re not asking for more.
I’ve never had a patient ask me to interpret a dream for them. What’s really interesting about the travel dreams is the dreamer is so often accompanied by somebody who’s almost like a guide for them. The notion here is that we are not alone—that we are loved and that we are going to be okay.
Yes, but they tend to be people who are symbolic of something. For example, a veteran soldier might meet someone who is or represents a soldier. People who have lost children will see babies—not necessarily their baby but a baby. There’s always an implication that it’s tied to some sort of personal meaning or reference point.
These are not hallucinations. It’s definitely their experience. And whether they are lucid dreaming or not, it’s something we need to honor.
Delirium is different and very common—particularly at the end of life—but it has very different characteristics. A delirious person’s thoughts are not integrated or organized. They are garbled, and usually disoriented. And the delirious person is often very distressed. Because they have no insight, they are frenetic and often just reaching to everything that they see. On the other hand, for people who are having the kind of end-of-life experiences we’re talking about, we observe that their thoughts are extremely organized, and they actually gain insight and are comforted. In contrast, people who have delirium are very agitated to the point that they might need to be medicated because of frightened distress.
Unfortunately, many people who are having end-of-life experiences often receive medicine that essentially sterilizes them from their important personal dying experience, which ends up dampening the life-affirming aspect of dying.
We’ve taken the universal human experience and we have unintentionally medicalized it and sterilized it. In doing so, we’ve disconnected ourselves in a way that makes death dehumanized. A person who is dying doesn’t care what their liver function or heart function is like. They’re having a separate experience that—paradoxically—can be very positive. But because we are a culture that is death-denying and death-defying, we focus on the body biologically and medically. Ultimately, people are dying because the medicine has reached its limit, and that’s when nature really takes its rightful place.
People need to be closer to the bedside, not farther. They need to be more connected to the patient. The difference is this: Dying is more than organ failure. It’s about the closing of a life. For example, when we see a ninety-five-year-old man who lost his mother at age five and is smelling her perfume and hearing her voice, that is about life. It’s not denying the finality of his life, but it transcends dying and becomes something more meaningful. Perhaps the good things aren’t lost. That is why this matters. We need to reclaim that piece of dying.
“People need to be closer to the bedside, not farther.”
When we’re healthy and we’re looking at death as something in the distant future, we tend to make assumptions. We think of dying in terms of experiencing physical distress and suffering, and a time of loss and grief. But the vast majority of people die comfortably. The experience of dying is more anticlimactic than climatic from a physical dimension. And most people don’t need a lot of physical management. Dying has a way of taking care of itself.
The vast majority of patients say that they are physically comfortable. Knowing that, your perspective on dying changes. Patients should be asked: “How are you feeling mentally? What are you experiencing? Do you feel safe? Are you in fear? Are you alone?” Those are the questions that matter much more, because they speak to what the person is actually experiencing.
The best of us–and the best of what we have lived through–comes to surface and is ultimately all that will define us. That is all we’ll be able to reclaim. Maybe the things we think we’ve lost—and loved the most–aren’t really gone. They return to us to put us back together in some way. That is what the end of life is for many people.
Christopher Kerr, MD, PhD, is the CEO and chief medical officer of the Hospice & Palliative Care Buffalo Research Department. He developed one of the nation’s largest home-based palliative care programs, Home Connections, and Essential Care for Children. His research has received international attention and has been featured in The New York Times and The Atlantic, and by the BBC. He is the author of Death Is But a Dream.
This article is for informational purposes only, even if and regardless of whether it features the advice of physicians and medical practitioners. This article is not, nor is it intended to be, a substitute for professional medical advice, diagnosis, or treatment and should never be relied upon for specific medical advice. The views expressed in this article are the views of the expert and do not necessarily represent the views of goop.
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