By T. Jared Bunch, MD / www.everydayhealth.com
In my medical practice there are many patients with advanced heart disease. Most of my patients are elderly and have developed their heart disease later in their life. As a physician who treats older patients with significant heart disease part of my practice involves end-of-life care and death. Regardless of the nature of my practice, I try to prevent death or postpone it as long as possible. However, over time I have come to understand death more and its’ place in our human experience.
I still can vividly remember my first patient that died. I was in my second year as a medical student and was assigned a few patients to see each day and help in their care. She was a beautiful 32 year old Native American. She had a life threatening disease due to very high blood pressure in her lungs. Unfortunately no medications were helpful in reducing the pressures in her lungs. As a consequence, the portion of her heart that pumped blood to her lungs began to fail. I remember entering her room the day she died. I remember the room, her personal blanket on the bed, and her lifeless body. I remember looking at the heart monitor above her bed that was now silent. I remember looking to my left and seeing her young grieving husband. I remember that I was unsure of what I should say and everything that came out felt awkward and misplaced. Most of all I remember the small boy that was standing on her right side holding her hand. The expression on his face is permanently embedded in my memory. Over fifteen years have passed since her death and these memories have not faded.
I have had the pleasure to be part of this human experience many times since. One aspect of the dying process I want to discuss today. It is highlighted in the following experience. A few years ago I admitted an elderly man who was dying of heart failure. His lungs had started to fill with fluid and he was having trouble breathing. We admitted him to use strong medications to remove fluid from his body and improve his breathing. When I had finished taking his medical history and performing a physical exam, he asked me to sit down. He took my hand and with teary eyes said “I am not ready to die, please don’t let me die”. He went on to say that he was old, but he still had goals and things he wanted to get done. He said he had a family that still needed him to be around. I told him that I was on his team and I would do everything possible to help him feel better and keep going. The following day he was feeling better and was able to walk around. He again asked me “You are not going to let me die are you?”. I again reassured him that our goals were the same and I was happy to see him doing better. The next morning things were different. His kidneys started to fail and we had to lower the doses of medications that were needed to remove fluid from his lungs and body. He again asked me to sit down. He again took my hand, but this time he told me something different. He said, “last night my father came, he has been dead over 20 years, and he said that he was there to help me die”. My patient said he told his father he was not ready to die. His father told him that he was scared when he died as well and his father came to help him. In a similar manner he was now there to help his son. My patient then told me that he was now ready to die. After a few days of saying good bye to his family, he slipped into a comatose state and died. He had a wonderful family here on earth that rejoiced in his life. I think he also has an amazing family that welcomed him to his new one.
These family experiences at the time of death are not rare. For the most part, these family experiences result in profound comfort and peace to the individual that is dying. I suspect most physicians and care providers that work with people at the end of life will also share this feeling. In the medical community, we try to answer such events with science and physiology. We simply tell ourselves there must be a basic biologic mechanism to explain them.
One proposed mechanism that is common is that the brain is deprived of oxygen and hallucinations occur. Different parts of the brain respond distinctly to low oxygen states. Some of the most sensitive regions of the brain to oxygen deprivation are those in which memories are stored. In the setting of low oxygen, these regions can create images. Thereby, it is plausible that low oxygen can irritate the brain and create hallucinations of deceased family members. This explanation has never made complete sense to me. If it is simply triggered hallucinations, then why are these events so common in so many diverse people? For example, I see brain injuries all the time in the form of strokes and head bleeds. People present and respond very differently to brain injury particularly when the injury is not in a small focal area of the brain. So why do so many patients relate similar detailed conversations with deceased family members and loved ones while maintaining a normal awareness to everything around them? They share similar conversations of the missions of the deceased persons that visit and that they are there specifically to be a comfort, guide, and partner to the dying individual.
Next, I have heard that a person’s background influences these experiences. For example, the dying person was a Christian and had a belief in the afterlife. Therefore preconceived beliefs influenced the dying process and these types of events. For a long time I thought about this possibility. Then I had an experience that made me doubt it. It was in the second year of my cardiology fellowship. I was caring for an Indian man who had spent his life as a physician. He was a devote Hindu. I was supervising a resident who was also of Indian heritage. He described himself as an agnostic. This resident came to me one night during our evening rounds. He said that our patient was hallucinating and he wanted to prescribe antipsychotic drugs to calm him. I went in to see this man. I asked him his name and he responded correctly. I asked him where he was and he told me the hospital and the care unit in which he resided. I asked him the date, who was the president, and about his prior career and again he answered correctly. I then asked him what he was seeing. He told me that for the past few nights his parents had come to his room. His parents had died years before in India. He told me that they were there to take him to paradise. He said that he looked forward to their visit each night and wanted to go with them. Each night they told him that it was not quite time yet. A few days later he died. I never had a chance to ask him about their last conversation and if they told him it was time for him to die. This man, as well as the resident that worked with me, were not Christian and did not have fundamental beliefs in a life after this one with family members.
Another rationale that I have heard is we develop hallucinations of family members near death because these come from stored memories that are pleasant to us. For example, in a time of stress we may envision our mother who was a source of comfort to us when we were children. This would account for similar experiences in diverse individuals when the brain is deprived of oxygen. I have had a few experiences that have made me doubt this rationale. The most interesting came from a man who was dying of chronic lung disease. His lungs had become heavily scarred with fibrosis and could no longer exchange oxygen well. I was leaving the hospital one afternoon and he asked if I would come in and talk. We ended up talking for about 3 hours. He was an extremely successful businessman and had grown to love developing and serving his employees more than growing his company. He said he always wanted to be there for his employees. He was like a father to many of his employees and had personally supported some of their children through school, paid for weddings, helped in times of crisis, etc. He told me he never had a father. His biologic father was abusive and left his mother alone when he was a small child. He said he hated his father for what he had done and as a consequence had spent his life becoming the opposite of his father. During his hospital stay he decided to enroll in hospice and start the dying process. As we made preparations for him to return to his home and die he shared on last experience with me. The night before his father had come to him. He told him he was sorry, that he loved him, and that he wanted to help him now. My patient said that he felt an overwhelming love for his father immediately and that all his hatred and anger was gone. He said he did not realize that he needed to forgive his father and that now he was completely ready to die. He died within a week of returning to his home. Our hospital put up the newspaper of his obituary that highlighted the life of a man who was defined by service and love. I have thought back upon this experience. If his brain was hallucinating and he needed comfort, then why bring up images of a person he did not know and professed to hate? To me, he mother who was his true companion in this life would have been the person that his brain would have associated with comfort and peace.
This topic came to mind because two weeks ago another patient of mine died. He was a devote Christian. He had a grown son who died of an overdose. He and his wife had mourned this death greatly and grieved over what would become of their son in the next life as they held strong beliefs about heaven. Shortly before his death, his son came to him. His son related to him that he was happy and well and had come to help his father die. This visit was of tremendous peace to my patient and his family.
Death is a great part of the human experience. Through these experiences that I shared and others, I am convinced it is an experience that we will not go through alone. I have seen many patients of all religions, races, and backgrounds receive great peace and comfort from these spiritual visits at the end of their lives. I cannot explain them fully based upon any scientific principles, but I am grateful that they occur.
If you know of similar experiences and want to share them with others as a source of comfort or strength, please add them to the comment section.