QJM: An International Journal of Medicine, 2017, 67–69
doi: 10.1093/qjmed/hcw185
REVIEW
Understanding the cognitive experience of death and
the near-death experience
S. Parnia
From the Resuscitation Research Group, Division of Pulmonary and Critical Care Medicine, Department of
Medicine, Stone Brook University, Stony Brook, NY, USA. email: sam.parnia@stonybrookmedicine.edu
Transcendental mystical or spiritual experiences close to death
have been described for millennia. However, following the birth
of modern intensive care medicine four decades ago, the specific
term ‘near-death experience’ (NDE) was coined.1 Current re-
search indicates that, regardless of cultural background, adults
and young children (<3 years) have described comparable experi-
ences in association with death.1 These include: feelings of im-
mense peace and love; a sensation of going through a tunnel;
seeing a bright warm welcoming light that draws the person to-
ward it; meeting a ‘being of light’; a feeling of entering a beautiful
‘heavenly’ domain; and encountering deceased relatives who are
often perceived as greeting and welcoming the individual. A re-
view of the person’s life from early childhood onward is another
commonly reported experience, as is a sense of separating from
the body and looking down from above, while observing events
during their resuscitation. This has often been referred to using
the ill-defined term of out of body experiences (OBEs).1
Much like profound mystical/spiritual or religious experiences,
these experiences are associated with long-term positive trans-
formational and psychological effects.2,3 People often report less
fear of death; a greater sense of altruism as evidenced by greater
love, empathy and responsibility towards others, increased faith
and interest in the meaning of life, and less materiality.2,3 This ef-
fect seems to predominantly reflect the impact of the experience
itself rather than having come physically close to death.2,3
In the past 40 years, some have attempted to explain the oc-
currence of NDE’s in terms of abnormal physiological brain
states. These theories largely categorize NDE’s as hallucinatory
or illusory responses to hypoxia,4 hypercarbia,5 hormone and
neurotransmitter release such as endorphins,6 serotonin,7 NMDA
receptor activation,8 activation of the temporal lobes leading to
seizures9 or limbic lobe activation10 and REM intrusion; a fre-
quent occurrence in healthy subjects.11 Alternative psychological
theories have also been postulated,12 while more recently some
Received: 14 July 2016; Revised (in revised form): 4 October 2016
C The Author 2016. Published by Oxford University Press on behalf of the Association of Physicians.
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have suggested that the so-called OBE sensation may be an illu-
sion caused by a dysfunction at the temporoparietal junction.13 It
has also been suggested that a burst of electrical activity in the
first 30 s after cardiac arrest/death by cardiopulmonary criteria
may cause NDE’s.14 By enlarge these theories categorize near
death or OBEs as being brought about by cerebral processes gone
‘awry’; as hallucinatory or illusory responses to a variety of
neurological events. Although some consider these theories to
represent a sufficient causative scientific model to explain NDE’s,
there are significant scientific and methodological factors that
limit this assumption.
One limitation is that data derived from rigorous experimen-
tal research to support a possible causal relationship or even an
association between so called NDE’s and the proposed physio-
logical intermediaries remain lacking. A second, and perhaps
more important, limitation relates to the scientific principles
that underlie the determination of reality with respect to
human experience. The observation that humans may at times
have hallucinatory experiences that may or may not loosely
share certain features with NDE’s (e.g. feeling happy or peace-
ful), after the use of drugs has led some to define NDE’s as hallu-
cinations. Yet, this is inconsistent with known scientific
principles. In particular, the notion that a hallucinatory experi-
ence occurring in response to one stimulus, implies that an-
other human experience in response to another stimulus (with
or without possible shared features) is also hallucinatory, is nei-
ther consistent with the scientific principles governing the de-
termination of reality, nor cause and effect.
A simple illustration of this point is the experience of love.
Humans may experience ‘love’ in response to a variety of
circumstances. This includes hallucinogenic drugs, alcohol in-
toxication or in the case of a mother and child relationship. It is
incorrect to assume that since hallucinogenic agents can bring
about the sensation of love, then other experiences involving
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 68 | QJM: An International Journal of Medicine, 2017, Vol. 110, No. 2
love are also hallucinatory. Similarly, one cannot assume that a
person’s love is real or hallucinatory based on the underlying
neurobiological correlates of love (e.g. dopamine, oxytocin and
vasopressin) as these are similar irrespective of whether love is
experienced in response to hallucinogenic or a real trigger.16
Thus, a hallucinatory experience does not imply that another
experience is also hallucinatory. Furthermore, adopting the
broader scientific principles underlying the determination of
reality and meaning in relation to human experience, it is clear
that until recently the categorization of these experiences (by
scientists or others) as hallucinations vs. real experiences sim-
ply reflected a given social group’s own consensus based on per-
sonal beliefs and not scientific studies.17 The principles that
underlie the determination of reality,17 while highly relevant
have typically been neglected in discussions regarding the
meaning and significance of NDE’s.
Two recent, but separate, studies have attempted to indirectly
address the issue of reality with respect to NDE’s through an
examination of memory quality.18,19 Both studies used a standar-
dized instrument designed to differentiate between imagined
events and real events, relying on the principle that memories of
imagined events have fewer phenomenological characteristics
than those of real events. Thus, to test the hypothesis that NDEs
are imagined experiences brought about by abnormal or ‘awry’
cerebral mechanisms, these studies analyzed the phenomeno-
logical characteristics of real and imagined memories. Both con-
cluded that NDE recollections are not consistent with illusory
experiences but with memories of real life events. In fact NDE’s
appeared ‘more real’ than actual real life events that were used
as controls.18,19. One study also explored brain waves during re-
call of NDEs which indicated that NDE’s were processed in a
manner similar to memories of real events.19 In this respect they
were found to be unlike hallucinations.
Limitations of the term NDEs
The term ‘near death’ was originally used to describe any situ-
ation in which a person would be likely to die without medical
intervention.1 From the perspective of modern intensive care
medicine, this definition is problematic.20 In particular the term
NDE lacks any relationship with established hemodynamic and
physiological markers of the severity of illness or physiological
proximity to death.20 Although many so-called NDE’s have been
reported by critically ill individuals; many experiences categorized
as NDE’s have also been reported from circumstances unrelated
to critical illness or death.21 The lack of specificity with respect to
the use of the term ‘near-death’ has contributed to the widely
quoted, yet inadequately validated, notion that people do not
need to be ‘near-death’ to have a NDE.21 One of the main factors
limiting standardized research into NDEs may be the term itself.
As such, it would probably be more accurate to suggest that
experiences with many shared features and interpreted as mys-
tical and spiritual by the experiencer may occur under a variety
of circumstances, including being critically ill, near death or
otherwise.20 However it is not clear whether all experiences cur-
rently labeled as NDE’s are in fact phenomenology and qualita-
tively comparable, or whether the relatively loose definition of
the term enables different experiences—such as so called posi-
tive and negative NDE’s—to be categorized together.20 This has
contributed to the fact that many experiences unrelated to death
or near-death are currently categorized as NDE’s, as are a variety
of other illusory and hallucinatory experiences. Thus, for the pur-
poses of standardized research and for gaining correct under-
standing of the actual experience of death, experiences being
researched should be related to a corresponding physiological
state that approximates death. Considering that cardiac arrest
and death by cardiopulmonary criteria are biologically synonym-
ous and represent a universal and well-studied physiological and
pathophysiological process, cardiac arrest is the most physiolo-
gically appropriate and accessible biological state for research
into the actual experience of death.20
Experiences of cardiac arrest/cardiac standstill
Only a handful of studies have examined the mental and cogni-
tive experience of cardiac arrest.2,3,15,22–24 The first demon-
strated that 6% of 63 cardiac arrest survivors reported lucid,
well-structured thought processes, together with reasoning and
memory formation compatible with the previously described
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NDE.15 No evidence to support a specific role for drugs, hypoxia,
hypercarbia, or electrolyte disturbances in association with the
experiences was found.15 Another study interviewed 344 cardiac
arrest survivors from 10 hospitals over a 2-year period. Here
12% reported experiences similar to those from the British
study,2 and at least one patient reported a sensation of separat-
ing from the body and observing the events from his own resus-
citation. Hospital staff corroborated the accuracy of his claims.2
As the recollections were compatible with real and verifiable
events this account is clearly inconsistent with a hallucinatory
or illusory experience.2 A US study of 1595 people admitted to a
cardiac unit found that experiences compatible with NDEs were
reported by 10% of cardiac arrest patients.22 A subsequent US
study found that up to 23% of cardiac arrest survivors report
NDEs, and that they had life-enhancing effects at 6 months.23
Carried out over a 4-year period, and in 15 hospitals, the
AWAreness during REsuscitation (AWARE) study included 2060
cardiac arrest subjects. This study examined the occurrence of
awareness and memories of cognitive processes during cardiac
arrest, while attempting to verify claims of awareness compat-
ible with so called OBE’s using specific tests.24 39% of 140 cardiac
arrest survivors described a perception of awareness without any
explicit recall. This observation raised the possibility that aware-
ness and consequently experiences in relation to death may be
more prevalent than had been estimated in the past. Thus, some
people may have had consciousness/awareness during cardiac
arrest, but subsequently forgotten their experiences when asked
to recall them. Although 39 subjects were too ill to continue with
the study, 101 were able to complete further questionnaires. 46%
reported memories containing seven themes. Some of these
were discordant with conventional accounts of NDEs. The seven
categories included: fear; animals/plants; a bright light; violence
 vu; seeing family;
or a feeling of being persecuted; a sense of déja
and recalling events that likely occurred after recovery from car-
diac arrest. This raised the possibility that the experience of
death may be broader than previously thought and described as
NDE’s. 9% of subjects had experiences compatible with conven-
tional NDEs and 2 individuals described ‘seeing’ and ‘hearing’ ac-
tual events related to the period of CA compatible with OBEs.
While one patient was too ill to have the accuracy of her experi-
ence verified, the other had a verifiable period of conscious
awareness lasting 3–5 min during CA/standstill. Thus, con-
scious awareness appeared to have lasted a number of minutes
into the period when the brain ordinarily stops functioning and
cortical activity ceases [reviewed in20]. As this recollection also
corresponded with real and verifiable events, it appeared incom-
patible with a hallucination or illusion.
This hypothesis generating study concluded that there may
be a wider spectrum of consciousness and awareness during

cardiac arrest than is apparent when survivors are asked to re-
call their memories through explicit recall alone.24 At one end
of the spectrum, there is no recall whilst, at the other end, 2%
exhibit full conscious awareness compatible with the recollec-
tion of real events through explicit recall. In between there is a
progression of cognitive recollections. It is unclear whether
there is a larger iceberg of memories beyond those accessible to
explicit recall alone and whether enhanced methods—such as
tests of implicit learning—may be more suited to an exploration
of the depth and spectrum of conscious awareness in relation
to death. However, as the frequency of implicit learning without
explicit recall was not specifically tested for, it was thus not
possible to determine whether a higher proportion of patients
had experienced awareness, but were subsequently unable to
recall it. Nonetheless, the study supports existing anecdotal evi-
dence, as well as the results of two other recent studies, includ-
ing one that indicated conscious awareness may occur in the
absence of brain function and that experiences in relation to
cardiac arrest may not be hallucinatory or illusory.2,25
Future directions and philosophical
implications for the study of consciousness
A number of important questions remain unanswered. These in-
clude: the significance and meaning of these experiences; their
underlying neural and physiological correlates; their longer term
life enhancing and positive psychological impact on human
lives; and the timing and relationship of reports of conscious-
ness together with cognitive and mental activity and brain states
during the physiological process of death [reviewed in20].
Given that cardiopulmonary resuscitation (CPR) is insufficient
to meet the metabolic requirements of the brain and that brain
function ceases even with CPR, and is associated with a concur-
rent slowing and absence of cortical EEG within 2–20 s [reviewed
in22], reports of consciousness during CPR—i.e. at a time when
the brain is thought to be ‘non-functional’—raise questions about
the relationship between mind and brain/body [reviewed in22].
The results of studies of consciousness during cardiac arrest have
been proposed to support the philosophical view that the mind or
consciousness is a separate entity that interacts with, but is not
produced by, the brain. Although, many more studies are needed,
at the very least, the recalled experience of death now merits fur-
ther genuine large-scale investigation without prejudice.
Conflict of interest: none declared.
Funding
Resuscitation Council (UK), Stony Brook Medical Center,
Department of Medicine Pilot Project Program Award,
Targeted Research Opportunities Grant, Stony Brook
University, American Heart Association Clinical Research
Program, New York State Empire Clinical Research
Investigator Program (ECRIP) Award.
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