The strange case of Near-Death experiences

What happens when we die? This seemingly simple question can be taken many ways. For a start, what is death? The clinical definition is: no respiration, no cardiac output, no ‘higher brain’ activity and no brain-stem reflexes (you have fixed, dilated pupils, and you cannot cough or choke—when you have, literally, coughed it). Although the definition is more of a justifiable working hypothesis than a proof of death, it seems self-evident that those in that state cannot answer the question. However, today we consider the seemingly impossible.

We have plenty of accounts of so-called near death experiences [NDEs] from the dying and the resuscitated. (Eight million or more Americans purportedly have had what are most likely to be Not Really Dead Experiences, or NRDs). They tell of a tunnel of light, with calming deceased loved ones at a bridge or cross-over point, from which they are had to return (or, in Gordon Brown’s case, no light at the end of the tunnel, a Returning officer, and an out-of-focus group telling him that the time for an election is not yet!)

Sceptics commonly dismiss the experience as the product of oxygen deficiency and a failing visual cortex producing tunnel vision, or alternatively, an over-active cortex inducing something like temporal lobe epilepsy, with uncontrolled neurone firings interpreted as suffusions of light; and the calming produced by prescribed or ‘natural’ protective opiates flooding the brain. The oxygen deficiency theory, advocated by Susan Blackmore, is as good as disproved by clinical fact. Lack of oxygen assumption is regularly encountered in emergency wards, and produces ‘acute confusion’ with no memory recall: the very opposite of an NDE, which has never been reported in those circumstances. Temporal lobe epilepsy produces distorted hallucinations, and clinical signs absent in NDE cases. It remains to be explained why brains in such disrepair should produce similar and coherent visions, experienced by the previously religiose and non-believers alike. However, I agnostically put tunnel NDE claims aside for another day.

For there is another category of reports of NDEs, which make these sorts of explanation inadequate, and seem to throw open the whole question of the nature of perception and the Mind-Body relation. Patients report viewing themselves in intensive care from a detached vantage point. They occur during cardiac arrests, and are termed Actual Death Experiences, or (I prefer) Temporary Death Experiences [TDEs]. Why?

An arresting experience

If your heart stops, within about 10 seconds your blood pressure is zero, and a scan of your brain waves will have gone flat. Exactly what this implies is contentious, but your loss of consciousness at arrest is pretty much as quick as if you had fainted. Your condition is clinically indistinguishable from that of death. You are very unlikely to come through such an attack unscathed. A UK survey in 1999 found that of 1,748 patients, only 126 survived: a rate of 7%, with only the best hospital units achieving 20%.

Induced blood circulation and pressure whilst attempting resuscitation is at best 30%, and when the heart does pick up, they are only gradually restored. Absence of brain activity during cardiac arrest surely suggests that consciousness in this state is impossible. If every brain system that constructs our world is down, we simply cannot, on any mind-brain identity or epiphenomenal theory, have fantasies, let alone a continuum of experiences. Consciousness after all but immediate resuscitation may not be regained for hours or days, and it is normally confused for some further time. Experiences occurring during the gradual return to consciousness, you would think, would be just as confused, and not generate the lucid story characteristic of TDEs.

An extraordinary anecdote

So what do they say? Here is a patient’s account of a typical TDE; it brings out issues that need to be addressed when appraising any purportedly ‘paranormal’ event: accounts naturally concentrate on the experience, and can be short on the detail a hardened sceptic might require. The man, a retired army officer of the old school, I guess in his mid-to-late 60s, reported seeing his wife visiting him in intensive care, wearing a red dress (apparently correct) that he did not recognise—from a vantage point up near the ceiling of the room. Possibly it was the unfamiliar dress that alerted him and stuck in his mind sufficiently for the episode to be remembered. He was not, I hasten to add, in the mould of the Major in Fawlty Towers. He came across as an articulate ‘no nonsense’, non-religious man, not given to feats of imagination, let alone invention. He appeared, as do most TDErs, unconfused, transparently honest, and not a self-publicist.

There are loose ends left untied, or that I missed. It wasn’t clear when he first remembered what he ‘saw’, to whom he first told of it, and whether the memory or tale changed over time. We men are notoriously ignorant or forgetful of our partner’s wardrobes. Did he describe the dress before his wife presumably produced it, or did a later sight of it prompt its identification? More importantly, the length of time he was unconscious, and the point at which his wife visited were not given. It seems he was still in coma in ‘recovery’, but there was no evidence of his medical state.

Books of anecdotes like this fired Sam Parnia, a young doctor doing postgraduate work at the University of Southampton Hospitals group, to lobby in 1996 for an extraordinary project: to place images on 150 ceiling tiles in the cardiac wards and ICU of his hospital, in the hope that some patients would report sightings of them. They were to ask all cardiac arrest patients whether they had had an NDE of some kind, enabling medical comparisons to be made between them. The idea was suggested by a longstanding believer in NDEs, Peter Fenwick, now Emeritus Professor of Neuro-psychiatry (at the Maudsley for 20 years), Senior Lecturer at the Institute of Psychiatry, Consultant Neuropsychiatrist at the Radcliffe Infirmary, Clinical Neurophysiologist at Broadmoor Hospital, and author of The Art of Dying (2008), whom I have recently heard speak very cogently on the matter. The project yielded very little directly, but generated a large number of accounts from the public, and importantly the medical professions, who felt enabled to speak on an erstwhile ‘taboo’ subject. Many of these are recorded in Parnia’s own book, What happens when we die (2008): to my mind a better and more focussed work.

Here is an account by a senior cardiologist to Dr Parnia, his junior colleague, when the project was still just an aspiration.

One night when I was on call there was a cardiac arrest call, and together with the rest of the team I ran to it. The patient was a 32 year old man. He had no pulse, wasn’t breathing and was in asystole [ie, a so-called ‘flatline’, the worst form of heart attack where the heart has no electrical activity, as well as not beating—in those cases electric shock treatment to reactivate it is pointless—and very few survive it] Chest compressions, adrenaline and atropine had no effect. We carried on for over half an hour, because he was so young, and eventually it became obvious we were not winning, and so as team leader I made the decision to stop. Before doing so, I once more checked the monitor and connections and that the patient had no pulse. We accepted that he was unfortunately dead.

I left him in the room with the nurses who were preparing his body and went outside and sat down by the nurses’ station to write in the medical records. I realised I couldn’t remember exactly how many vials of adrenaline we had given him, so about 15 minutes later I went back into the room to check. While I was there, I looked across at the patient and noticed that he has not quite so blue as when I left him ... (eventually) rather hesitantly, I checked his groin for a pulse. I couldn’t believe it! Now he had a pulse! So we had to restart resuscitation .. and eventually managed to stabilise him..

A week or so later he came back from ICU to the ward, fully recovered and without any brain damage! When I saw him later he told me that he had watched everything from above. He told me everything I had said and done, such as checking the pulse, deciding to stop resuscitation, going out of the room, coming back later, looking across at him, going over and rechecking his pulse, etc... he got all the details right. What he told me really freaked me out, and to this day I haven’t told anyone about it, because I just can’t explain it.. I know that I definitely checked the monitor, the leads, the gain [ie, that the ‘flatline’ is truly flat] as well as the pulse before stopping...

Well, what are we to make of this (apart from not relying on nurses noticing you have come back to life!)? What is claimed is not just a flicker of consciousness, but continuous observation. Parnia knew that his colleague had, curiously, no interest in NDEs; so was he having his leg pulled? Sceptics will say that the circumstances of the young man’s survival must have been recounted to him by a nurse, and he decided to wind up the cardiologist, if not give him a heart attack. (Probably the latter did not quiz the ward nurses as to what they had said, for fear of appearing foolish.)

Kids, eh

But patient fabrication doesn’t run in the case of a nine year old girl with severe kidney failure, sedated on a life-support machine, who had to be rushed from Kent by ambulance in dense traffic to Great Ormond Street. During the journey her heart stopped. The crew tried over and over to restart it without success. Within the ambulance was an American doctor, with purely the job of attending ferried patients, who insisted against the evidence that they should complete the journey, rather than divert to a local hospital and declare the child dead. Something told her, she says, to start talking to the child whilst continuing resuscitation, “even though it made no sense to me really”. They got her heart to restart just as they arrived at Gt Ormond Street, and ‘miraculously’, she survived unimpaired—survival rates are better for children. Many months later, the child revisited the hospital to thank her carers. She asked one of the nurses, “”Where is the American doctor who looked after me in the ambulance and who talked to me?” She had watched everything ‘from above’, and recalled all the details. The doctor was amazed when told, “as the child had never seen me throughout the trip”.

Parnia collected several accounts by pre-school children, and reproduces their drawings of them floating at the end of a cord and watching themselves being operated on. For example, one told his mother: “the lady came and we floated up... I was up on the ceiling and when I looked down I was lying on a bed with my arms by my sides and doctors were doing something to my chest”. A year later, the child saw a child having heart surgery on the TV programme Children’s hospital, and insisted “he had had the [bypass] machine”. “No; and how do you know, you were asleep”, said his mother. “I saw it when I floated up with the lady” was the response. Later still, the child was shown a photo of his (predeceased) grandmother, and out of the blue, said “that’s the lady ...”.

A respectable study

Consideration of TDEs went respectable and beyond anecdote in 2001 with the publication in the Lancet [358: pp2039-45] of Near-death experience in survivors of cardiac arrest: a prospective study by a Dutch cardiologist, Pim van Lommel, covering research done a decade earlier. I quote from it:

We included [all 344] patients who were successfully resuscitated in coronary care units in ten Dutch hospitals during a research period varying between hospitals from 4 months to nearly 4 years (1988-92). The research period varied because of the requirement that all consecutive patients who had undergone successful cardiopulmonary resuscitation (CPR) were included. If this standard was not met we ended research in that hospital. All patients had been clinically dead, which we established mainly by electrocardiogram records. All patients gave written informed consent. We defined clinical death as a period of unconsciousness caused by insufficient blood supply to the brain because of inadequate blood circulation, breathing, or both. If, in this situation, CPR is not started within 5-10 min, irreparable damage is done to the brain and the patient will die. We did a short standardised interview with sufficiently well patients within a few days of resuscitation. We asked whether patients recollected the period of unconsciousness, and what they recalled.

62 patients (18%) reported NDE, of whom 41 (12%) described a ‘core experience’— not very well defined, in my opinion. Curiously, van Lommel’s main puzzlement was why the experience was not universal— possibly explained, in my view, by the fact that:

234 (68%) patients were successfully resuscitated within hospital. 190 (81%) of these patients were resuscitated within 2 min of circulatory arrest, and unconsciousness lasted less than 5 min in 187 (80%). 30 patients were resuscitated during electrophysiological stimulation; these patients all underwent less than 1 min of circulatory arrest and less than 2 min of unconsciousness. Only 12 (9%) patients survived a circulatory arrest that lasted longer than 10 min. 36% (123) of all patients were unconsciousness for longer than 60 min, 37 of these patients needed artificial respiration through intubation. Intubated patients received high doses of strong sedatives and were interviewed later than other patients; most were still in a weakened physical condition at the time of first interview and 24 showed memory defects.

So, there was a preponderance of patients who were very briefly ‘dead’: inevitable given the mortality rates. One could argue that they didn’t all have time to generate an NDE; or that those that did and reported one were not totally unconscious; or non-reporters were too long gone and damaged to remember. Certainly the study does not support his observation that “if there was a physiological cause, all the patients should have had an NDE"; on which the New Scientist [14/12/ 2001] presumably based their headline to an otherwise good summary: “No medical explanation for near death experiences”.

The paper has been challenged by Dr Jason Braithwaite, Senior Research Fellow in Behavioural Brain Sciences at the University of Birmingham, in a paper for the Skeptic [vol 21, summer 2008] Towards a Cognitive Neuroscience of the Dying Brain. His main points are that levels of anoxia were not established, and that a flat EEG as measured by electrodes on the skull does not mean a cessation of all sub-cortical brain activity: deeper rooted epileptic seizures, that may produce hallucinations, may not show up.

Much has been claimed for a Swiss case, reported briefly in Nature 419 (2002): 269-270 [Blanke Stimulating illusory own-body perceptions], where electrode implants in the angular gyrus region of the brains of intractable epileptics in an attempt to find where their seizures originated, generated a report by one patient of ‘lying in bed from above’, and ‘floating near the ceiling’. At last, a first person account of what was happening at the time! But apparently she could only ‘see’ her legs and lower trunk, and it is thought this may well be what she was actually seeing from her position on the bed, but re-orientated. Of course sceptics should not rush to believe her, if they have tried to rubbish other accounts. Believers in NDEs, I think, should rejoice that, just possibly, re-orientated normal vision, with attendant somatic ‘positioning’ of self, may be induced, and that NDEs may not be confined to the END! They are not thereby shown to be an illusion, but are reinforced by an account that is not dependent on memory. But there are descriptions by casualties of scenes of accident that defy a re-orientation theory. Here is one last anecdote, by a nurse, from van Lommel’s paper:

During a night shift an ambulance brings in a 44-year-old cyanotic, comatose man into the coronary care unit. He had been found about an hour before in a meadow by passers-by.

After admission, he receives artificial respiration without intubation, while heart massage and defibrillation are also applied. When we intubate the patient, he turns out to have dentures in his mouth. I remove these upper dentures and put them onto the 'crash car'.

After about an hour and a half the patient has sufficient heart rhythm and blood pressure, but he is still ventilated and intubated, and he is still comatose. He is transferred to the intensive care unit to continue the necessary artificial respiration.

Only after more than a week do I meet again with the patient, on the cardiac ward. The moment he sees me he says: 'Oh, that nurse knows where my dentures are'— ‘you were there when I was brought into hospital and you took my dentures out of my mouth and put them onto that car, it had all these bottles on it and there was this sliding drawer underneath and there you put my teeth.'

I was amazed because I remembered this happening while the man was in deep coma and in the process of CPR. When I asked further, it appeared the man had seen himself lying in bed, that he had perceived from above how nurses and doctors had been busy with CPR. He was also able to describe correctly and in detail the small room in which he had been resuscitated ..

Such an account is still a sort of shorthand, with the implications understood by professionals, but not by laymen. (The term ‘coma’, when unqualified, is too unspecific, as it covers a behavioural scale of states lacking both awareness and wakefulness, up to bodily responsiveness to speech. NB: patients in a ‘vegetative state’ have awakened from coma, but still have not regained awareness.) Is it medically naive to ask ‘were his eyes open at any point’, or ‘were they fixed and dilated throughout?’ Could the details of the room, etc, been in his actual field of view as he was whisked in and worked upon on the trolley-bed?’ How can one possibly say? Such questions of a third party, let alone a survivor, appear ridiculous and impertinent. The implication of the child’s memory of the ‘American doctor’ talking to her, by the way, is that she heard, and not merely observed, the doctor; how else would she have identified her accent?

The ‘eyes’ have it

What then to make of it? One could say that if what they ‘see’ has the perspective and focus of relocated normal vision appropriate to the lighting conditions, and so forth, then this seems a suspicious restriction on a power if it does not rely on eyes, even though daydreams seem to be similarly restricted. Maddeningly, there is no data on the normal vision of TDErs, or the precision with which they ‘saw’— short-sightedness is common, and I certainly would not be able to make out my teeth or a target card in any detail from the ceiling without my specs. Have any claimed to see things they could not naturally see in focus at that distance? We rarely have memories of what we can’t make out (rather than the attendant frustration).

More research is needed, and it is at last happening. The weight of cases has enabled Parnia to get funds and, over the last two years or so, authority from a growing number of hospitals’ committees to undertake a larger scale attempt to verify claims to NDEs in cardiac arrest cases. The ideal was to install video cameras in the ‘target’ wards & units, but the costs, and the medical ethics of such monitoring, have been prohibitive. Instead they are going back to images at ceiling height; two sided, with only one side potentially visible from bed level. Another idea was to make the images electronic, and change, to tie down the time of the TDE. Cost, and the distracting effect, has again made this a non-runner. They have trialled portable brain monitors to measure brain activity more precisely, but there has to be a medical reason for doing so.

So, it is a work in progress. What to try to conclude, as one must? I think that we are confronted by a consistent experience, which we cannot dismiss on Humean grounds that it is miraculous, and so disproved ex hypothesi. At the very least, a sceptic must, I think, radically revise our view of normal perception. We seem forced to consider at least the possibility that some sort of unconscious recording goes on of everything within one’s field of view, that is normally integrated into consciousness, and remains laid down in a very primitive part of the brain, and available to be worked over afterwards when vital questions like ‘what happened to my teeth’ drive memory. But this probably won’t do for many cases. The world is stranger than fiction.