“ERASING DEATH” by SAM PARNIA (Part I)
Joe Tiralosi a chauffeur working in New York is feeling a little nauseated and somehow off-color. He is glad his shift has ended but as he drives home to Brooklyn and continues to sweat profusely, the feelings become unbearable. A co-worker who finds him pulled over at the corner of the Eightieth and Second Avenue in Manhattan just manages to rush him to the New York Presbyterian Hospital where he collapses in the ER with a cardiac arrest! Joe Tiralosi is dead! As this happens, Code Blue, meaning cardiac arrest, is called, and nurses and doctors come racing over from every direction placing bags of ice along his sides, under his neck and armpits and begin cardiopulmonary resuscitation (CPR). All this takes only one minute!
Seconds, then minutes pass to the steady rhythm of chest compressions, accompanied by occasional injections of adrenaline and defibrillator shocks. After 10 minutes the medical staff begins to lose hope because that has been long considered a dividing line in resuscitation science. Damage to the brain from lack of oxygen is thought to become permanent after that time.
Twenty minutes, thirty minutes, forty minutes … finally after having received thousands of chest compressions and having had his heart shocked more than a half-dozen times someone screams with excitement : “I feel a pulse, I think we have got him back.”
It is not only the pace at the beginning of “Erasing Death”, that makes it such a fascinating and gripping read. The author, Sam Parnia, is a critical care doctor and director of resuscitation research at the Stony Brook University School of Medicine, who brings many decades of experience in researching resuscitation and cognitive experience during cardiac arrest.
Parnia is researching optimal ways of caring for cardiac arrest patients and restarting their hearts so that patients can be brought back without brain damage. He offers the startling conclusion that, unlike the well accepted social perception where death is viewed as an irreversible point of no return, an irrevocable, terminal outcome, it is instead a biological process. This is because although (in the vast majority of cases) death is determined when the heart stops, a person stops breathing and the brain stops functioning (this is known as death by cardio-pulmonary criteria), today it has become evident that this state is potentially reversible for quite some time, just like a potentially treatable condition. Consequently many people could be brought back to life well past the point that has been traditionally considered the end - tens of minutes, perhaps hours after the heart has stopped beating and breathing as well as electrical activity in the brain have ceased.
REVERSING DEATH AND ADVANCES IN RESUSCITATION SCIENCE
In the first part of the book Parnia discloses facts that are not commonly known to the public, for example:
- a) after introducing readers to the current scientific-technological state of cardio-pulmonary resuscitation (CPR), he explains the recent, amazing progresses in resuscitation science enabling medical teams, employing the most advanced techniques, to resuscitate patients even hours after their hearts have stopped and they have reached the criteria for death. This is because the cells inside the body do not suddenly die after death. They go through their own process of death after a person has died. So, although the concept of an irreversible loss of vital organ function has been the hallmark of all major definitions of death, this does not coincide with the moment when death becomes truly and absolutely irreversible from a cellular perspective. The moment when the process of cell death has physiologically and biologically reached a point where no interventions today or in the future can alter it, is not well known. However studies have shown that stem cells can be obtained through biopsies of brains from cadavers hours after death.
b) The enormous variations among hospitals, in the management of cardiac arrest patients to the point that Parnia talks about a "zip code" lottery which reflects the variations in resources as well as skills of the people attempting resuscitation. Resuscitation processes that could be improved are not the exception but rather the norm, even in the Western world. For example, although induced hypothermia has been shown to increase significantly the survival rate after cardiac arrest, it is not always used and certain optimal methods are more widespread in Japan and South Korea and more rare in other nations.
When patients are resuscitated without using appropriate measures such as hypothermia (cooling of body temperature), during cardiac arrest and especially during the post-resuscitation period, they can end up with widespread brain damage, returning as a shadow of their former selves leading to enormous suffering (and huge costs). In short there are recommended medical standards, but there is little regulation and no will to implement the recommendations of international medical guidelines at the national level in most countries.
Now, this could be avoided in many cases if resuscitation protocols following accepted international guidelines (published since 2008), were implemented. Their implementation would limit brain damage hence increase the chances for patients to resume their normal lives.
It is shocking to read that survival of cardiac arrest has not improved much despite all the advances in medical knowledge since 1965 because implementation of guidelines for optimal resuscitation is not enforced.
Since cardiac arrest is the only condition that will affect every single one of us - in other words - we will all die of some cause and whatever that may be, the final step that defines our death will be cardiac arrest at some point in our lives, this part of the book is a must read, its importance is beyond argument.
ACTUAL VERSUS NEAR DEATH EXPERIENCES
The second part of the book talks about actual death experiences (ADEs) - the experiences of people who have gone beyond the threshold of death and come back. The study of these experiences is an inadvertent consequence of the resuscitation work described in the first part. As the boundaries between life and death are constantly pushed back, and more and more patients come back from cardiac arrest (death), they may report what happened when they died (1). Since these patients went beyond the threshold of death and entered the period after death, ADEs provide an indication of what we're all likely to experience during death.
Why ADE and not near death experience (NDE)? Although recognizing that the use of the NDE term (2) has undoubtedly focused greater interest on the study of the cognitive and mental experience associated with death, numerous scientific limitations and ambiguities associated with this imprecise term over the past 40 years have also created particular challenges for scientific study. ADEs is a term which the author prefers to NDEs, since it avoids lumping together experiences that take place under very different circumstances where the human body has a completely different physiology or is not even close to death (3) as it is currently the case with NDEs. Currently many experiences with different phenomenological features and characteristics are all labelled NDE's even if the experience was not related to being in a life threatening situation. Focusing exclusively on cardiac arrest patients’ ADEs (patients who have biologically died and have then been resuscitated) is important because during cardiac arrest, the body’s physiology is exactly known and has been the object of numerous studies. For instance, in the case of cardiac arrest, it is well known that the immediate cessation of blood flow that follows the heart stopping leads to the instant cessation of respiration and brain stem activity as well as whole brain function, owing to the immediate cessation of oxygen delivery to vital organs (4). As the function of the heart, lung and brain stem are exquisitely linked together, any process that leads one organ to stop functioning will inevitably lead to the cessation of activity and functioning in the other two organs.
People who've had a cardiac arrest die and their brain stops functioning within moments leading to a complete flat-lined state. There is inadequate blood getting into the brain, so the brain circuits can no longer function. Many studies have all demonstrated that after cardiac arrest, consciousness is lost immediately. Hence there should be no memories whether hallucinatory, illusory or real since, in order for someone to even hallucinate, they have to have a functioning brain (5). Even activity in the brain stem is lost which can be demonstrated by the absence of the gag-reflex and no respiratory effort. (6)
Unlike actual death experience, the term near death experience is very imprecise. It is a blanket term used for all sorts of clinical situations, besides cardiac arrest and cardiac arrest in myocardial infarction. (7)
When patients recall their experiences in relation to different illnesses or physical states, unlike in the case of cardiac arrest, one does not know what the brain state had been since the clinical conditions vary significantly. This fundamental difference has provided plenty of ammunition for scientific arguments, criticizing or disregarding data from studies since without a clear definition it's easy to be comparing apples and oranges. Another ambiguity has been claims that people's experiences must not reflect what happens when we die as they had not really died, that they were ONLY “near death” etc … Thus the term ADEs closes the ambiguity which is left when the original term NDEs is used because the population studied is not near death.
STUDIES OF ACTUAL DEATH EXPERIENCES
Parnia explains how 4 recent studies (8), (9), (10), (11) have attempted to standardize what they were studying by focusing on ADEs and by studying patients’ recollections and experiences during death by cardio-pulmonary criteria (cardiac arrest) whilst most earlier studies focused on examining the occurrence of conventional NDEs (by focusing on predetermined features such as those of the Greyson scale) and not on cognitive experiences during the wider experience of death.
The studies’ results been published in peer reviewed journals and they have all suggested that patients suffering from cardiac arrest can have lucid well structured thoughts with reasoning and memory formation, when their brains, according to current neuroscience, were not likely to be working. In one of the studies at least one patient (9) accurately reported being able to watch and recall events from his own cardiac arrest (compatible with conventional out of body experiences), and the validity of his claim were corroborated by hospital staff. This did not appear consistent with hallucinatory or illusory experiences, as the recollections were compatible with and verifiable rather than imagined events.
And here lies the crux of the matter, according to the author, since no cognitive thoughts or memories should be formed during the period of circulatory standstill since there is an immediate drop in cerebral blood flow to levels less than that required to maintain cellular activity and brain function ceases immediately. However, paradoxically these 4 prospective studies have suggested that patients have mental and cognitive experiences during their time of cardiac arrest. This has raised a need for further studies to focus on ADEs, and confirm or refute these initial findings.
……… We hope you have enjoyed this first article on Sam Parnia’s book, “Erasing Death”. If you wish to read the second part, please visit our web site (12)
(1) Cardiac arrest is synonymous with death according to the scientific community. If nothing is done to reverse an arrest then the patient “stays” dead and the brain cells die and cannot be saved. Also a patient’s mental condition (total absence of consciousness) is just the same for the patient in the first few seconds after arrest as it is a few hours after arrest if nothing is done.
(2) See Intro to the NDE Phenomena
(3) Human physiology seeks to understand the mechanisms that work to keep the human body alive, how our cells, muscles and organs work together, how they interact. Physiology spans from the study of cellular function to the whole integrated behavior of the body.
(4) Rubenstein, A., E. Cohen & E. Jackson. 2006. The Definition of Death and the Ethics of Organ Procurement from the Deceased. President’s Council on Bioethics.
(5) The neo-cortex is the area of the brain where spatial reasoning, all our experiences, sensory perceptions, our model of the world, conscious thought and language originate.
(6) Actual death is the absence of three or more internationally accepted signs: no heartbeat, no respiratory effort and no brain stem function (no gag reflex and fixed /dilated pupils which do not respond to light). The only exception to this is the relatively small group of patients who have suffered brain death following catastrophic brain injuries but whose respiratory and circulatory functions are able to be artificially maintained in spite of brain death, through life-support measures. Such patients can be declared dead on the basis on brain-death criteria, even in the presence of a heartbeat.
(7) illness, accidents, attempted suicides, shocks in postpartum loss of blood or in perioperative complications, mountain-climbing accidents, septic or anaphylactic shocks, electrocution, coma resulting from traumatic brain damage, intra-cerebral hemorrhage or cerebral infarction, near-drowning or asphyxia, apnea, serious depression …
(8) Parnia S, Waller DG, Yeates R, Fenwick P. A qualitative and quantitative study of the incidence, features and aetiology of near death experiences in cardiac arrest survivors. Resuscitation. 2001 Feb;48(2):149-56.
(9) Van Lommel P, van Wees R, Meyers V, Elfferich I. Near-death experience in survivors of cardiac arrest: a prospective study in the Netherlands. Lancet. 2001 Dec 15;358(9298):2039-45.
(10) Greyson B. Incidence and correlates of near-death experiences in a cardiac care unit. Gen Hosp Psychiatry. 2003 Jul-Aug;25(4):269-76.
(11) Janet Schwaninger, Paul R. Eisenberg, Kenneth B. Schechtman, Alan N. Weiss. A Prospective Analysis of Near-Death Experiences in Cardiac Arrest Patients. Journal of Near-Death Studies. June 2002, Volume 20, Issue 4, pp 215-232.