The ending is about a loving sacrifice destroying evil. To me, it's Ellen's physical embodiment of Christ that unmakes the demonic entity of Orlock. It's like she becomes a super-crucifix.
Did the others (not just their friends, but other citizens inflicted with the Orlock-brought plague) die in vain? Yes and no. My take is that technically, yes, they would not have died if Ellen had sacrificed herself earlier. However, at the time, she was unaware or unwilling to accept that her sacrificing herself would be the only way to destroy Orlock. After attempting to resist him in other ways, she ran out of time and came to the conclusion that Von Franz does: she must die that others will live. Part of the tragedy here is how long it takes Ellen to come to terms with what her fate must be.
Orlock, in my opinion, doesn't completely willingly let himself die. He engages with Ellen because he is as strangely bewitched by her as she is by him. She has a hold on him, and by devoting herself to him for that night, he is not thinking clearly, nor is he completely in control of his faculties. He essentially gets sex drunk enough that he doesn't notice the passage of time or consider the consequences of his actions. This has to do with these two characters being bound up in each other on a spiritual level. How does that happen? Well, let me answer that by answering your question about the opening scene.
Yes, it's real. Ellen, when younger, is lonely and depressed, yearning for love. Some of this is romantic and some of this is a titillation at the dark, sexual aspects of love. In the nadir of her despair, she calls for any being to connect with, and Orlock answers. She makes a deal with a devil. Like all deals with devils, this goes horribly wrong. She is sexually assaulted and then breaks off with her demon lover. She meets Thomas, her nightmares subside, and she thinks she's in the clear. However, seeking to renew his evil lust, Orlock has been in contact with Knock and weaves his trap, bringing Thomas to his castle and setting about the events that will reunite him with Ellen.
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