End-of-life dreams and visions in a patient with delirium: A Brazilian case report and narrative review.

Near death, end-of-life dreams and visions (ELDVs) and delirium often overlap, making them hard to tell apart. This case report describes an elderly Brazilian woman with metastatic cancer who experienced both. ELDVs involved vivid encounters with deceased relatives and biographical themes, but many were distressing and occurred alongside fluctuating attention typical of delirium. The Confusion Assessment Method (CAM) identified delirium but could not distinguish ELDVs within delirious states. ELDVs often emerged during lucid windows with preserved recall and insight. Distress alone did not differentiate the two. Supplementing CAM with qualitative criteria—content, vividness, biographical meaning, insight, cultural fit, and recall—may prevent misclassification and support holistic palliative care.

Study at a glance

Abstract

End-of-life dreams and visions (ELDVs) and delirium frequently occur near death but differ in core features. Clinical differentiation becomes challenging when they co-occur. This case report illustrates the interplay between ELDVs and delirium, examines the limits of current diagnostic criteria in mixed cases, and outlines a nuanced approach to distinction. We report the case of an elderly Brazilian woman with metastatic cancer who exhibited both ELDVs and delirium. Mental status was serially assessed using the Confusion Assessment Method (CAM). ELDV accounts were prospectively triangulated across patient, family, and clinician reports to enhance reliability and contextual understanding. The patient's experiences showed ELDV hallmarks - vivid, realistic encounters with deceased relatives, biographical relevance, and preparatory themes - yet many were affectively distressing and occurred alongside fluctuating attention and consciousness consistent with delirium. CAM effectively identified delirium but could not, on its own, distinguish ELDVs within delirious states. When co-occurring, ELDVs often emerged during "windows of lucidity" marked by preserved autobiographical context, intact recall with subsequent coherent narration, and insight, despite intense emotional valence. Distress alone was not discriminatory, probably being shaped by psychosocial and cultural factors. These observations indicate the need to supplement CAM with qualitative and phenomenological criteria, including content, vividness, biographical meaning, insight, cultural fit, and acuity/recall. To our knowledge, this is the first case to map evolving end-of-life mental status using serial CAM while prospectively documenting ELDVs via triangulated reports. The findings highlight the complexity of differentiating co-occurring ELDVs and delirium and challenge the sufficiency of CAM alone. An integrated approach - combining CAM screening with structured ELDV assessment - may prevent misclassification and support holistic, dignified palliative care. As a single case in an underexplored domain, these insights require confirmation in larger, prospective studies to assess generalizability.