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For those who want to understand the nature of this phenomenon, there's still little to go on.

Published On October 7, 2019

CLINICAL CARE

Back From the Brink

Near-death experiences have been the domain of pseudoscience. But clinicians ignore them at their peril.

WHEN LIGHTNING STRUCK orthopedic surgeon Tony Cicoria by an outdoor pay phone, he was lucky that a nearby intensive care nurse immediately began administering CPR. He survived, but it took many years for Cicoria, who at the time in 1994 was 42 and chief of orthopedics at Chenango Memorial Hospital in Norwich, New York, to make sense of it, especially the memories between the moment the lightning stopped his heart and when it started pumping again. He recalls watching people clustered around his lifeless body and the sensation that he had morphed into a ball of energy, able to pass through walls as he looked for his children. He says he saw scenes from his life play out and felt “absolute love and peace” as he was immersed in a bluish-white light.

This was a near-death experience, or NDE, and in its wake, Cicoria’s life took a bizarre turn. He became obsessed with playing classical piano and composing music—despite consciously remembering nothing from his childhood piano lessons. He achieved some fame as a musician and performed internationally, but now considers the years he spent relentlessly pursuing his music while also working as a surgeon a “destructive element of my NDE” that ultimately cost him his marriage and time with his kids. “For a long time, I was convinced that the only reason I survived was for the music, which I pursued with a vengeance to my own detriment,” says Cicoria. These days he practices orthopedic surgery part-time in Damariscotta, Maine, and says he has finally achieved a balance between his music and the rest of his life. 

There is no precise definition of NDEs—the term is widely used to describe a conscious experience of a close brush with death, as when the heart stops beating—and the exact prevalence of such experiences is also subject to debate. NDEs may happen to about one in 10 survivors of cardiac arrest, and NDEs also occur after accidents or when people are gravely ill. Yet despite this uncertainty, there is a large body of writing on the topic, from both professionals and self-styled experts. Those who study NDEs have observed that for many, like Cicoria, the event sparks a profound psychological shift that can alter the course of careers and relationships. Accounts of those life-changing moments can also, curiously, share common elements. Many people report leaving their bodies and rushing toward a bright light or recount intense feelings of peace and review scenes from their lives. Indeed, fascination with NDEs and what they may say about the mind and an afterlife has led to a flood of books, websites and even some peer-reviewed research.

Yet for those who want to understand the nature of this phenomenon, there’s still little to go on. While some people consider an NDE an encounter of a spiritual or religious reality, neuroscientists propose that NDEs involve aspects of the brain, a supremely complex organ, that aren’t yet understood, says Brian Edlow, associate director of the Center for Neurotechnology and Neuro-recovery and director of the Laboratory for NeuroImaging of Coma and Consciousness at Massachusetts General Hospital. “The brain can create very complex realities, such as psychosis or what happens after taking a hallucinogenic drug, that are beyond our ability to comprehend today,” Edlow says. “There’s no reason to doubt that NDEs exist, but I don’t think anyone understands them well enough to have firm convictions about what is happening.”

Still, says Edlow, there is value in trying to unravel how NDEs happen. “If we can identify the brain structures or connections that are preserved and remain active in people having an NDE, perhaps we can use that resilience for other purposes—for instance, to predict who might be more likely to recover consciousness after brain injury,” he says.

The psychological impact of an NDE seems important in itself, since the mental state may carry into encounters with physicians and others who care for those who have had the experience. About one in 20 NDEs is distressing rather than uplifting, and those who experience hellish images may struggle for years to come to grips with what they’ve witnessed. Those who have positive NDEs, meanwhile, may have less anxiety about dying. Some researchers have proposed using pharmacologically induced NDEs—or even a virtual-reality NDE—as an approach to alleviate anxiety about death, or to model the life-transforming aspects of an NDE as a potential treatment for anxiety, depression and other stresses that face the living.

MOST ATTEMPTS TO EXPLAIN near-death experiences in medical terms run aground on basic facts of human physiology. The brain needs blood, oxygen and glucose constantly, and when the heart stops pumping blood, the brain shuts down in 20 seconds—which should make any conscious experience impossible. Until the heart’s rhythm is restored and normal blood flow resumes throughout the body, the chest compressions of CPR can force only 15% to 20% of normal blood flow to the brain. “That’s typically not enough to activate metabolism in the brain,” says Sam Parnia, associate professor of medicine and director of the Critical Care and Resuscitation Research Program at New York University’s Langone Medical Center.

In fact, most people who are revived by CPR can’t remember the time before their heart stopped, let alone what happened while they lacked a pulse. “As a result of resuscitation, the brain swells and memory circuits are affected by the lack of oxygen,” says Parnia, who has written extensively about the physiological effects of cardiac arrest, death and NDEs and is leading studies on the quality of brain resuscitation following cardiac arrest. “This insult to the brain causes people to lose memory for events prior to a cardiac arrest or accident and afterwards. Days of memory can be wiped out. Yet people who have near-death experiences can recall them in great detail and say they are more real than any other experiences they’ve had.”

Those who appear to be lifeless may, however, retain sufficient consciousness to register part of what’s happening during efforts to revive them, says Kevin Nelson, professor of neurology at the University of Kentucky in Lexington, who has written a book about brain function during spiritual experiences. “During resuscitation, you’re likely to have varying degrees of blood flow to the brain, which may allow consciousness to be gained and lost,” he says. “With cardiac arrhythmias, the heart alternates between pumping blood efficiently and inefficiently to the brain. It is very common during a medical crisis for consciousness to wax and wane.

“The richness of the NDE narratives demands a rich engagement of the brain that involves multiple mechanisms, not all of which we understand,” says Nelson, who notes that there is no scientific evidence that people can have an experience of anything without brain function. “NDEs must occur before cardiac arrest or after a patient has been revived,” he says. “Having an NDE and remembering it requires a functional brain.”

Another hypothesis for how NDEs might occur is that a critical mass of brain cells large enough to form a neural circuit could, theoretically, continue functioning while disconnected from other parts of the brain that have shut down while a patient is unresponsive, says MGH neurologist Edlow. Yale researchers recently demonstrated that they could restore basic cellular activity in the brains of pigs that had been dead for four hours. It’s possible that in humans, select neural networks important in conscious thought remain active for longer after the heart stops than is generally thought possible.

Others in the medical field have proposed an idea that runs counter to this current understanding of the body. Psychiatrist Bruce Greyson, who has studied NDEs for 40 years, believes that consciousness may somehow exist outside the brain and outside the body itself during an NDE. The human brain might act as a filter, giving access only to thoughts essential to survival, suggests Greyson, professor of psychiatry and neurobehavioral sciences at the University of Virginia Health System. When the brain shuts off as someone approaches death, perhaps it gains access to thoughts that until then were unavailable, Greyson says.

That idea appeals to Tony Cicoria, who for years had a running debate with eminent neurologist and author Oliver Sacks about NDEs. The late Sacks interviewed Cicoria in 2006 and featured him in a 2007 New Yorker article and in Sacks’s book, Musicophilia: Tales of Music and the Brain. After that, Sacks periodically sent Cicoria articles and explanations of how NDEs were manifestations of brain anatomy and neural circuitry under insult. But Cicoria was never convinced. “Consciousness survives death,” says Cicoria. “People who have an NDE come back with something they didn’t have before. In my case, it was music.”

NEUROLOGISTS MAY BE A long way from determining exactly what causes a near-death experience. “If someone says they went to another realm, how do you corroborate that?” Greyson says. Yet he believes that to focus on explanations of how and why NDEs happen may be asking the wrong questions. How the experiences change people is much more interesting and important, he says, and much easier to study. “Many NDEs are followed by dramatic changes in attitudes, beliefs and values, which can put a strain on relationships,” says Greyson, who has interviewed more than 1,000 people who have had NDEs and has counseled many patients struggling to come to grips with their experiences. Divorce and job shifts are common, he says. People with highly competitive careers, for example, may end them, while police officers or military personnel may decide they can no longer carry a gun. Those who have undergone what they consider religious experiences may not be able to relate to a nonspiritual spouse. “People also report being less afraid of death after an NDE, they engage more in life and may have a new sense of purpose, and they are more altruistic and humanistic,” he says.

After his NDE, Tony Cicoria took stock of his professional life and decided that “moving down the path of academia, publishing articles and organizing orthopedic spine meetings was no longer that important,” he says. “I let go of some of those things and became more empathetic and aware of people’s feelings.”

An NDE can also profoundly affect family members. After her mother’s near-death experience 27 years ago, Julie Supple decided to leave a career in real estate to train as a hospital chaplain. “I wasn’t particularly religious before my mother’s NDE, but I recognized the meaning and power of her experience,” says Supple, who is now a chaplain at MGH. “It caused me to question my priorities and was life changing for me.”

People who have distressing NDEs, however, may find them particularly difficult to incorporate in their lives. These NDEs typically involve hostile or terrifying encounters with malevolent beings, or with a vast emptiness that evokes sadness.

Some people interpret hostile or frightening NDEs as a call to change their ways, and they often become dogmatically religious, according to Greyson. Others may explain them as hallucinations, perhaps resulting from drugs they’ve been given in the hospital. Those in a third group may attempt to repress the memory of a dark NDE and often land in psychotherapy—only to have a therapist seem to dismiss the NDE and prescribe medication to quash the anxiety, says Greyson.

SEVERAL YEARS AGO A neighbor told ophthalmologist John C. Hagan III about his NDE. The neighbor explained that during exploratory surgery, a surgeon had accidently lacerated his liver, causing uncontrolled bleeding and cardiac arrest. In the next 40 minutes, the man’s heart stopped several times, requiring him to be defibrillated. After he was revived, he told his medical team what he remembered—that he had gone to heaven, seen God and talked to his deceased mother. The response from his physicians was greatly upsetting to him. “They said, ‘Don’t tell anyone about your hallucination or people will think you have brain damage,’” says Hagan.

That felt wrong to Hagan, and he resolved to learn everything he could about NDEs and to pass along his knowledge to other physicians. As the editor of Missouri Medicine, Hagan has published a series of physician-bylined articles about NDEs, and he lectures on the subject around the country in hospital grand rounds, which he says often draw standing-room-only crowds. “I’m not invited to talk to physicians about the supernatural or about heaven and hell,” he says. “Rather, I talk about NDEs as a medical syndrome that physicians need to recognize. They don’t have to buy into patients’ interpretations of what has happened to them, but they do need to understand that this is likely to be a life-changing event and that an inappropriate response can create harm.”

But talks at grand rounds are often all physicians hear about NDEs, and because these patient experiences fall outside their areas of expertise—or the comfort zone of what they’re prepared to discuss—patients who have had NDEs often are referred to a hospital chaplain.

MGH chaplain Kate Gerne recalls one referral, a patient in her eighties who was facing major surgery and who told Gerne about an NDE that had occurred 60 years earlier during childbirth—and that had taken away the patient’s fear of death. “She had felt such peace then, and she remembered the details as if it had happened yesterday,” says Gerne, who notes that it’s not unusual for patients to confide in her about long-ago NDEs that they’ve never disclosed to anyone else. “They’ve been afraid they would be considered crazy if they talked about their experiences,” she says.

Yet when patients are made to feel comfortable discussing an NDE, it may not only relieve their anxiety but also ease the grieving process of family and friends when death occurs. When chaplain Julie Supple was called to the bedside of a dying patient to provide end-of-life support to her and her family, the woman’s daughter told her about her mother’s NDE two weeks earlier after cardiac arrest. Once terrified of dying, the mother said she had experienced a place of great love where she was greeted by departed friends and family members. Although she didn’t want to leave what she perceived as heaven, the mother knew she had to return to the living to say goodbye to her family and tell them not to grieve when she died. “I told the family that the NDE was a gift that allowed their mother to replace dread of dying with peace,” says Supple. “For the daughter, losing her mother suddenly and without knowledge of her NDE would have been very different and much more painful,” she says. With her own mother, says Supple, “knowing that she was going to the beautiful place she described from her NDE and that she was at peace brought all of us comfort when she died.”

At MGH, a chaplain is paged to support the family whenever a patient undergoes resuscitation, and patients who are successfully revived will get a visit from a chaplain. Often, those patients are starting to process why they survived and what that may mean for the rest of their lives. “Many times, these patients are so sick that the medical team is focused on taking care of their medical needs,” says chaplain Erica Long. “Patients are comfortable talking to a chaplain because we offer a spiritual context and can help them create meaning and personal growth from their traumatic, life-threatening event.”

After Cicoria went public about his near-death experience, his hospital in New York would occasionally ask him to talk with patients who reported having an NDE or to terminally ill patients who were anxious about dying. Cicoria would tell those who were near death that he had visited a place of love and peace during his own NDE and he reassured those who were bewildered by an NDE that they weren’t crazy. “I told them that what they experienced was real and not their imagination,” he says.

In his New Yorker article, Oliver Sacks wrote that he had “never met another person with a story like Tony Cicoria’s,” referring to the physician’s musical talent that emerged only after he had nearly died. Sacks concluded that the lightning had somehow reorganized Cicoria’s brain: “I suspected that his brain must be very different now from what it had been before he was hit by lightning,” he wrote. Cicoria, however, declined Sacks’s offer to do a scan of his brain to see what answers it might reveal. “I knew what I knew,” he says. “I didn’t need a brain scan to tell me why my life had been dramatically altered.”

DOSSIER

Characteristics of Memories for Near-Death Experiences,” by Lauren E. Moore and Bruce Greyson, Consciousness and Cognition, May 2017. In this study of individuals who had a close brush with death, the researchers found that their NDE memories were more vivid and detailed than memories of real events.

The Spiritual Doorway in the Brain: A Neurologist's Search for the God Experience, by Kevin Nelson (Dutton/Penguin Group, 2011). Nelson relates specific stories of NDEs and offers possible neuroscientific mechanisms behind these experiences.

The Science of Near-Death Experiences, edited by John C. Hagan III (University of Missouri Press, 2017). This collection of essays by prominent NDE researchers includes accounts by physicians who have experienced NDEs and how they’ve reconciled their journeys to another realm with science.