What Happens When People Sense Death Is Near

Sedona had a keen sense of the theatrical, guiding her family dramas like a regal choreographer. She was also a woman of immense faith who would tell anyone who'd listen that it was God who had gotten her through her 83 years. In fact, faith took up so much real estate in Sedona's soul that scarcely a sentence emerged from her meticulously painted lips that wasn't peppered with a reference to God or Jesus.

These utterances were so common that her last words didn't land with the force that they might have in someone whose daily existence was more profane. Lying back in a recliner, she raised both hands as if she were leading a praise meeting for her church. She gazed around at her assembled family, then up at the ceiling. "I'm coming, Lord. I'm coming home."

Her eyes closed; her arms fell limp beside her. Her breathing became irregular, then shallow. A minute or two later, she stopped breathing, and soon after that, her heart stopped. Five minutes after her dramatic testimony, she was dead.

She'd known. Somehow, she'd known that she was going to die. That was an impressive feat of prophecy. The best prognostic models in the world, fed the most intricate biological data, aren't that precise. And my clinical intuition, such as it is, doesn't come close. She saw the end coming before any of us did.

That was a remarkable performance but not, I think, an unusual one. People near the end of life often sense when death is close. Not infrequently, they do so before anyone else does.

When it's expressed, this feeling takes the form of gnomic phrases that are overdetermined and layered with multiple meanings. Of these, by far the most common I’ve heard is a person’s statement that she's ready to go home.

A Euphemism for Heaven

True, home in that context could mean exactly what it says. And sometimes that's all it means, particularly for a patient who has been trapped in a hospital and wants more than anything to break free. But sometimes home is a euphemism for heaven.

Other common declarations allude to God, as Sedona did, or being ready, or allusions to a journey ("I'm going." "I'm leaving." "It's time.")

Some people claim this awareness happens most of the time, but I haven't found that to be true. Perhaps one patient in 10 is closer to the mark, but then I'm relying on what patients tell me, or what their family members tell me. I'm willing to believe that my patients have a greater awareness than they bother to share with me.

However, I’m also certain that these instances seem more common than they really are because we all remember them selectively. That is, a statement about being ready might be ignored in most situations. Or at least easily forgotten. Unremarkable and therefore unremarked. But when that statement is followed in a matter of minutes by death, any words seem to be powerfully prescient. Statements like Sedona’s may appear to be more prophetic than they actually are.

How these prophecies are possible is as much a mystery as how often they happen. At least it is to me, and I've tried for years to make sense of these moments. I've found that my patients typically can't tell me why they feel that death is close. Asking why they said what they said is a dead end far more often than not.

Instead, I ask what they feel. Or, sometimes, when their gaze wanders, what they see.

What they tell me is that they feel—something. Something different, or changing, or new. One young man dying of a sarcoma told me he felt free. Another middle-aged woman dying of liver cancer said she felt like she was falling out of a plane. Both had been correct to sense something amiss, and both died within the hour.

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I don't know how we could possibly foresee our own deaths. I'm not saying it's impossible; it's just beyond my power to explain.

Signs of Impending Death

I lean on a more simplistic theory. Maybe the physiological changes near the end of life, like a drop in blood pressure, lack of oxygen, and reduced blood flow, create a sense of unease. And in that setting, it's logical for a person who knows she's dying to assume that those perturbations are a sign of impending death.

The last hours of life upend normal physiology in countless ways. Blood flow is often decreased, and oxygen is in short supply. Cells run out of energy and begin to shut down irreversibly. Ions like sodium and potassium are thrown far out of their normal narrow tolerances. And surges in catecholamines like adrenaline cause both physiological changes (elevated heart rate and blood pressure) and phenomenological alterations, such as a feeling of anxiety or jitteriness.

Those physiological changes should be more than enough to explain a sense that things are not right because they most certainly are not.

And yet, there's still plenty of mystery in that pedestrian theory. The sensation of unease is endlessly varied, or so it seems to me. A sensation of lightness or falling or flying. In one memorable moment, a woman's bemused report that she felt like she was turning into a ghost.

Source: Courtesy of Health Communications

It's hard to explain how the physiological changes that afflict us near the end of life can manifest in such wildly disparate ways. But culture and personality almost certainly play an outsized role. For Sedona, a woman whose identity was so inextricably intertwined with her relationship with God, it seems natural and even inevitable that she'd interpret those sensations as somehow divine. But how one person feels a sensation of falling, while someone else—of a similar age, gender, and with the same diagnosis—feels that she's being transformed into a ghost is beyond my meager capacity to explain.

To be honest, I’m grateful for that ambiguity. To dismiss those varied experiences as nothing more than products of catecholamine surges and decreased perfusion cheapens them, somehow. There's a scientific explanation of that, I'm certain. But within the bounds of that explanation, there's still plenty of elbow room for mystery and wonder.

Excerpted from Undiscovered Country: A Doctor's Travel Guide to the End of Life.

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