Background     Near death awareness (NDA) is a term to describe a dying person’s experiences of the dying process and broadly refers to a variety of experiences such as end of life dreams or visions. Information comes from broadly reported anecdotes and several case series which suggest that up to 50-60% of patients will experience some form of NDA prior to their death(1). The language patients use to communicate NDA may be symbolic and if caretakers are not aware that NDA can occur, patients may be ignored, treated condescendingly, or inappropriately medicated for delirium.  Family, friends, and health professionals may respond with annoyance, frustration or fear. This, in turn, may cause isolation, suffering, and impair the dying person’s ability to communicate meaningful experiences at the end of life. 

NDA vs. Delirium     In studies engaging both patients and caregivers, NDA emerges as distinct from delirious states. In general, as opposed to hallucinations in delirious states, NDA occur in clear consciousness; they are reported with clarity, detail, and organization; and they often evoke feelings of comfort, rather than distress (2-3)  See Fast Facts #1 for further information on delirium.

Impact of NDA on Existential Distress: NDA also differ from deathbed hallucinations with respect to their impact on patients. In her 2010 analysis of deathbed phenomena, Mazzarino-Willett found that NDA tends to be spiritually transformative, while hallucinations tend to be relatively insignificant (1). In addition, deaths including NDA are more frequently calm and peaceful than are deaths without such experiences (4).Thus NDA has been distinctly observed to affect positively the quality of the dying process.

Near Death Phenomena     The recognition of NDA requires attentive listening.  Health professionals, family, friends and caregivers can help decipher NDA messages. The content of NDA often will vary based on cultural background, but several common experiences relating to NDA have been described and include (5-6): 

• Communicating with or experiencing the presence of someone who is not alive.
• Preparing for travel or a change.
• Describing a place they can see in another realm (i.e. heaven).
• Knowing when death will occur.

Pearls for Listening and Responding to NDA Phenomena

The literature suggests that caring for patients experiencing NDA should center on eliciting communication about the experience and accepting their significance for patients and families (1, 3). Specifically, providers should:

* Evaluate for causes of delirium and treat when appropriate while taking care not to blame a emotionally or spiritually significant experience on delirium 

* Empathetically explore the meaning behind an expression of NDA and its impact on a patient’s psychosocial, emotional or spiritual distress. Accept and validate what the patient is telling you; do not challenge or argue. Specifically, validate the meaning behind the NDA experience and the impact it may have on a dying process.

Further Resources      See the following references for clinical examples.  Examples in the Callahan and Kelley text provide guidance for caretakers on how to help patients who are experiencing NDA.

References:

1. Mazzarino-Willett A. Deathbed Phenomena: Its role in peaceful death and terminal restlessness. Am J Hospice Palliat Care 2010;27(2):127-133.

2.  Nosek CL, Kerr CW, Woodworth J, Wright ST, Grant PC, Kuszczak SM, Banas A, Luczkiewicz DL, Depner RM. End-of-Life Dreams and Visions: A Qualitative Perspective from Hospice Patients. AmJHospPalliat Care 2014 (e-pub ahead of print, at http://ajh.sagepub.com/content/early/2014/01/15/1049909113517291.full.pdf+html, accessed on 4/3/2015).

3.  Fenwick P, Lovelace H, Brayne S. Comfort for the Dying: Five Year Retrospective and One Year Prospective Studies of End of Life Experiences. Arch Gerontol Geriatr 2010;51(2): 173-179.

4.  Lawrence M and Repede E. The Incidence of Deathbed Communications and Their Impact on the Dying Process. Am J HospPalliat Care 2013;30:632-639.

5.  Kellehear A, Pogonet V, Mindruta-Stratan R, Gorelco V. Deathbed Visions from the Republic of Moldova: A Content Analysis of Family Observations. Omega 2011;64:303-317.

6.  Kerr CW Donnelly JP, Wright ST, Kuszczak SM, Banas A, Grant PC, LuczkiewiczDL.End-of-Life Dreams and Visions: A Longitudinal Study of Hospice Patients’ Experiences. JPalliat Med 2014;17(3):296-303.

Version History:  This Fast Fact was originally edited by David E Weissman MD and published in August 2004. Re-copy-edited in April 2009.  In October 2015 it was significantly revised to expand upon the effect Near Death Awareness can have on existential distress; updated references were also utilized to reflect advances in the field which were incorporated in the text.