The day before he died, my father, who over the course of several years had suffered a steadily decreasing awareness of and interest in his and others’ lives, finally appearing to no longer have an inner life, suddenly, briefly and inexplicably returned to the world. I described this here.
I’ve found out two things since then. There are many anecdotal reports about this phenomena, and there is next to no medical research, explanations, or theories about how this happens.
I can’t really imagine how researching an unexpected event could proceed. I suppose there could be people on call, like transplant teams, but then what? Would the dying person who has returned one last time to engage with the world be rushed into an MRI and subject to various medical tests? Perhaps some would agree to this, if they believed that by so doing others could be spared their suffering, and if they were asked before they lost the mental capacity to make that decision: you can see the difficulties.
I finally found one study about this subject: “Terminal Lucidity in Patients With Chronic Schizophrenia and Dementia: A Survey of the Literature” by Michael Nahm and Bruce Greyson, published in The Journal of Nervous and Mental Disease (December 2009, pp 942-944).
Below are extensive quotations from the article since for many of you, finding it for yourself may be difficult or impossible.
The unexpected return of mental clarity and memory shortly before death is a curious phenomenon that has so far not received much attention from psychiatrists or other physicians. We refer to such cases as “terminal lucidity.” The most remarkable cases involve patients who were mentally ill but seemed to recover shortly before death. Despite their potential to trigger the development of new forms of therapies and to contribute to an enhanced understanding of cognition and memory processing, terminal lucidity in mental disorders was largely ignored by psychiatrists and other physicians during the 20th century. In this article, we present results of a literature survey regarding terminal lucidity in mental disorders.. . .
After the mid-19th century, academic interest in terminal lucidity decreased. Accounts of terminal lucidity were published most often by authors interested in the philosophy of mind and brain, not necessarily physicians. Because these terminal lucidity reports mirrored the cases described earlier by physicians, we assume that they generally constitute reliable case reports.
It was not until 1975 that another detailed article on terminal lucidity was published in a medical journal, this one concerning 3 cases of chronic schizophrenia (Turetskaia and Romanenko, 1975). That article is the only publication on terminal lucidity in mental disorders we could find in medical journals during the 20th century.
Within the last few years, interest in terminal lucidity in mental disorders has increased again, as indicated in the publication of cases by Brayne et al. (2008) and by Grosso (2004), and the brief review of terminal lucidity in mentally disorders included in Kelly et al. (2007). Most of these recent cases involved terminally ill patients who suffered from severe dementia. In one study of end-of-life experiences, 70% of caregivers in a nursing home reported that during the past 5 years, they had observed patients with dementia becoming lucid a few days before death (Brayne et al., 2008). Members of another palliative care team confirmed that such incidents happen regularly, and one interviewee also reported that her own mother had dementia and could not recognize her family until her last day (Brayne et al., 2008). Similarly, a woman aged 92 who had been diagnosed with Alzheimer’s disease for 9 years and did not recognize close family members, including her son, recognized them again 24 hours before she died. Moreover, she knew how old she was and where she was, which she had not known for many years (Grosso, 2004).
Temporal Aspects of Terminal Lucidity
As far back as the early 19th century, Burdach (1826) noted that there are 2 ways in which terminal lucidity may manifest. First, the severity of mental derangement can improve slowly in conjunction with the decline of bodily vitality. The cases of schizophrenia reported by Turetskaia and Romanenko (1975) fall into this category. Second, full mental clarity can appear quite abruptly and unexpectedly shortly before death. Many of the cases involving dementia can be filed in this second category.
Table 2 shows the onset of terminal lucidity as described in the 49 case reports we were able to trace, separated into 4 clusters according to their timing. In 84% of the cases, terminal lucidity seems to occur within the last week before death, with 43% occurring within the last day of life.
. . .
From a medical perspective, terminal lucidity in patients suffering from schizophrenia and dementia is of primordial importance due to its potential to improve the mental conditions of chronic patients by a deeper understanding of the psychopathology and neuropathology involved. Yet, it is rarely if ever mentioned in scholarly books on schizophrenia or dementia and their treatment. . . .
The same applies for patients suffering from the various forms of advanced dementia. Here, it is additionally intriguing that several forms of dementia, notably Alzheimer’s disease, are largely caused by degeneration and irreversible degradation of the cerebral cortex and the hippocampus, resulting among other symptoms in confusion, disorientation, and memory loss (Wenk, 2003). It is unclear how severely demented patients can sometimes recognize their family members and remember their lives again shortly before death, suggesting that the memories in these cases had been rendered inaccessible but not entirely deleted.
We have limited our literature review to cases of terminal lucidity in mental illness that were not satisfactorily explained in medical terms. Most often, a medical explanation was not even attempted. However, some authors suggested that high fever prior to dying might induce terminal lucidity (Freidreich, 1839), a mechanism that was at one time used in a treatment for one specific mental illness.
Another article by Dr. Nahm, “Terminal Lucidity in People with Mental Illness and Other Mental Disability: An Overview and Implications for Possible Explanatory Models,” was published in the Journal of Near–Death Studies (Winter 2009), but I haven’t yet gotten a copy of it. Also, he and Dr. Peter Fenwick will be speaking on the subject of “Ordered Minds with Disordered Brains: from Evidence to Insight” at the Society for Psychical Research in London on November 27, 2010.
Dr. Greyson is Professor of Psychiatric Medicine and the Director of the Division of Perceptual Studies, University of Virginia.