Ann. N.Y. Acad. Sci.

ISSN 0077-8923

A N N A L S O F T H E N E W Y O R K A C A D E M Y O F SC I E N C E S
Issue: Rethinking Mortality: Exploring the Boundaries between Life and Death

Death and consciousnessan overview of the mental

and cognitive experience of death
Sam Parnia
The State University of New York at Stony Brook, Stony Brook, New York

Address for correspondence: Sam Parnia, M.D., Resuscitation Research Group, State University
of New York at Stony Brook, Stony Brook Medical Center, T17-040 Health Sciences Center, Stony Brook,
NY 11794-8172. sam.parnia@stonybrookmedicine.edu

Advances in resuscitation science have indicated that, contrary to perception, death by cardiorespiratory criteria can
no longer be considered a specific moment but rather a potentially reversible process that occurs after any severe
illness or accident causes the heart, lungs, and brain to stop functioning. The resultant loss of vital signs of life
(and life processes) is used to declare a specific time of death by physicians globally. When medical attempts are
made to reverse this process, it is commonly referred to as cardiac arrest; however, when these attempts do not
succeed or when attempts are not made, it is called death by cardiorespiratory criteria. Thus, biologically speaking,
cardiac arrest and death by cardiorespiratory criteria are synonymous. While resuscitation science has provided novel
opportunities to reverse death by cardiorespiratory criteria and treat the potentially devastating consequences of the
resultant postresuscitation syndrome, it has also inadvertently provided intriguing insights into the likely mental
and cognitive experience of death. Recollections reported by millions of people in relation to death, so-called out-
of-body experiences (OBEs) or near-death experiences (NDEs), are often-discussed phenomena that are frequently
considered hallucinatory or illusory in nature; however, objective studies on these experiences are limited. To date,
many consistent themes corresponding to the likely experience of death have emerged, and studies have indicated
that the scientifically imprecise terms of NDE and OBE may not be sufficient to describe the actual experience of
death. While much remains to be discovered, the recalled experience surrounding death merits a genuine scientific
investigation without prejudice.

Keywords: death; cardiac arrest; resuscitation; death by brain death criteria; death by cardiorespiratory criteria; apop-
tosis; necrosis; postresuscitation syndrome; near-death experiences; out-of-body experiences; actual death experience;
consciousness

Introduction brain death following catastrophic brain injuries,

The questions of why people die and what happens
after death have intrigued human beings through-
out time. While, historically, the exact mode used
for the determination of death has been debated, in
general the loss of vital signs of life has for many
years signified the death of a person.1 Today, the
loss of vital signs (albeit in a more precise fashion),
namely the cessation of the heartbeat, respiration,
and brain stem function (death by cardiorespira-
tory criteria), continues to remain the standard by
which physicians declare death for the vast majority
of people.2 The only exception to this is the rel-
atively small group of patients who have suffered
doi: 10.1111/nyas.12582
Ann. N.Y. Acad. Sci. 1330 (2014) 7593 
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but whose respiratory and circulatory functions are
able to be artificially maintained in spite of brain
death through modern life-support measures.3 Such
patients can be declared dead on the basis of brain-
death criteria, even in the presence of a heartbeat.3
Death by cardiorespiratory criteria occurs when
any illness, accident, poisoning, or other event leads
to the cessation of the heartbeat (cardiac arrest).
Cardiac arrest and death by cardiorespiratory crite-
ria are thus biologically synonymous. While cardiac
arrest is the final step that defines death irrespective
of cause (aside from death by brain-death criteria),
in cases where attempts are made to medically
intervene in the ensuing pathophysiological events,
75
The mental and cognitive experience of death
the event is technically referred to as a cardiac arrest
and subsequently referred to as death, on the basis
of the assumption of the irreversible loss of life when
attempts at cardiopulmonary resuscitation (CPR)
are deemed to have failed or are stopped. Yet, from
a biological perspective, the pathophysiological
events that occur after the cessation of the heartbeat
remain the same irrespective of the terminology
used to describe it. On the other hand, for those
with a do not resuscitate request, the time of
cardiac arrest/circulatory standstill is the time used
to declare the time of death on medical charts and
death records.
Deatha reversible medical condition or
an irreversible absolute end?
Despite largely widespread philosophical and social
perceptions that view death as a philosophical point
of no return, death is, in fact, a biological process
with a specific, highly complex, and precise science
involving a cascade of hemodynamic and cellular
biological events. Physiologically, the immediate
cessation of blood flow that follows the heart stop-
ping 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 functions 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 func-
tion in the other two organs (with a resultant loss of
all vital signs of life and life processes) and death. For
instance, when a person with respiratory distress
becomes apneic without cardiac arrest, the ensuing
loss of oxygen delivery to the heart and brain causes
both organs to stop functioning, while damage
to the brain stem (e.g., after massive intracerebral
hemorrhage) causes cardiopulmonary function to
cease, as loss of brain stem reflexes lead to apnea and
cardiac arrest. Thus, throughout history, the loss of
function in any of these three vital organs, which
occurs with cardiac arrest, would mean that life
could not be restored and a person would remain
motionless, lifeless, and dead, fulfilling the social
and philosophical notion of death as an irreversible
point of no return.1 As a result, the prevalent philo-
sophical view of death that has materialized and still
permeates much of society is of a clear black and
white moment, which manifests in a multitude of
ways, ranging from the way death is depicted in the
76 Ann. N.Y. Acad. Sci. 1330 (2014) 7593 
Parnia
media and literary works to the recording of a spe-
cific time of death by physicians on patients death
records. However, the 21st-century picture of death
that has emerged through resuscitation science and
is challenging many long-held perceptions is not
so much of an absolute black and white moment
but rather a gray zone5 that may be potentially
reversible for prolonged periods of time after it has
begun.
Although for centuries, for religious and scien-
tific reasons, it had been considered impossible
or even blasphemous to attempt to reverse death,
from the 18th century onward the possibility of re-
suscitation began to be explored more seriously.6
While many differing unsuccessful methods were
attempted, during the subsequent two centuries hu-
man beings gradually acquired the skills to success-
fully overcome two of the main obstacles needed to
overcome and reverse death: the abilities to main-
tain respiration (culminating in the discovery of
positive-pressure ventilation) and to restore the
heartbeat after cardiac arrest, culminating in the de-
velopment of the modern system of CPR in 1960.7
These and other related discoveries eventually led to
the birth of the new field of resuscitation science in
the latter part of the 20th century.8
Now, more than 50 years later, greater knowledge
regarding the pathophysiological processes that ac-
company death has provided novel opportunities
to intervene medically and to reverse death, not
only in the immediate postmortem period but also
potentially for relatively prolonged periods of time
after it has occurred, while also providing intrigu-
ing new insights regarding the age-old philosophical
question of what happens to the human mind and
consciousness after death. Arguably the most signif-
icant discovery to affect 21st-century resuscitation
science has been the realization that human cells
do not become irreversibly damaged or die imme-
diately postmortem.4,9 While irreversible cell death
occurs at differing times in different organs follow-
ing anoxia in the postmortem state, brain cells, in
particular, have been shown to be more resistant
to the effects of postmortem anoxic injury than had
been realized until recently.911 In a landmark study,
Palmer et al.10 demonstrated that cadaveric human
brain biopsies obtained 7 h or longer postmortem
could yield viable neuronal stem cells. This has also
been demonstrated in many animal studies, with
some suggesting that it may be possible to culture
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Parnia
such cells up to 140 h postmortem.11 Furthermore,
it has been demonstrated that anoxic injury leads to
brain cell death through a combination of enzyme-
driven processes that are potentially amenable to
therapeutic interventions, such as apoptosis, au-
tophagocytosis, and necroptosis, rather than necro-
sis alone.1217 It may thus be feasible to potentially
alter the cellular, biochemical, and pathophysiolog-
ical processes that take place postmortem before
cell death and destruction have become irreversible
and final.12,13 This has enabled clinicians to poten-
tially reverse death after relatively prolonged periods
(rather than simply reversing critical illnesses lead-
ing to death), particularly today in circumstances
where people die in a cold environment, owing
to the fact that hypothermia can both ameliorate
enzyme-mediated cell death and any subsequent
reperfusion injury. Consequently, as resuscitation
science of the 21st century continues to evolve,
the key factor in determining whether someone
can be successfully resuscitated will likely depend
first on whether the underlying condition leading
to death is treatable, and second on whether the
highest standards of resuscitation have been im-
plemented. The second major discovery to affect
resuscitation science has been the realization that
much of the cellular damage leading to mortality
and morbidity following cardiac arrest occurs after
the return of spontaneous circulation (ROSC) fol-
lowing resuscitation, rather than solely during the
no-flow period of cardiac arrest itself.18,19 Follow-
ing ROSC, the reintroduction of blood and oxy-
gen to ischemic vital organs, including the brain,
leads to reperfusion injury with resultant oxygen
free radicalmediated neuronal cell damage.20,21 In
the brain, this problem is compounded by other
complications, including cerebral edema and distal-
vessel vasospasm, leading to a significant reduction
(<50% of baseline) in cerebral blood flow (CBF)
in the distal brain tissue that may last up to 24
72 hours.20,22 The magnitude of this secondary in-
jury process, referred to as postresuscitation syn-
drome, appears to be directly related to the mag-
nitude of the initial anoxic/ischemic event during
the no-flow state of cardiac arrest. This relation-
ship can be analogized to that of an earthquake
and a tsunami. Thus, the greater the anoxic no-
flow or low-flow period of cardiac arrest, the greater
the magnitude of secondary postresuscitation syn-
drome and resultant long-term mortality and mor-
Ann. N.Y. Acad. Sci. 1330 (2014) 7593 
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The mental and cognitive experience of death
bidity, and vice versa.a This new understanding bet-
ter explains the observations made from studies
in the 1940s1960s that indicated that permanent
brain damage is likely beyond 510 min of ischemia,
as the magnitude of the postresuscitation syndrome
leading to brain cell death in the subsequent hours
to days after ROSC grows significantly beyond that
time frame of the initial no-flow state. This ma-
jor realization has led to the birth of medical man-
agement strategies such as hypothermia and other
postresuscitation-directed therapies, aimed at tar-
geting these secondary tsunami-like injury processes
that have already been shown to improve survival
and neurological outcomes following cardiac arrest
resuscitation.2325
Irreversibility of death: the challenge
of distinguishing absolute from practical
irreversibility
From a cellular and biochemical perspective, anoxic
neuronal injury leading to cell death (unless caused
by an extreme event (such as an explosion)) is
equivalent whether attributable to a cerebrovascu-
lar accident (CVA), the inhalation of air with a low
fractional concentration of oxygen, or death by car-
diorespiratory criteria. Thus, in principle, similar
to a CVA, the postmortem state remains potentially
amenable to alteration many hours after the inciting
event, until cell death becomes permanent. While a
CVA typically leads to the cessation of blood flow to
a localized region of the brain, death by cardiorespi-
ratory criteria leads to the global cessation of blood
flow to the entire brain. As the exact time of irre-
versible cell damage and death in the postmortem
period is unknown, the key issue of when death
becomes truly and absolutely irreversible from a
cellular perspective (i.e., when the process of cell
death has physiologically and biologically reached
a point where no interventions today or in the fu-
ture can alter it), rather than irreversible in a prac-
tical sense owing to either deficiencies in medical
knowledge or inadequacies in the implementation
of the highest levels of medical care at any given
a
Although international consensus-based medical guide-
lines regarding the necessary steps required to mitigate
this injury process have been published since 2008, many
of the specific aspects of these recommendations have not
been routinely implemented.
77
The mental and cognitive experience of death
institution, remains unknown. Although the for-
mer is somewhat self-explanatory, the latter has
been highlighted in recent studies in which signif-
icant variations in long-term survival rates follow-
ing out-of-hospital cardiac arrest across the United
States have been demonstrated. These variations are
thought to reflect the impact of discrepancies in the
provision and implementation of cardiac arrest care
(rather than different geographical patient-related
characteristics).26 Under such circumstances, car-
diac arrest sufferers may be declared irreversibly
dead (based upon criteria for death by cardiorespi-
ratory criteria) and will indeed remain irreversibly
dead without necessarily having reached the point
of absolute biological and cellular irreversibility at
the time of being declared dead, and could possibly
have had a different outcome under different cir-
cumstances. In spite of this major dilemma, the con-
cept of an irreversible loss of vital organ function has
been the hallmark of all major definitions of death.
For instance, the Uniform Determination of Death
Act defines death as either the irreversible cessation
of circulatory and respiratory functions (death by
cardiorespiratory criteria) or the irreversible ces-
sation of all functions of the entire brain, including
the brain stem (death by brain-death criteria).27
Thus, while the key feature in the determination of
death, whether from the perspective of the public or
the medical profession, remains the issue of an irre-
versible end of life (i.e., irreversible loss of vital or-
gan functions), by and large when death is declared,
this does not necessarily reflect absolute irreversibil-
ity from a cellular and biological perspective. As it
still remains unknown when this point truly occurs
in the postmortem state, it may be possible to re-
verse death after prolonged periods of time. Today
much of the focus of cardiac arrest care relates to
the reduction of the initial ischemia time through
effective delivery of chest compressions,28 avoidance
of hyperventilation,29 timely defibrillation,30 opti-
mization of hemodynamics,31 and the use of extra-
corporeal membrane oxygenation.32 Efforts aimed
at reducing the impact of postresuscitation syn-
drome include the use of hypothermia and the
avoidance of further organ damage that can take
place through fever,22 seizures, hyperoxia, hypoxia,
hypercarbia, and hypocarbia,22 as well as the opti-
mization of hemodynamics focusing on adequate
cerebral perfusion pressure so as to avoid fur-
ther ischemic damage.22 Although these measures
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Parnia
have been shown to be efficacious and have largely
been recommended through international medical
guidelines, they have rarely been implemented in
their entirety, possibly owing to the lack of exter-
nal regulations regarding the provision of cardiac
arrest care. Areas of current research that may in-
fluence future resuscitation and postresuscitation
care include the use of more profound levels of
hypothermia (as opposed to mild hypothermia)33
and the use of inhibitors of apoptosis and other cell
death pathways3436 that could further expand the
boundaries considerably between reversible and ir-
reversible cell death during the postmortem period.
Although undoubtedly there will be more far-
reaching discoveries to influence the field of resus-
citation in the coming decades, one of the intrigu-
ing consequences of discoveries in this field to date,
with particular regard to the ability to reverse death
for relatively prolonged periods of time, has been
greater understanding of the likely mental and cog-
nitive experience of death.
Near-death experiences: an emerging
science of what happens after death?
Despite humankinds fascination with death, as well
as many reports of unusual experiences close to
death for millennia, the question of what happens
to the human mind and consciousness after death
has traditionally been considered largely a matter
of faith rather than a subject amenable to scien-
tific study. Reports of a close brush with death have
been found throughout history.37 While the first
systematic collection of accounts from people who
had experienced a close encounter with death was
carried out by a 19th-century Swiss geologist and
mountaineer,38 it took another century before a sci-
entific approach to the study of what happens after
death became a possibility. The birth of modern
CPR and intensive-care medicine in the 1960s en-
abled people who had reached death (by cardiores-
piratory criteria) to be resuscitated back to life and
subsequently maintained alive through life-support
measures.39 Now, more than 50 years later, while
much research has been conducted on understand-
ing the pathophysiology and treatment of cardiac
arrest and postresuscitation syndrome, a number
of studies have also shed light on the intriguing
question of what happens to the human mind and
consciousness after death.
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Parnia
Although reports of profound transcendental
mystical or spiritual experiences close to death
have been described for millennia, it was not until
15 years after the discovery of CPR in 1975 that
widespread knowledge of their existence entered the
public domain.40 Raymond Moody, an American
psychiatrist, collected and published the experiences
of 150 people who had been near death and termed
their experiences near-death experiences (NDEs).40
Moody defined near-death as a medical situation in
which a person would likely have died without med-
ical intervention.40 [Although this is a vague and
imprecise definition from the perspective of critical-
care medicine (as firstly there is no accepted physio-
logical definition of being near death, and secondly
since the use of the term near death is unrelated to
physiological parameters relating to the severity of
illness (such as the severity of hemodynamic com-
promise and shock)), nevertheless this phrase has
remained in common use to date.] Today it is un-
derstood that people with so-called NDEs may de-
scribe experiencing feelings of immense peace and
love, going through a tunnel, seeing a bright, warm,
welcoming light that draws the person toward it,
and encountering deceased relatives who are often
perceived as greeting and welcoming the individual.
Other elements include meeting a being of light,
and a life review of everything the person had expe-
rienced from early childhood onward.4043 Other el-
ements include a perception of becoming separated
from the body and observing specific events from
a vantage point above (often referred to as an out-
of-body experience (OBE)) and entering a beautiful
heavenly domain.4043 Similar experiences have
since been reported globally and across different cul-
tures, including in India and China.44,45 Although
the central features of the experience appear univer-
sal, the interpretation of the experience appears to
be influenced by personal, religious, philosophical,
or cultural views.4043
Interestingly, similar experiences have also been
described in children, often using childrens termi-
nology and during the course of play, sometimes
over many months.4650 In some cases, the experi-
ences have occurred in age groups (e.g., <3 years)
where children would not have been expected to
have developed cultural insights into concepts re-
lated to an afterlife and thus unlikely to have imag-
ined their experiences through the influence of
cultural and religious traditions.51 Two illustrative
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The mental and cognitive experience of death
childrens NDEs are presented in Table 1. Much
like profound mystical/spiritual or religious expe-
riences, NDEs have long-term positive transforma-
tional effects.40,41,52,53 People often report less fear
of death, a greater sense of altruism as evidenced
by greater love, empathy and responsibility toward
others, increased faith and interest in the meaning of
life, and less materiality.40,41,52,53 This effect seems to
predominantly reflect the impact of the NDE itself
rather than the experience of having come physically
close to death.52,53
True visions of death or fragmented
recollections of a dying brain?
Some have proposed that NDEs are likely hal-
lucinatory or illusory experiences brought about
by aberrant brain functioning close to the time
of death due to hypoxia;5456 hypercarbia;57 the
release of hormones and neurotransmitters such
as endorphins,58,59 or serotonin;60 N-methyl-d-
aspartic acid (NMDA) receptor activation;61 or ac-
tivation of the temporal lobes leading to seizures62
or limbic lobe activation.63 Other theories include
the possibility that rapid eye movement (REM)
intrusion, a frequent occurrence in healthy sub-
jects, may cause NDEs as a disorder of the arousal
system.64 Alternative psychological theories have
also been postulated,65,66 while, more recently, some
have suggested that OBEs may be illusory experi-
ences caused by a dysfunction at the temporopari-
etal junction.6769 However, in spite of these diverse
theories, the mechanisms by which the NDE occurs
and its neural correlates remain unknown.
Reality, illusions, or hallucinations?
Limitations of theories of aberrant neural
functioning
Owing, in part, to a general paucity of research in
this field, the proposed theories outlined above have
significant limitations, which may be divided into
three categories. These are (1) theoretical supposi-
tions without supporting research data (such as the
hypoxia/anoxia, NMDA, serotonin, and endorphin
theories), (2) very weak association data (such as the
hypercarbia and REM-intrusion theories), or (3) the
misuse of terms such as NDE and OBE in relation to
other phenomenologically dissimilar experiences.
With regard to the first category, while hy-
poxia has been extensively researched as part of a
wide range of medical disorders, such as asthma,
79
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Table 1. Two illustrative childrens near-death experiences (reported by their parents)

Case 1: Johns heart had stopped . . . . There was a lot of commotion . . . they were pressing on his chest and he was
lifeless and blue . . . . They put him in an ambulance and took him to hospital . . .
[After he had been discharged from hospital] one day, during the course of play, he said, Grandma, when I died, I
saw a lady. He was not yet three years old. I asked my daughter if anyone had mentioned anything to John about
him dying and she said, No, absolutely not. But over the course of the next few months he continued to talk about
his experience. It was all during the course of play and in a childs vocabulary.
He said, When I was in the doctors car the belt came undone and I was looking down from above. He also said,
When you die, it is not the end . . . a lady came to take me . . . . There were also many others, who were getting new
clothes, but not me, because I wasnt really dead. I was going to come back.
Interestingly, Johns parents noticed that he kept on drawing the same picture over and over again. As he got older, it
got more complex. When asked what the balloon was, he said, When you die you see a bright lamp and . . . are
connected by a cord.
Case 2: My son Andrew, then three and a half years old, was admitted to hospital with a heart problem . . . . He had to
undergo open heart surgery.
About two weeks after the surgery he started asking when he could go back to the beautiful sunny place with all the
flowers and animals. I said, Well go to the park in a few days when you are feeling better. No, he said, I dont
mean the park, I mean the sunny place I went to with the lady. I asked him, What lady? and he said, The lady
that floats. I told him I didnt know what he meant and that I must have forgotten where this sunny place was, and
he said, You didnt take me there, the lady came and got me. She held my hand and we floated up . . . . You were
outside when I was having my heart mended . . . . It was okay, the lady looked after me, the lady loves me, it wasnt
scary, it was lovely. Everything was bright and colourful [but] I wanted to come back to see you. I asked him,
When you came back, were you asleep or awake or dreaming? and he said, I was awake, but I was up on the
ceiling and when I looked down I was lying in a bed with my arms by my sides and doctors were doing something
to my chest. Everything was really bright and I floated back down . . .
About a year after his operation we were watching Childrens Hospital (a television program filmed in a hospital) and
a child was having heart surgery. Andrew got really excited and said, I had that machine (a bypass machine). I
said, I dont think you did. He said, Yes, I did really. But, I said, you were asleep when you had your
operation, so you wouldnt have seen any machines. He said, I know I was asleep, but I could see it when I was
looking down. I said, If you were asleep, how could you be looking down? He said, You know, I told you, when
I floated up with the lady . . . .
[One day] I showed him a photo of my mum (she had passed away) when she was my age now, and he said, Thats
her. Thats the lady.

emphysema, and acute respiratory distress syn-
drome, no association between NDEs and hypoxia
has been found. Furthermore, a hypothesis pro-
posed more than 20 years ago that hypoxia may
cause an illusion of seeing a tunnel54,55 remains
untested and unsupported by scientific studies to
date. At least one study of cardiac arrest survivors
has demonstrated no difference between oxygen lev-
els in patients with NDEs and those without,57 while
another study has demonstrated a possible inverse
relationship.70 The theories involving NMDA recep-
tor activation, serotonin, and endorphin release are
also unsupported by scientific studies at this time.
Regarding the second category of theories, al-
though one small recent study observed a possible
association between NDEs and hypercarbia,57 this
condition, much like hypoxia, has also been exten-
sively studied as part of a diverse group of medical
disorders without any association with NDEs, while
an earlier study of NDEs in cardiac arrest found no
association with hypercarbia at all.70 Similarly, the
REM-intrusion theory is based on limited data from
one small study with possible design flaws,71 which
has so far not been replicated or validated.
Regarding the third category, certain phe-
nomenologically different experiences, including

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autoscopic phenomena and optical illusions (cre-
ated in a laboratory using specially mounted cam-
eras) with little or no phenomenological features
consistent with OBEs traditionally described in re-
lation to being close to death, have also been labeled
by some investigators as OBEs.6769 Although this
most likely reflects the fact that the term OBE has
not been clearly defined scientifically, the use of this
term to describe a wider range of experiences with
little similarities has nonetheless confused the is-
sue greatly. Overall, this reflects the need for more
detailed studies of so-called OBEs and other asso-
ciated phenomena, as well as clearer and consistent
universally accepted definitions.
The final additional major limitation that applies
to all the above theories is that all human experi-
ences, irrespective of whether they occur in response
to a real event or an imagined event (including ubiq-
uitous experiences such as love, anger, and depres-
sion), are mediated by a series of different neuro-
transmitters and modulators (e.g., hormones and
neuropeptides) in multiple brain regions.72 Thus,
the discovery of the circuitry that modulates a spe-
cific human experience, such as love, does not prove
or disprove the reality of the experience. When the
circuits involved with a specific experience, such as
love, are activated in response to a real event (e.g.,
when seeing a loved one) or an illusory or hallu-
cinatory event (e.g., feeling love after using sub-
stances such as drugs), the same experience will
likely arise, as the neuromodulators involved are
the same. Consequently, there are no specific neu-
romodulators that can distinguish between experi-
ences arising in response to a real or unreal event.
Furthermore, neuromodulators such as serotonin,
while modulating a specific human experience such
as happiness and love, are also involved with mul-
tiple other experiences as well as neuronal activities
that do not lead to conscious experiences, together
with activities that are entirely nonneuronal.7274
This limits the ability to ascribe meaning to any hu-
man experience simply based on the identification
of the activity of any specific modulators. Although,
in most cases, alterations in the levels of these in-
termediaries in the brain modulate experiences in
relation to real events, in certain states their activa-
tion can also occur in response to experiences that
do not correspond to realitythat is, a hallucina-
tion or illusion. Thus, the notion that alterations
in specific modulators involved with everyday real
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The mental and cognitive experience of death
experiences can also lead to illusions or hallucina-
tions, while correct, does not prove or disprove the
reality of any specific experience, whether it be love,
NDEs, or otherwise.b In fact, the reality of any expe-
rience and the meaning associated with it is deter-
mined socially rather than neurologically.75 Reality
is determined through a social process whereby hu-
mans determine and ascribe meaning to phenom-
ena and experiences within any given culture or so-
ciety (including scientific groups and societies).c,75
Nonetheless, two separate studies have attempted
to address the issue of reality in different ways. The
first, a small study of coma survivors, attempted
to explore this question based on the principle
that memories of imagined events are distinguish-
able from memories of real events, since memories
of imagined events have fewer phenomenological
characteristics. In particular, they contain fewer per-
ceptual (i.e., visual, auditory, gustatory, and olfac-
tory sensations), temporal, and spatial details, and
emotional information.76 Thus, to test the hypoth-
esis that NDEs are imagined experiences brought
about by abnormal or awry cerebral mechanisms,
Thonard et al.76 analyzed the phenomenological
characteristics of real and imagined memories in
21 patients who had recovered from comas. The
results showed that NDE memories had more char-
acteristics associated with memories of reality (i.e.,
appeared more real) than memories of imagined
or even actual real events (P < 0.02). They con-
tained more self-referential and emotional informa-
tion and had better clarity.76 The investigators con-
cluded that NDE memories are not consistent with
imagined memories. The second study, AWAreness
during REsuscitation (AWARE), a large multicen-
ter international study, aimed to test and verify
the timing of awareness and consciousness during
b
For instance, although hallucinogenic drugs such as
ketamine, which binds to the NMDA receptor, and phen-
cyclidine (LSD), which binds to multiple receptors includ-
ing dopamine, adrenoceptors, and serotonin receptors in
the brain, can cause hallucinatory experiences, activation
of these receptors is also involved in everyday, real hu-
man experiences. Consequently, even if the precise neural
intermediaries modulating NDEs are discovered, identi-
fying the neurological changes that mediate any human
experience cannot identify or determine the reality of the
experience.
c
For a more detailed discussion, please refer to Ref. 75.
81
The mental and cognitive experience of death
cardiac arrest. Although only 2% of cardiac arrest
survivors were found to recall awareness with ex-
plicit recall compatible with so-called OBEs, in at
least one case, in which the reports of awareness were
consistent with an OBE, the recalled experience re-
lating to actual events occurring in the resuscitation
room was verified as being accurate, correct, and
consistent with real events. The investigators con-
cluded that, while a larger study is needed, in some
cases of cardiac arrest, memories of visual awareness
compatible with so called out-of-body experiences
may correspond to actual events.77
Are near-death experiences better defined
as deep religious/mystical experiences in
relation to death?
During religious and mystical experiences, people
may report profound joy and comfort, as well as
moments of insight regarding realities that had been
unknown to them, a feeling of oneness, serenity, and
a loss of the sense of space and time, all of which
have also been described as aspects of NDEs.4043,78
NDEs also share the same transformative long-term
effects described during many deep religious and
mystical experiences, which may explain the para-
doxical observation that NDEs may also occur when
people are not in life-threatening circumstances.66
Deep religious/mystical experiences occur under di-
verse circumstances, including life-threatening sit-
uations; however, after Moody labeled the mystical
experiences that occur in relation to potentially life-
threatening illnesses as NDEs, this term has contin-
ued to be used in this context. However, under non-
life-threatening circumstances, similar experiences
are typically referred to as deep religious or mystical
experiences. Nonetheless, from a phenomenolog-
ical perspective, there may be little to distinguish
between the two.4043,78
Research has elucidated the neural correlates of
religious experience, which includes connections
between almost all of the major brain structures,
including the limbic system, the cerebellum, the
temporal lobe, the prefrontal cortex, and the me-
dial parietal lobes.79,80 A conclusion, based on the
similarities between the phenomenology of conven-
tional NDEs and religious experiences, is that it is
likely that the neural correlates of NDEs may be dis-
covered to share similar pathways to deep mystical/
religious experiences.
82 Ann. N.Y. Acad. Sci. 1330 (2014) 7593 
Parnia
Temporal lobe epilepsy, religious
experience, and near-death experiences
Religious experiences have been reported in 1.3%
of epilepsy and 2.2% of temporal lobe epilepsy
(TLE) patients.81 Patients with TLE may report vivid
dream-like states, deja vu experiences, and repeated
automatisms during which they may repeat phrases,
such as God, God, God, as well as depersonaliza-
tion and fearful and anxiety-eliciting experiences.81
A proposal, based on this, is that NDEs and reli-
gious experiences may be brought about by aberrant
functioning of the brain during TLE.82 However, as
NDEs are phenomenologically quite dissimilar to
TLE characteristics, others have argued against this
theory.83
The lack of an accepted universal definition of
what constitutes a religious experience (which still
remains vague) may further explain why, in certain
circumstances, the simple mention of a religious
symbol, personality, or phrase (e.g., cross, Jesus,
or God), during certain neurological or psychiatric
disorders such as TLE or schizophrenia, has led
some to classify the experiences as religious. While
patients with neurological or psychiatric disorders
may experience visions or auditory phenomena
involving a wide range of social, cultural, national-
istic, and religious symbols (reflecting their unique
psychological background), this cannot be assumed
to affect the reality of another persons experience
involving the same images or symbols.d Similarly,
d
For instance, someone with grandiose delusions may ex-
perience being bestowed power by a higher religious
authority (such as a deity) or by a nonreligious authority
(such as the president), while people with delusional psy-
chosis may experience being told to commit an irrational
or criminal act by a person in a religious or nonreligious
position of authority, reflecting the many psychological
and social factors involved in the visual and auditory im-
agery during hallucinatory and delusional experiences.
For instance, while a delusional person may experience
seeing and hearing the president giving him/her power,
this does not imply that another person receiving power
from the president in real life is delusional or halluci-
natory. Activation of cerebral regions modulating vivid
experiences, including religious experience (e.g., the tem-
poral lobes), whether due to pathological states such as
seizures, drugs, or real experiences, are likely to lead to
a conscious experience involving feelings or imagery that
may be associated with religious experiences.
C 2014 New York Academy of Sciences.
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the assumption that all religious experience is neces-
sarily delusional or hallucinatory on the basis of the
observation that certain hallucinatory experiences
involve religious symbols may be an overly simplistic
reaction that does not take into account the neuro-
logical limitations of assigning reality and meaning
to human experience. The key scientific question
thus remains the same for NDEs and other religious
experiences: How can one distinguish between
qualitatively different experiences that may share
certain religious symbolismin particular, between
hallucinatory or delusional experiences that contain
a prominent religious symbol/imagery (such as a
schizophrenia sufferer with a vision of Jesus telling
him to hurt his wife, or a person with bipolar
disorder with grandiose delusions of being Jesus or
God)and a conventional deep religious/mystical
experience leading to greater humility, higher levels
of altruism, less fear of death, greater engagement
with family and society, and an overall positive
transformative effect? While the answer to the ques-
tion is beyond the scope of this article, it is obvious
that the answer lies beyond whether the simple
description of religious symbolism was a part of an
experience.
Ineffability: the flatland story of
near-death experiences?
People with NDEs and other deep religious and mys-
tical experiences have consistently described their
experiences as ineffable. Some think this may relate
to restrictions on their ability to express themselves
through the intermediary of the neural apparatus
and language, particularly as all inner states and
experiences must be expressed through one of a
series of discrete brain states (e.g., happiness, sad-
ness, euphoria, light, darkness, and colors) and ter-
minology that is available in language.e As a re-
sult, at times qualitatively different states may be
expressed by a series of possible states that may
or may not reflect the true qualitative nature of
the experience. For instance, experiencing seeing a
bright light may arise after looking at a light or as a
e
While certain languages have a broader array of terms
available to describe inner states and in particular mystical
and religious states, according to some scholars, certain
languages such as English may have a more limited range
of terms available for this purpose.
Ann. N.Y. Acad. Sci. 1330 (2014) 7593 
C 2014 New York Academy of Sciences.
The mental and cognitive experience of death
result of an ophthalmic disorder, a disorder of the
occipital lobe, the impact of drugs, or a deep reli-
gious and mystical experience such as occurs during
an NDE. While qualitatively different, the experi-
ences are likely to all be expressed as seeing a bright
light. Another contributing factor leading to the
issue of ineffability may relate to the human brains
and sensory organs inherent limitations with re-
spect to the ability to perceive reality. The limitations
of the five sensory organs to gather data regarding
external realities have been well documented.f How-
ever, the brain also has computational limitations,
which, while not initially obvious, become evident
when attempting to make sense of information be-
yond its usual processing capabilities. In its sim-
plest form, this may be experienced when, for in-
stance, examining visual/optical illusions (such as
an Escher drawing) or in a more complex form
when attempting to tackle realities that exist be-
yond the limits of detection of the sensory organs.g
Although some physicists believe that at least 10
dimensions exist in the universe,84 understanding
the realities that lie beyond our three-dimensional
world are not readily accessible using our three-
dimensional brain.h Even if such realities could be
theoretically perceived, as soon as someone tries to
express them to others, they will be transfigured
into the framework of a three-dimensional reality by
virtue of going through a three-dimensional brain
rather than as the reality may have existed in a fifth
or sixth dimension. This point has been explained
further by prominent modern-day physicists, such
as Lisa Randall, by reference to the characters of a
f
For instance, while the human eye is only capable of
detecting electromagnetic waves in a very specific and
narrow range (i.e., light waves only), a bees eye or a snakes
eye can detect wavelengths that lie outside the range of the
human eye. Dogs have a far more sensitive sense of smell
than humans, and so on. As a result, animals may detect
certain realities that lie beyond the capabilities of humans.
g
As an example, something that exists and emits electro-
magnetic (EM) radiation beyond the visible light range
will not ordinarily be perceived and knowable to hu-
mans unless seen with the aid of technology that can
detect the specific EM radiation outside this range.
h
For instance, the existence of fifth and sixth dimensions
and their realities is ordinarily completely unknowable
to humans, as the human brain can only perceive three-
dimensional realities.
83
The mental and cognitive experience of death
well-known 19th-century book Flatland: a Romance
of Many Dimensions.84
Although whether NDEs or deep religious or
mystical experiences reflect an external reality is un-
known, many people with these experiences have
described a belief that their experiences are real.
Many believe they have perceived a different real-
ity, or as one person stated to the author, a reality
from a different dimension. Many feel unable to
express themselves adequately, as the qualitative na-
ture of their experiences are necessarily changed and
transfigured through the limitations of the brain.
Consequently, the experiences are expressed using
terms commonly shared with other human expe-
riences, such as seeing a tunnel or a bright light,
irrespective of what may have been experienced. In
other words, while it is possible that people with
NDEs may have experienced seeing exactly what
they describe, for example, seeing a tunnel or a light,
it may also be possible that their experiences had a
different qualitative nature initially, which is then
transfigured into one of a series of available brain
states (such as seeing a tunnel) when recalled. The
answer to the question of the reality and meaning of
the experiences may not be readily available; how-
ever, it can be concluded that while science today
has not been able to prove the reality or meaning of
these experiences, it also has not disproved them.
From near-death experiences to actual
death experiences
While the use of the NDE term has undoubtedly
focused greater interest onto the study of the cog-
nitive experience associated with death, the scien-
tific limitations and ambiguities associated with this
imprecise term over the past 40 years have also cre-
ated particular challenges for scientific study. Per-
haps the most important limitation has been the
fact that there is no universally accepted physiolog-
ical definition of being near death. Consequently,
the term NDE has been used to refer to the mental
state associated with a heterogeneous and diverse
group of critical and at times noncritical medical
conditions with differing underlying pathophysi-
ological states,41,50,70 as well as experiences unre-
lated to physical illness66 that may loosely share a
religious or transcendental theme. In fact, in many
cases, phenomenologically dissimilar experiences or
experiences that only share minor similarities have
been referred to as NDEs; more ambiguous terms
84 Ann. N.Y. Acad. Sci. 1330 (2014) 7593 
Parnia
have been used, such as negative NDEs, or NDE
when the person is not near death. The practice
of comparing mental states and physiological pro-
cesses that are different or occur under widely dif-
ferent pathophysiological conditions has undoubt-
edly contributed to much of the scientific debate,
simply as a result of the likelihood of comparing
apples and oranges (as has also occurred with the
use of the term OBE). Undoubtedly, as the patho-
physiology of so-called near-death conditions, such
as acute myocardial infarction, is likely to be quite
different from other conditions, such as meningitis,
severe pneumonia, or hemorrhagic shock following
a car accident, then so too will be the cytokine and
hormonal changes affecting the brain in response
to these conditions. Consequently, it is scientifically
quite difficult to compare experiences under such
diverse conditions simply based on the notion of
being near death, particularly in view of the fact
that this commonly used term is not even related to
whether patients were in a state of hemodynamic
compromise and shock, which most critical-care
physicians would take as an indicator of whether
someones life has been threatened. Moreover, expe-
riences that would ordinarily be considered pleas-
ant, together with others that may be considered
frightening, may have contributed to the notions of
heavenly or hellish experiences, even though it
is unclear what the specific pathophysiological pro-
cesses that underlie such experiences had been.
Considering that the final common biological
pathway to death is cardiac arrest, with a well-
described universal pathophysiology irrespective of
the cause of death, it would perhaps be more precise
to concentrate on the specific mental and cogni-
tive state of cardiac arrest for a more accurate and
scientific study of the mental experience of death.
Experiences occurring at the time of cardiac arrest
would be more appropriately termed an actual death
experience (ADE) and could be distinguished from
the ambiguous use of the terms NDE and OBE.
The study of death and consciousness
during cardiac arrest in the 21st century:
implications for understanding what
happens when we die
To date, only a handful of prospective studies have
examined the mental and cognitive experience of
undergoing cardiac arrest.52,70,77,8587 Most early
studies focused on examining the occurrence of
C 2014 New York Academy of Sciences.
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conventional NDEs in cardiac arrest.52,70,77,8587 The
first published prospective study to identify NDE ac-
counts in cardiac arrest survivors was a small 1-year
British study published in 2001 that demonstrated
that 6% of 63 cardiac arrest survivors reported
having lucid, well-structured thought processes,
together with reasoning and memory formation.70
The authors found no evidence to support a specific
role for drugs, hypoxia, hypercarbia, or electrolyte
disturbances in the causation of the experiences. In
a larger Dutch study published in the same year, 344
cardiac arrest survivors from 10 hospitals were inter-
viewed over a 2-year period, and 41 (12%) reported
similar experiences to those from the British study.52
At least one patient accurately reported being able
to watch and recall events from his own cardiac ar-
rest (compatible with a conventional OBE), and the
validity of his claims were corroborated by hospital
staff. This did not appear consistent with halluci-
natory or illusory experiences, as the recollections
were compatible with real and verifiable rather than
imagined events.52 A U.S. study of 1595 people ad-
mitted to a cardiac unit found that NDEs were re-
ported by 10% of patients following cardiac arrest.86
A subsequent U.S. study found that up to 23% of
cardiac arrest survivors may report NDEs, and the
experience contributed to positive transformations
and life-enhancing effects at 6 months.87
The recent AWARE study, carried out over a
4-year period across 15 hospitals between 2008 and
2012, examined the occurrence of awareness and
memories of cognitive processes during cardiac ar-
rest while attempting to objectively verify potential
claims of awareness using specific tests.77 Among
2060 cardiac arrest events, 101 of 140 survivors were
able to complete the questionnaires, with 46% re-
porting memories containing seven major cognitive
themes that were incompatible with conventional
NDEs: fear, animals/plants, a bright light, violence
or a feeling of being persecuted, deja vu experi-
ences, seeing family, and recalling events that likely
occurred after recovery from cardiac arrest. A fur-
ther 9% had experiences compatible with conven-
tional NDEs, and 2% (n = 2) described awareness,
with explicit recall of seeing and hearing actual
events related to the period of cardiac arrest (com-
patible with so-called conventional OBEs). While
one patient was too ill to have the accuracy of her
experience verified, the other patient had a verifi-
able period of conscious awareness lasting approx-
Ann. N.Y. Acad. Sci. 1330 (2014) 7593 
C 2014 New York Academy of Sciences.
The mental and cognitive experience of death
imately 3 min during a specific period of cardiac
arrest. In particular, conscious awareness appeared
to have taken place beyond the first 2030 s after the
heart had stopped (when some residual brain elec-
trical activity may occur) and had lasted a number
of minutes into the period when the brain ordinar-
ily stops functioning and cortical activity becomes
isoelectric.77,88 The study concluded that cardiac ar-
rest survivors experience a broad range of cognitive
themes (aside from those compatible with conven-
tional NDEs) that relate to the period of circulatory
standstill as well as the postresuscitation period. Al-
though 2% reported full awareness with explicit re-
call, the frequency of implicit learning without ex-
plicit recall was not specifically tested, and it was thus
not possible to determine whether a higher propor-
tion of patients had experienced awareness but were
subsequently unable to recall it. Nonetheless, the
study supported the many anecdotal reports to date
as well as the results of two other recent studies dur-
ing cardiac arrest and deep hypothermic circulatory
arrest that indicated that conscious awareness may
paradoxically occur at a time when brain function
ceases.52,70,105 The individual verified report of vi-
sual and auditory awareness (referred to sometimes
as an OBE) during cardiac arrest was not typically
consistent with a hallucination, illusion, or imagi-
nary experience, but instead corroborated with ac-
tual and real events.77 This study indicated that it
may be beneficial to focus future research on the
mental state of cardiac arrest, which may be more
accurately referred to as an ADE, particularly as pa-
tients in cardiac arrest are technically not near death
but have biologically gone through various stages of
the process of death itself.77
Potential implications of the study of the
mental and cognitive experience of cardiac
arrest for the science of consciousness
During circulatory standstill, brain function ceases
immediately, as there is an immediate drop in
CBF to levels less than that required to main-
tain cellular metabolic activity before CBF ceases
completely within a few seconds.88,89 The initia-
tion of CPR typically cannot meet the metabolic
requirements of the brain, resulting in a loss of
brain function and evidenced clinically by the
immediate loss of brain stem reflexes as well
as consciousness.90,91 Concurrent EEG monitor-
ing has also confirmed the concomitant loss of
85
The mental and cognitive experience of death
cortical function.9298 The loss of CBF initially man-
ifests as a slowing of the EEG that progresses to an
isoelectric (flat) line within 220 s and remains flat
in spite of attempts at CPR at least until after the re-
sumption of the heartbeat.95 In cases of prolonged
cardiac arrest, however, EEG activity may not return
for many tens of minutes or hours after the heart-
beat has been restored (or never, depending on the
extent of the cerebral insult).97 Interestingly, two re-
cent studies, one carried out in animals and the other
in humans, both observed a brief surge of electrical
activity within the first 30 s after cardiac standstill,
which some have speculated may reflect the occur-
rence of NDEs.99,100 However, while it is not known
whether anyone had such an experience (as no one
survived to recall their experiences and animals are
not known to have NDEs), it is far more likely that
the observed spike reflected the intracellular influx
of calcium at around 30 s after anoxic brain injury,
rather than an actual cognitive experience such as
an NDE.101 While certain deep coma states occur-
ring in noncardiac arrest circumstances may lead to
a selective absence of cortical electrical activity in
the presence of deeper brain activity,102 this is un-
likely during cardiac arrest, as this condition is as-
sociated with global cerebral hypoperfusion rather
than selective cortical hypoperfusion. Furthermore,
as expected, pathophysiological processes resulting
from the loss of cerebral perfusion show that loss
of cortical EEG activity during cardiac arrest corre-
lates with loss of activity of deep brain structures as
measured by in-dwelling electrodes.103
The accumulating reports of conscious awareness
and, in particular, lucid, well-structured cognitive
processes, including attention and memory recall
of specific events at a time when cerebral func-
tion is severely impaired or absent during cardiac
arrest, raises a number of interesting and perplex-
ing questions, particularly as cerebral localization
studies have indicated that cognitive processes are
mediated through the activation of multiple corti-
cal regions. Therefore, a globally disordered brain
including a nonfunctioning cortex should not sup-
port lucid thought processes and memory recall.
Furthermore, even relatively minor reductions in
CBF lead to confusional states and impaired atten-
tion followed by loss of consciousness, rather than
lucid thought processes, attention, and memory that
are ordinarily reserved for a normally functioning
brain.104 The experiences reported are clearly not
86 Ann. N.Y. Acad. Sci. 1330 (2014) 7593 
Parnia
confusional and are reported to occur at a time
when consciousness and memory formation should
not be possible in relation to the underlying levels
of cerebral activity and CBF.88 Alternatively, it has
been proposed that the experiences may occur ei-
ther before the brain shuts down completely or just
after recovery from cardiac arrest, when brain func-
tion resumes. While the AWARE study indicated
that certain memories may occur after brain func-
tion has resumed, it also provided some support
for the many anecdotal reports, as well as findings
from two recent studies regarding patients claims
of conscious awareness and recall of specific details
relating to the period of cardiac standstill when the
brain does not ordinarily function.i These results
suggest that, for memory to take place, conscious-
ness would need to have been present during the
actual period of cardiac standstill itself, rather than
before cardiac standstill or after recovery from car-
diac standstill. Thus, within a model of conscious-
ness that assumes a causative relationship between
cortical activity and consciousness, the occurrence
of mental processes, memory, and the ability to ac-
curately describe events when cerebral function is
ordinarily absent or at best severely impaired is per-
plexing and suggests alternative mechanisms may
need to be considered.106
Although science has yet to discover the na-
ture of human consciousness, overall, two broad
mechanisms have been proposed to account for
this phenomenon. It is thought that consciousness
may be the product of either a down-up phe-
nomenon, that is, consciousness or psyche (self
or soul) is a by-product of brain cell activityan
epiphenomenonarising from the coordinated ac-
tivities of cerebral regions; or a top-down phe-
nomenon, that is, consciousness is a separate entity
that, while undiscovered by science today, is not
i
In the AWARE study, a 57-year-old man described the
perception of observing events from the top corner of the
room, and continued to experience a sensation of look-
ing down from above. He accurately described people,
sounds, and activities from his resuscitation. His med-
ical records corroborated his accounts and specifically
supported his descriptions and the use of an automated
external defibrillator (AED). Current AED algorithms
show that this likely corresponded with up to 3 min of
conscious awareness during cardiopulmonary arrest and
CPR.77
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Parnia
produced by conventional brain cell activities and
can itself independently modulate brain activity.88
While further studies are needed, the finding that
the human mind, consciousness, or psyche (self)
may continue to function when brain function
has ceased during the early period after death has
raised the possibility that the latter may have to be
considered.88,106
Toward an understanding of the cognitive
and mental experience of death
Despite traditionally diverse opinions regarding
what happens after death, one of the most signifi-
cant consequences of research into the brain, mind,
and consciousness after cardiac arrest/standstill has
been to provide humankind with a framework for
an objective scientific approach to this subject for
the first time in history.
Although further comprehensive studies are
needed to more fully delineate the phenomeno-
logical and qualitative nature of the experience of
death, the cognitive themes that have emerged so
far have provided intriguing insights regarding the
likely experience of death. An examination of over
200 self-reported ADEs and NDEs compiled from
nonsuicide patients were analyzed for themes cor-
responding to the likely experience of death by the
author. From this analysis, 20 themes were iden-
tified, which have been summarized in Table 2.
These descriptions suggest the mental experience
of death in nonsuicide cases may be associated
with a sense of comfort, joy, and a feeling of light-
ness. Unlike experiences that occur in relation to
known self-perceptual illusions such as autoscopy
(where the individual typically observes a replica of
him/herself)107 during conventional so-called OBEs
in relation to death, the phenomenological expe-
rience differs, as people do not describe seeing a
double, but instead perceive the self as separate
from the body while observing the body and other
events from above.4043 Furthermore, under these
circumstances, people perceive the self as a com-
pletely separate entity from the body, which is shed
from the self, much like a piece of clothing or skin
(analogous to a molting animal). Some have further
described a perception that the body is connected
to the self through a cord, which if disconnected
signifies permanent death of the body. There is a per-
ception of being welcomed and greeted by deceased
relatives, or in some cases a luminous being of light.
Ann. N.Y. Acad. Sci. 1330 (2014) 7593 
C 2014 New York Academy of Sciences.
The mental and cognitive experience of death
Communication is typically perceived as nonver-
bal and instead occurs through thoughts (much like
dreams in which communication typically occurs
without the mouthing of words), and there is a gen-
eral sense that benevolence permeates everything.
Overall, the experience is perceived as an educa-
tional process whereby each person judges his/her
own actions and intentions, which are perceived to
have been recorded in his/her own self. This may
occur while accompanied by a being of light, who is
often described as compassionate, perfect, and a
benevolent educator. Consequently, the individual
judges each of his/her own actions and intentions,
and there is a general perception that no actions or
intentions remain hidden. People often report re-
viewing all their actions and intentions from early
childhood onward and perceive experiencing the ex-
act same feelings and/or pain that their actions or
intentions may have caused others. Although these
feelings may be quite uncomfortable and feel like
being in hell, the being of light may intercede
and try to ease the persons discomfort while help-
ing him/her better understand his/her mistakes. The
being of light is described as having a kind and com-
passionate personality, often with other characteris-
tics such as humor, while displaying understanding
regarding human beings and their errors. During
the experience, there may be a gradual realization
of entering a new domain. At times, there may be a
perception of learning about certain specific events
that had not been known before the encounter with
death. A different value system centered on selfless
rather than self-centered actions is perceived to exist,
compared to the prevalent value system experienced
in life that largely focuses on personal gain and ben-
efit. Consequently, many perceive a deeper purpose
to life and that altruism (i.e., actions carried out
with the intention of helping others without self-
interest), including, in particular, seemingly ordi-
nary day-to-day actions and interactions, has great
value when carried out with a purely humanitar-
ian intention. This may explain why, after recovery,
many survivors often believe they have been given
a second chance to lead their lives differently and
more correctly in accordance with this alterna-
tive value system. This may also explain the positive
transformation that many experience, which leads
to a greater interest in helping family and others.
Many lose their fear of death and develop a strong
belief that their experience provides an indication
87
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Table 2. Major cognitive themes perceived and recalled by patients with NDEs and ADEs

1. Sense of joy, comfort, and peace

I was very happy, very peaceful
2. Perception that the self is separate from the body
my consciousness left my body at light-speed
3. Going through a tunnel
There was a large tunnel.
I remember going down a tunnel.
4. Seeing a bright warm welcoming light
The light was so beautiful. I had never seen such a light before and never felt such peace.
5. Perception of looking down and seeing the body/events
I was high on the ceiling of the ward looking down upon the bed and saw the doctors and nurses working on
the person lying there.
During the operation I was floating around the operating theatre. I could see the surgeon and nurses working
on my body . . . I could also hear their conversations.
I looked down and could see Dr. G., . . . I saw him run round the bottom end of the delivery bed . . . he must
have forgotten a bucket was there because I saw him kick it in his haste to get round the other side and he
kicked this bucket and it knocked into a trolley with all the instruments on, bowls etc. . . . you could see things
falling off it and then came round to me on my left side and I saw him thumping on my chest, thumping and
thumping . . . .
6. Loss of fear
I did not feel frightened or threatened.
went to the place where I reminded myself there was nothing to fear.
7. The perception of shedding the body
I remember thinking, so this is dying, I never thought it would be so easy. It was like taking off your coat . . . .
8. Perception of being connected by a cord
I could see I was attached to a thin line, a sort of lifeline.
I suddenly found myself standing beside myself looking at a cord which connected me to my body and
thinking how thin and wispy it was.
9. Meeting a being of light
Someone was beside me. I was made to feel secure and encouraged to trust my companion
a beautiful experience . . . to be in the presence of such unconditional love, humor . . . understanding
[His] compassion was so strong, his love and caring so abundant
I found there was a being beside me. I could feel his presence. It was a comforting presence, a reassuring
presence, but was also a presence of magnitude and power
10. Greeted/helped by deceased loved ones or beings in light form
I saw all the relatives who had passed on.
My brother appeared with his usual smile and I called to him. Hi Monty. He had died six months earlier of a
heart attack.
My husband and father (both had previously died) came towards me.
I was met by other beings of light.
In reference of a childs NDE [after the surgery] he started asking when he could go back to the beautiful
sunny place with all the flowers and animals. I said, Well go to the park in a few days when you are feeling
better. No, he said, I dont mean the park, I mean the sunny place I went to with the lady. I asked him,
What lady? and he said, The lady that floats . . . You didnt take me there, the lady came and got me. She
held my hand and we floated up . . . [One day] I showed him a photo of my mum (she had passed away)
when she was my age now, and he said, Thats her. Thats the lady.
11. Nonverbal communication
I did not need to speakthoughts were sufficient.
Continued

88 Ann. N.Y. Acad. Sci. 1330 (2014) 7593 

C 2014 New York Academy of Sciences.
Parnia The mental and cognitive experience of death

Table 2. Continued

12. Benevolence
His radiance was everywhere. To this day I still look back with elation at this experience.
13. Judgment process/educational process
My actions were not judged by others, I judged myself. My presence could see into my mind and there was no
way I could hide any thoughts.
Gently I was encouraged to understand how my mistakes hurt others by experiencing what others felt as a
result of my actions.
I began a review of my life, of the key moments of my life. But at the same time I was experiencing it from the
other peoples points of view and that was a stunner because you feel their pain . . . you feel the hurt.
14. Entering a new domain
[entered] another dimension of high density
parallel worldneither up nor downright here
The word death was never mentioned, yet somehow I came to understand that I was in that place where the
newly dead move on to.
15. Learning events unknown before encounter with death
[came to know] there would be another [child]
I was told I had been pregnant [patient had not been aware].
16. Hierarchy of levels of understanding
I could definitely feel that the other dimension involves a hierarchy of increasing levels of quality.
17. Value of life in relation to what happens after death
As a result . . . the earthly dimension appears to me much more valuable. I understand its meaning and
function . . . [it is important for] achieving the quality of consciousness [understanding] that will be useful in
the other dimension and that will always be a part of my self.
18. Sense of heightened/sharpened consciousness
I had the incredible feeling of being awakened. By contrast, coming back was like falling back into the world of
sleep . . . . Down here our consciousness is like a dim and diffuse light. There, our consciousness is like a highly
condensed laser beam.
19. Importance of actions/intentions
Eventually nothing gets lost, even the slightest intentions, regardless of the worldly hierarchies and values.
Thus the fear of life or death is replaced by the fear of ones own actions.
20. An alternate value/evaluation system
Worldly values lose their weight and substance.
All of lifes fears and worries seemed so unimportant, so absolutely nothing to worry about, and all our fearful
fretting seemed so unnecessary.

of what lies beyond death and that death is not the
end. They are often not concerned with what oth-
ers may think about their experiences, even though
they realize some may believe they have had hallu-
cinatory experiences. Another commonly reported
perception is that the self remains the same after
death and that, by and large, people maintain the
same level and type of thinking and understand-
ing that had been gained before dying, without
a sudden change or alteration in their understand-
ing or knowledge. For instance, a person who is an
atheist may maintain the same outlook during the
experience and may continue to interpret his/her
own experience within that framework even after
recovery. Equally, those with a particular religious
mindset may maintain the same thoughts and beliefs
that they had come to believe before their encounter
with death and interpret their experience with this
specific mindset.
Interestingly, while, to an outside observer, the
qualitative nature of the recalled experiences may
have a religious/mystical theme, the experiences do
not seem to necessarily reflect conventional religious
teachings regarding what happens after death (even

Ann. N.Y. Acad. Sci. 1330 (2014) 7593 

C 2014 New York Academy of Sciences. 89
The mental and cognitive experience of death
though people may later interpret their experiences
from their own personal, religious, or cultural beliefs
and background).
Many people who have NDEs and ADEs have ex-
pressed a need for support and greater understand-
ing within the healthcare professions regarding their
experiences. Even though a comprehensive review
of the prevalent philosophical, religious, and cul-
tural beliefs related to what happens when humans
die is beyond the scope of this article, many have
found it rewarding and comforting to find others
with similar experiences, or to identify views ex-
pressed by some scholars regarding the experience
of death that may have similarities to their own ex-
periences.j
While further large-scale research into the phe-
nomenological and qualitative experience of death
in cardiac arrest survivors is needed, the themes
that have emerged to date appear to provide in-
triguing insights into the possible cognitive expe-
rience of death. As millions of people have now
reported consistent experiences from all over the
world, the key scientific challenge is, thus, perhaps
learning how to accommodate and objectively study
these qualitatively and phenomenologically similar
reports, without dismissing them, while also inte-
grating them with current and future quantitatively
based scientific tools and data to build a compelling
picture of what happens when we die. In conclusion,
the recalled experience surrounding death merits a
genuine investigation without prejudice.
Acknowledgments
I thank Dr. Ebby Elahi, M.D., for insights relating to
reality and meaning in relation to subjective human
experience (and in particular NDEs), as well as the
challenges faced by neuroscience in integrating hu-
man experience with quantitative measures. These
points, which had been largely absent from previous
discussions on the subject of NDEs, have provided
the basis for the authors subsequent exploration
and incorporation into discussions related to this
subject (in this and other publications).
j roprotective strategies. Pharmacol. Rep. 64: 115.
For those seeking a metaphysical perspective on the sur-
vival of human consciousness beyond death, one of the
most interesting viewpoints encountered by the author is
that of Ostad Elahi (18951974). For more information,
see Ref. 108.
90 Ann. N.Y. Acad. Sci. 1330 (2014) 7593 
Parnia
Conflicts of interest
The author declares no conflicts of interest.
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