OBJECTIVE: To learn more about the effect of virtual reality videos on patients' symptoms near the end of life, including which are most effective, how long the effect lasts, and which patients benefit the most. PATIENTS AND METHODS: We conducted a prospective study of 30 patients in a regional hospice and palliative care program from March 11, 2022, through July 14, 2023. Using a head-mounted display virtual reality, all participants viewed a 15-minute video of serene nature scenes with ambient sounds. Fifteen patients also participated in a second session of viewing bucket-list video clips they selected. Symptoms were measured with the revised Edmonton Symptom Assessment Scale before, immediately after, and 2 days after each experience. Participants rated their bucket-list selections by level of previous experience, strength of connection, and overall video quality. Functional status was also recorded. RESULTS: Nature scenes significantly improved total symptom scores (30% decrease, <.001), as well as scores for drowsiness, tiredness, depression, anxiety, well-being, and dyspnea. The improved scores were not sustained 2 days later. Overall, bucket-list videos did not significantly improve symptoms. Neither previous experience with an activity nor a strong connection correlated with significant improvement; however, when patients rated video quality as outstanding, scores improved (31% decrease, .03). Patients with lower functional status tended to have more symptoms beforehand and improve the most. CONCLUSION: Serene nature head-mounted display virtual reality scenes safely reduce symptoms at the end of life. Bucket-list experiences may be effective if they are high-quality. More infirm patients may benefit the most.