P0537 - Dreams as a Gateway to Facilitate Difficult Discussion at the End of Life

Title: Dreams as a Gateway to Facilitate Difficult Discussion at the End of Life

Objectives:
1. Recognize the common experience of dreams at end-of-life
2. Explore how disclosure of dreams at end-of-life may facilitate difficult conversations with patients and families
3. Recognize the utility of integrating dream assessment into routine care

Background:
Dreams and visions at end-of-life have been documented throughout history and across cultures. Studies of bereaved family members of adult patients have reported that revelation of loved one’s dreams at end-of-life have provided “comfort” and “hope.” Adult studies have also shown that these dreams have allowed for processing of emotions and healthcare information. Dreams in adolescents or their family members may offer a window into patient and family coping in terminal stages of disease.

Case Description:
19-year-old female with relapsed acute lymphoblastic leukemia admitted to the pediatric intensive care unit following stem cell transplant. Her course was complicated by multiple infections, graft-versus-host disease of the liver, renal failure requiring hemodialysis, and hypoxic respiratory failure requiring mechanical ventilation. Ultimately this patient chose to withdraw life-sustaining therapies and passed away from organ failure. Approximately two months prior to her death she disclosed to her mother and bedside nurse that she experienced a dream in which she had to explain to friends and family that she was dying. The dream was explored with her mother, whose initial reaction was to provide reassurance. The mother then discussed this dream with the patient’s medical providers and explored what this might mean in the context of the patient’s physical and emotional health. This ultimately allowed for further, more open discussions with staff regarding patient and family goals and questions surrounding expectations, limitations, and end-of-life.

Conclusion:
Disclosure of dreams in terminal illness may help to facilitate difficult discussions around end-of-life issues especially in adolescents who are still developing a language around life and death and spirituality. Analysis of dreams themselves may not be necessary for medical providers looking to use disclosure of dreams to better define goals of care but rather bearing witness to concerns may help to facilitate these difficult conversations.