Family Caregiver Perspectives on End-of-Life Dreams and Visions during Bereavement: A Mixed Methods Approach.

Background: End-of-life dreams and visions (ELDVs) are prevalent experiences that provide comfort and meaning to dying individuals. Limited research has examined the impact of ELDVs on the bereaved. Objective: This study aimed to explore differences in self-reported grief for people whose loved ones shared ELDVs and those who did not, and to describe the role of ELDVs in the grieving process. Design: Mixed-methods cross-sectional survey. Settings/Subjects: A total of 228 bereaved family caregivers (FCGs) of patients who died while under the care of a comprehensive hospice program were recruited. Measurements: Demographics and ELDV prevalence were collected. Bereavement was assessed using the Core Bereavement Items (CBI) a validated measure. Impact on grief was also evaluated using an ad hoc tool. Results: Comfort from dreams significantly related to total CBI score (r = 0.224, p = 0.047) as well as the images and thoughts (r = 0.258, p = 0.025) and acute separation subscales (r = 0.224, p = 0.047). Comfort from dreams had a positive relationship with accepting the reality of loss (r = -0.511, p < 0.001), working through the pain of grief (r = -0.556, p < 0.001), adjusting to the new environment (r = -0.405, p = 0.001), and continuing bonds (r = -0.538, p < 0.001). CBI scores were not significantly different between caregivers who reported loved ones with ELDVs and others. Open-ended responses were thematically analyzed resulting in three emergent themes: comfort, reflection and emotions, and sense-making. Conclusions: ELDVs' impact extends beyond those experiencing them to bereaved loved ones. Bereaved FCGs report that comforting ELDVs experienced by their dying loved ones influenced their grief process in terms of the Worden's tasks of mourning.

A close look at therapist contributions to narrative-emotion shifting in a case illustration of brief dynamic therapy.

Objective: In a secondary analysis of Friedlander et al.'s [(2018). "If those tears could talk, what would they say?" multi-method analysis of a corrective experience in brief dynamic therapy. Psychotherapy Research, 28, 217-234. doi:10.1080/10503307.2016.1184350] case study of Hanna Levenson's Brief Dynamic Therapy over Time (from APA's Psychotherapy in Six Sessions DVD series), we re-visited the Narrative-Emotion Process Coding (Angus, L. E., Boritz, T., Bryntwick, E., Carpenter, N., Macaulay, C., & Khattra, J. (2017). The Narrative-Emotion Process Coding System 2.0: A multi-methodological approach to identifying and assessing narrative-emotion process markers in psychotherapy. Psychotherapy Research, 27, 253-269. doi:10.1080/10503307.2016.1238525) to identify specific therapist behaviors that may have facilitated the client's movement from expressing mostly Problem markers in early sessions to expressing considerably more Transition and Change markers in later sessions. Method: Using open coding and constant comparison qualitative methods, we identified Levenson's behaviors immediately preceding the client's "change shifts" (Problem → Transition/Change and Transition → Change) and "problem shifts" (Transition/Change → Problem). Results: Compared to problem shifts, change shifts were preceded by more therapist behavior reflecting Attaching New Meaning (e.g., linking the client's self-deprecation to her avoidant behavior) and Exploring/Expanding emotions (e.g., inviting the client to give voice to her tears), cognitions (e.g., pointing out the client's self-talk) and motivation (e.g., reflecting on the client's dissatisfaction with her defenses). Conclusions: In this successful case, facilitative therapist behavior reflected common therapeutic responses (e.g., validating the client's perspective) as well as responses characteristic of brief dynamic therapy (e.g., interpreting the client's defenses) and the therapist's personal style (e.g., repeating the client's words for emphasis).

Expanding the Understanding of Content of End-of-Life Dreams and Visions: A Consensual Qualitative Research Analysis.

Background: Research has established End-of-Life Dreams and Visions (ELDVs) as prevalent, meaningful valid experiences that may help patients cope with illness and approaching death. However, no inductive qualitative analysis has explored the phenomenology of ELDVs from the perspective of hospice homecare patients. Objective: The purpose of this study is to evaluate the content of ELDVs by using a rigorous qualitative approach. Design: Five hundred forty-eight ELDVs were collected from weekly interviews of hospice homecare patients and analyzed by using Consensual Qualitative Research Methodology. Settings/Subject: Participants were enrolled in a county-wide hospice homecare program between January 2013-March 2015. Results: The following domains emerged: (1) Interpersonal, (2) Affective Experience and Reflection, (3) Activities, and (4) Setting/Location. Conclusions: This study suggests that ELDV content may include a broader spectrum of experiences that reflect waking life than previously believed. Clinical implications suggest that it may be important for providers to engage with ELDVs, as they are psychologically significant experiences that may be a source of clinical insight.

"If those tears could talk, what would they say?" Multi-method analysis of a corrective experience in brief dynamic therapy.

We analyzed master theorist/therapist Hanna Levenson's six-session work with "Ann" in American Psychological Association's Theories of Psychotherapy video series to determine if and how this client had a corrective experience in Brief Dynamic Therapy. First, we identified indicators of a corrective experience in the therapist's and client's own words. Complementing this analysis, we used observational coding to identify, moment by moment, narrative-emotion markers of shifts in Ann's "same old story"; the frequency, type, and depth of immediacy; and the client's and therapist's behavioral contributions to the working alliance. Additionally, we qualitatively analyzed Levenson's session-by-session accounts of the therapy from two sources. Convergent evidence from these multi-method analyses suggested how the intertwined relational and technical change processes seemed to bring about this client's corrective experience. Through consistent attention to the alliance and increasingly deep immediacy, Levenson created a safe space for Ann to "bring down the wall"-by allowing herself to cry and be deeply understood and cared for in a way that she had never before experienced. Concurrently, Ann began seeing herself quite differently, signified by self-identity narrative change. Then, following Session 4, she took Levenson's suggestion to risk behaving more authentically with a friend and with her romantic partner.

Screening for Delirium: Development and Validation of the Buffalo Delirium Scale for Use in a Home-Based Hospice Setting.

BACKGROUND: Delirium is a challenging occurrence among people at end of life. It can be difficult to detect and treat because of its episodic nature. The Buffalo Delirium Scale (BDS) was designed to identify risk factors for hospice patients in the prodromal stage of delirium. OBJECTIVE: This study evaluated the psychometric properties of items assessing delirium risk factors related to cognitive problems, psychological distress, and sleep problems. METHODS: Hospice nursing staff assessed patients with the 11-item BDS over a 6-month period as part of standard weekly visits to monitor for emerging signs of delirium, for example, sleep patterns, cognition, and behavior. SETTING/PARTICIPANTS: The rating period produced 4992 assessments from 817 hospice home care patients. RESULTS: Factor analysis of nurses' ratings identified 3 factors: (1) cognitive problems, (2) distress, and (3) sleep problems. Coefficient αs for these factors and total score were moderate to high (range = .66-.82). Nurses' ratings of presence of delirium highly correlated with scores on distress ( r = .40, P < .01), while dementia highly correlated with cognitive problems ( r = .50, P < .01). Analysis of at-risk cases with high BDS total scores where no delirium was assessed indicated that quality sleep may mitigate delirium onset. CONCLUSION: Preliminary psychometric testing suggests BDS to be a valid and appropriate measure for hospice patients. Use of BDS may help differentiate individuals in prodromal stage of delirium versus dementia. Examination of BDS scores may help identify patients for whom sleep interventions may delay onset of or reduce the frequency of delirium.

Caregiver Self-Esteem as a Predictor of Patient Relationship Satisfaction: A Longitudinal Study.

OBJECTIVE: Longitudinal assessment of patient-caregiver relationships will determine whether caregiver self-esteem determines patient relationship satisfaction at end of life. BACKGROUND: Research on close relationships and caregiving supports the idea that informal caregivers' self-esteem may influence their relationships with their terminally ill loved ones. However, this connection has not yet been investigated longitudinally, nor has it been applied specifically to care recipients' relationship satisfaction. METHODS: A sample of 24 caregivers and 24 patients in a hospice home care program were recruited. Multiple patient and caregiver interviews were used to conduct a longitudinal study to measure fluctuations in patient health, changes in patient and caregiver relationship satisfaction, and self-esteem over a three-month period. RESULTS: An interaction between caregiver self-esteem and patient relationship satisfaction demonstrated the role that self-esteem plays between caregivers and patients enrolled in hospice care. Specifically, for patients with caregivers with low self-esteem, patient relationship satisfaction significantly decreased as the patient's physical health decreased, whereas for patients whose caregivers had high self-esteem, patient relationship satisfaction marginally increased during poorer physical health. DISCUSSION: High self-esteem may allow caregivers to overcome feelings of burden and maladaptive anticipatory grief to remain satisfied in their relationship with the patient. Caregiver self-esteem appears to play a role in fostering patient relationship satisfaction at the end of life.

End-of-Life Dreams and Visions: A Qualitative Perspective From Hospice Patients.

End-of-life dreams and visions (ELDVs) are well documented throughout history and across cultures with impact on the dying person and their loved ones having profound meaning. Published studies on ELDVs are primarily based on surveys or interviews with clinicians or families of dead persons. This study uniquely examined patient dreams and visions from their personal perspective. This article reports the qualitative findings from dreams and visions of 63 hospice patients. Inductive content analysis was used to examine the content and subjective significance of ELDVs. Six categories emerged: comforting presence, preparing to go, watching or engaging with the deceased, loved ones waiting, distressing experiences, and unfinished business.

Meaning-centered dream work with hospice patients: A pilot study.

OBJECTIVE: Hospice patients often struggle with loss of meaning, while many experience meaningful dreams. The purpose of this study was to conduct a preliminary exploration into the process and therapeutic outcomes of meaning-centered dream work with hospice patients. METHOD: A meaning-centered variation of the cognitive-experiential model of dream work (Hill, 1996; 2004) was tested with participants. This variation was influenced by the tenets of meaning-centered psychotherapy (Breitbart et al., 2012). A total of 12 dream-work sessions were conducted with 7 hospice patients (5 women), and session transcripts were analyzed using the consensual qualitative research (CQR) method (Hill, 2012). Participants also completed measures of gains from dream interpretation in terms of existential well-being and quality of life. RESULTS: Participants' dreams generally featured familiar settings and living family and friends. Reported images from dreams were usually connected to feelings, relationships, and the concerns of waking life. Participants typically interpreted their dreams as meaning that they needed to change their way of thinking, address legacy concerns, or complete unfinished business. Generally, participants developed and implemented action plans based on these interpretations, despite their physical limitations. Participants described dream-work sessions as meaningful, comforting, and helpful. High scores on a measure of gains from dream interpretation were reported, consistent with qualitative findings. No adverse effects were reported or indicated by assessments. SIGNIFICANCE OF RESULTS: Our results provided initial support for the feasibility and helpfulness of dream work in this population. Implications for counseling with the dying and directions for future research were also explored.

End-of-life dreams and visions: a longitudinal study of hospice patients' experiences.

BACKGROUND: End-of-life dreams and visions (ELDVs) have been well documented throughout history and across cultures. The impact of pre-death experiences on dying individuals and their loved ones can be profoundly meaningful. OBJECTIVE: Our aim was to quantify the frequency of dreams/visions experienced by patients nearing the end of life, examine the content and subjective significance of the dreams/visions, and explore the relationship of these factors to time/proximity to death. METHODS: This mixed-methods study surveyed patients in a hospice inpatient unit using a semi-structured interview. Sixty-six patients admitted to a hospice inpatient unit between January 2011 and July 2012 provided informed consent and participated in the study. The semi-structured interviews contained closed and open-ended questions regarding the content, frequency, and comfort/distress of dreams/visions. RESULTS: Fifty-nine participants comprised the final sample. Most participants reported experiencing at least one dream/vision. Almost half of the dreams/visions occurred while asleep, and nearly all patients indicated that they felt real. The most common dreams/visions included deceased friends/relatives and living friends/relatives. Dreams/visions featuring the deceased (friends, relatives, and animals/pets) were significantly more comforting than those of the living, living and deceased combined, and other people and experiences. As participants approached death, comforting dreams/visions of the deceased became more prevalent. CONCLUSIONS: ELDVs are commonly experienced phenomena during the dying process, characterized by a consistent sense of realism and marked emotional significance. These dreams/visions may be a profound source of potential meaning and comfort for the dying, and therefore warrant clinical attention and further research.

The impact of dreams of the deceased on bereavement: a survey of hospice caregivers.

Many recently bereaved persons experience vivid and deeply meaningful dreams featuring the presence of the deceased that may reflect and impact the process of mourning. The present study surveyed 278 bereaved persons regarding their own perspective of the relationship between dreams and the mourning process. Fifty eight percent of respondents reported dreams of their deceased loved ones, with varying levels of frequency. Most participants reported that their dreams were either pleasant or both pleasant and disturbing, and few reported purely disturbing dreams. Prevalent dream themes included pleasant past memories or experiences, the deceased free of illness, memories of the deceased's illness or time of death, the deceased in the afterlife appearing comfortable and at peace, and the deceased communicating a message. These themes overlap significantly with previous models of bereavement dream content. Sixty percent of participants felt that their dreams impacted their bereavement process. Specific effects of the dreams on bereavement processes included increased acceptance of the loved one's death, comfort, spirituality, sadness, and quality of life, among others. These results support the theory that dreams of the deceased are highly prevalent among and often deeply meaningful for the bereaved. While many counselors are uncomfortable working with dreams in psychotherapy, the present study demonstrates their therapeutic relevance to the bereaved population and emphasizes the importance for grief counselors to increase their awareness, knowledge, and skills with regards to working with dreams.

Progression of delirium in advanced illness: a multivariate model of caregiver and clinician perspectives.

BACKGROUND: Delirium is one of the most distressing and difficult to manage problems in advanced illness. Family caregivers have a unique view of the progression of delirium. OBJECTIVE: This study examined precursors to delirium from the perspective of family caregivers. DESIGN: This study utilized a two-stage concept mapping design that began with semistructured interviews with caregivers of patients suffering with delirium. The interview data was sorted and rated by clinicians prior to quantitative data analysis via multidimensional scaling (MDS) and cluster analysis. SUBJECTS/SETTINGS: The subjects were 20 family caregivers of patients with a diagnosis of delirium in a hospice inpatient unit. RESULTS: The main outcome of the study was a multidimensional model of precursors of delirium that included 99 specific items. The model included ten clusters within three general domains: Cognition, Distress, and Rest/Sleep. An exploratory analysis suggested that Rest and Sleep issues were evident to caregivers much earlier than other kinds of problems (mean=17.56 weeks prior to hospice admission, 95% CI=9.2-25.0 weeks). CONCLUSIONS: This study provides detailed insights from family caregivers about the progression of delirium. The caregiver observations were clustered by multivariate analysis to provide a map of symptom domains. The principal finding of this study is that sleep disturbance was identified by almost all family caregivers much earlier than other more commonly recognized symptoms associated with delirium. The study highlights the importance of sleep fragmentation in the temporal progression of delirium and points toward opportunities for improved measurement, prevention, and treatment.