May stem from confusion itself and may mean nothing at all, or may be expressions of readiness for or knowledge of impending death

May mention the need to make final arrangements:

• "You're going to need to talk to the funeral home."

• "Soon you're going to be planning my funeral."

• "Tonight I'll end."

May mention unfinished business:

• "Is there money in the bank?"

• "Did Jeffrey ever repay that loan?"

• "Who will plant the garden for me in the spring?"

• One young girl in the final stages with a brain tumor was no longer speaking but was frantically making repetitive hand motions. Her father finally recognized the motions and realized that his daughter was weaving invisible friendship bracelets, finishing them and setting them aside one after another at manic speed, as if realizing the time was drawing short for completing these "gifts" for her friends.

May make references to travel, dressing, packing, or preparing for a special event:

• "I need to have my boots cleaned and placed by my bed for my walk."

• "Keep my golf club up here on the bed. I'm going to need it when I get back up."

• "We need to hurry. I have somewhere I need to go."

• "How are we going to be able to get to the wedding?" (when no wedding is scheduled)

• "I'm going to need to have some outfits ready."

• "I'll be needing a tie."

May refer to time drawing short:

• "Come on, come on! There isn't much time left."

• "You don't understand. I won't have time to get back in to see the
  doctor."

• "I only have four more days." (Note: Patients are rarely accurate on
  the time that remains.)

May claim to see deceased friends and relatives:

• "My father was here."

• "I saw Aunt Bessie and I also saw Mom. They were here in the room. Many other people were here in the room with me."

May claim to see angels or make spiritual references:

• "She's beautiful. Can't you see the angel down by the end of the bed?"

• "They let me kneel."

May claim to see other comforting people they cannot identify:

• "How can that many people" (looking around the room) "be that quiet?"

• "Can you help me count how many people are in line?"

• "Where did the man go who was sitting in that chair earlier?"

• "Somebody told me I have to get dressed. I don't know who it was."

May be confused when questioned to provide more information

May give a teasing look and cryptic answers when questioned to tell more

Usually the patient will not find these references in any way odd or discomforting when relating them to others

Comforted by seeing familiar or reassuring faces

Excited to be reunited with loved ones who predeceased him or her

Agitated that things aren't moving along quickly enough for "the trip"

Unable to accurately convey where he or she will be going, but aware that the event is important...even exciting

Confused about what he or she needs to do in order to get ready

Uncomfortable with the idea that "it's not time yet"

Hopeful that caregivers can provide more information about "the trip"

Reassured by caregivers' assurances that things are well under control and that more information will come along soon

Very rarely are patients afraid or fearful by this stage

What is actually behind these references may be less at issue than the patient's needs or feelings in expressing them. Try to look toward how something is communicated (with concern or with relief?) rather than necessarily what is being said.

It is counterproductive to debate visions with the patient. Don't get wrapped up in fact-based responses.

Not: "Honey, there wasn't any man in that chair. I left
the room for just two minutes. Don't you think I
would have seen him if some man came in here?"

Better: "Was he a friend? Did he seem friendly? Yes? Well,
I'm glad he could sit with you for a while. Is he
someone you know? No? Well, I'm still glad he came,
and I'm glad you're happy about having a visitor."

When the patient raises anxieties about unfinished business, it is best to be reassuring that things are being handled just as he or she would like them to be. The patient can be particularly frustrated when immobile, having to entrust various duties to others who can get around. When the chore is legitimate, assign it to someone as quickly as possible and give the patient reassurances that it has been handled. When the chore stems from mere confusion and makes no real sense, simply tell the patient it's all set and there is no need for worry. White lies sent straight from the heart can be gifts of reassurance when necessary.

Family members might like to read the book Final Gifts: Understanding the Special Awareness, Needs, and Communications of the Dying even before this stage is reached. The book, by hospice workers Maggie Callanan and Patricia Kelley, has been out for some time; most good-sized library systems should stock it, or it is available through www.amazon.com (where readers gave the book a five-star rating). It is a quick read because it is broken down into individual cases. Although most of the stories are about long-term illnesses other than brain tumors, the phenomenon the authors term "near-death awareness" does seem to apply generally. Examples like those I have provided above (which are all from actual brain tumor patients) appear throughout the book. If the caregiver is afraid that the patient might see the book's title, the dust jacket of another, similar-sized book can be wrapped around this one.

If a caregiver gets the sense that the patient might like a visit from his or her priest, rabbi, or other spiritual leader, raise the question with the patient and see where it leads. If the patient is confused and conversation is difficult but one senses that such a visit would be understood and would bring comfort on some level, pursue it. If the patient has not been a regular member of a specific religious community, the hospice chaplain can serve very sensitively in this capacity and is extremely comfortable in the role of reassuring the dying and their families.