AWARE and AWARE II are large-scale studies carried out between 2008 and 2023 in an attempt to test for veridical perceptions recalled by hospital patients during near-death experiences resulting from cardiac arrests. Both projects were led by British medical professor and resuscitation specialist Sam Parnia.
Contents
Background
The acronym AWARE derives from AWAreness during REsuscitation. Prior to the project, anecdotal accounts of near-death experiences had been widely publicized, many suggesting an ability on the part of subjects to accurately observe their surroundings while unconscious, looking down from a position near the ceiling. Few scientific studies had been carried out, but they included cardiologist Pim van Lommel’s study of 344 cardiac patients, published in The Lancet in 2001, in which one man accurately recalled a view of his dentures during the time his brain had been non-functional.1Van Lommel, Wees Van, Meyers, & Elfferich (2001). See Parnia, Waller, Yeates, & Fenwick (2001). About AWARE, Parnia explained: ‘In this study we wanted to go beyond the emotionally charged yet poorly defined term of NDEs to explore objectively what happens when we die’.2University of Southampton News (7 Oct. 2014).
Methods and Results
The study was begun in 2008 and involved fifteen hospitals in the UK, the USA and Austria.3Parnia et al. (2014). All information for this section and the next is drawn from this source except where otherwise noted. A total of 2060 cardiac arrests were recorded, which 330 patients survived. To be eligible, patients had to have suffered full cessation of heartbeat and respiration, be over eighteen years old, be well enough to be interviewed as judged by their physicians and caretakers and have provided consent. Some 140 persons were deemed eligible.
Methods were pilot-tested at five hospitals during 2007–8, and fifteen hospitals were recruited. Each hospital installed between fifty and a hundred high shelves in areas where cardiac arrest resuscitation was likely to happen, such as emergency rooms and intensive care units. Each shelf held one visual image that faced upwards and thus was only visible from a vantage point near the ceiling. The images were unique and included national and religious symbols, people, animals and major newspaper headlines.
Patients were enrolled between 2008 and 2012. An initial interview was carried out while they still in hospital, if possible, from three days to four weeks following the experience; otherwise they were contacted by telephone, between three and twelve months later. In the first interview they were asked if they remembered anything from the time of their unconsciousness. Fifty-five people answered positively. All had been verifiably unconscious as measured by lack of response to stimuli, including pain caused by chest compressions.
A second interview was carried out, based on Bruce Greyson’s sixteen-item NDE Scale4Greyson (1983). to ascertain whether they had actually had experienced an NDE. Their memories while unconscious were divided into three categories:
- detailed non-NDE memories without recall or awareness of events that happened around them while they were unconscious
- detailed NDE memories without recall or awareness of events
- detailed NDE memories with detailed auditory and/or visual awareness and recall of events
Forty-six persons reported non-NDE memories, which could be divided into seven main themes: fear; animals and plants; a bright light; violence or a feeling of being persecuted; déjà vu experiences; seeing family members; recalling events that likely occurred after recovery.
Seven reported NDE memories without recall or awareness of events, describing time passing either slower or faster, feelings of peace and pleasantness, being separated from their bodies, having heightened senses, and other sensations typical of NDEs. Parnia and his co-authors quote one account:
I have come back from the other side of life… God sent (me) back, it was not (my) time—(I) had many things to do… (I traveled) through a tunnel toward a very strong light, which didn’t dazzle or hurt (my) eyes… there were other people in the tunnel whom (I) did not recognize. When (I) emerged (I) described a very beautiful crystal city… there was a river that ran through the middle of the city (with) the most crystal clear waters. There were many people, without faces, who were washing in the waters… the people were very beautiful…there was the most beautiful singing… (and I was) moved to tears. (My) next recollection was looking up at a doctor doing chest compressions.5Parnia et al. (2014), 5, Table 2.
Finally, two patients reported NDE experiences combined with auditory/visual awareness and recall of events.
Recollection #1:
(Before the cardiac arrest) I was answering (the nurse), but I could also feel a real hard pressure on my groin. I could feel the pressure, couldn’t feel the pain or anything like that, just real hard pressure, like someone was really pushing down on me. And I was still talking to (the nurse) and then all of a sudden, I wasn’t. I must have (blanked out)… but then I can remember vividly an automated voice saying, “shock the patient, shock the patient”, and with that, up in (the) corner of the room there was a (woman) beckoning me…
I can remember thinking to myself, “I can’t get up there”… she beckoned me… I felt that she knew me, I felt that I could trust her, and I felt she was there for a reason and I didn’t know what that was… and the next second, I was up there, looking down at me, the nurse, and another man who had a bald head… I couldn’t see his face but I could see the back of his body. He was quite a chunky fella… He had blue scrubs on, and he had a blue hat, but I could tell he didn’t have any hair, because of where the hat was.
The next thing I remember is waking up on (the) bed. And (the nurse) said to me: “Oh you nodded off… you are back with us now.” Whether she said those words, whether that automated voice really happened, I don’t know… I can remember feeling quite euphoric… I know who (the man with the blue had [sic] was)… I (didn’t) know his full name, but… he was the man that… (I saw) the next day… I saw this man [come to visit me] and I knew who I had seen the day before.
Recollection #2
At the beginning, I think, I heard the nurse say “dial 444 cardiac arrest”. I felt scared. I was on the ceiling looking down. I saw a nurse that I did not know beforehand who I saw after the event. I could see my body and saw everything at once. I saw my blood pressure being taken whilst the doctor was putting something down my throat. I saw a nurse pumping on my chest… I saw blood gases and blood sugar levels being taken.6Parnia et al. (2014), 5, Table 2.
These two patients were contacted for further in-depth interviews. One was unable to continue due to ill health. The 57-year-old man who described Recollection #1 was able to accurately describe people, sounds and activities during his resuscitation. Medical records confirmed the use of an automated external defibrillator with an automated voice (hence the robotic words ‘shock the patient’), and the role of the man in the blue hat. It was calculated that the patient had been aware for as much as three minutes after cardiac arrest.
However, these cases exposed a key limitation: although a thousand shelves had been set up in key areas in the participating hospitals, as many as 78% of the cardiac arrests recorded in the study happened in rooms that were not so equipped. While the patients who supplied the descriptions quoted above might have been in a position to observe the image on the upper side of the shelf – fulfilling the study’s aims – neither could have done so, since there was none.
Discussion
Parnia and his co-authors were struck by the high proportion of patients who reported memories while unconscious. They also noted that the incidence of NDEs (9%) was consistent with previous studies (around 10%).
The authors note that the study’s results, particular the one verified case of visual awareness, suggest that awareness during cardiac arrest is different from awareness during anesthesia, as measurable brain function ceases within seconds of cardiac arrest and the entire brain is without electrical activity until CPR provides enough blood flow to fulfill its metabolic needs. Within a model that assumes cortical activity generates consciousness, the authors write, this evidence of consciousness over a period of minutes in a patient lacking cortical activity lasting is ‘perplexing… as reductions in [cerebral blood flow] typically lead to delirium followed by coma, rather than an accurate and lucid mental state’.7Parnia et al. (2014), 5.
Media Attention
Following publication, the AWARE study was widely reported. Articles were written in The New Republic, The Atlantic, The Telegraph, Psychology Today and others, generally taking a neutral stance. A mildly sceptical view can be found on Insight on skeptic.com.
AWARE II
Plans for a second AWARE study were described on the UK Clinical Trials Gateway, a clearinghouse for medical studies in the UK. The now-defunct page, still available via the Internet Archive, anticipated that the study would run from 1 August 2014 to 31 May 2017 and involve 900-1500 patients. It described a new visual-target method: ‘Research staff will be alerted to cardiac arrest and will attend with portable brain oxygen monitoring devices and a tablet which will display visual images upwards above the patient as resuscitation is taking place’.8UK Clinical Trials Gateway (n.d.).
According to Twitter notifications by Parnia (now lost), the study was delayed as Parnia moved from the University of Southampton in the UK to the Stony Brook School of Medicine on Long Island, New York, USA. AWARE II is summarized on Stony Brook’s website with a greater emphasis on the relationship between quality of brain resuscitation and functional and cognitive outcomes, but still including the test of whether ‘mental and cognitive activity and awareness during CPR may reflect verifiable events’.9Stony Brook School of Medicine (n.d.). As of November 2017, Parnia had moved to the New York University Medical Center, but the AWARE II study was continuing as planned, with twelve sites actively working on the study and others planning to start in 2018.
In a 2019 abstract in the journal Circulation, Parnia and three co-authors reported a scaled-down and retitled version of the completed study which now included both auditory and visual stimuli. Of 465 patients, 44 were successfully resuscitated and 21 were interviewed. Four people reported memories including some suggestive of external awareness, and one correctly recalled the auditory stimuli given, but none the visual.10Parnia, Keshavarz, McMullin, & Williams (2019).
Methods and Results
AWARE II ultimately involved 25 sites. In each hospital, cardiac arrest patients’ electroencephalography (EEG) and cerebral oxygenation (rSO2) monitorings were recorded in real time as they underwent cardio-pulmonary resuscitation (CPR), while at the same time their awareness was tested for using explicit and implicit learning using a computer and headphones.
Those who survived (53 out of 567, or 9.3%), were asked if they would like to be interviewed about any experiences they might have had. Those who agreed were screened, leaving a final sample of 28. None of these patients explicitly recalled seeing the image that had been shown to them during resuscitation or hearing the auditory stimuli, and none could identify the visual image from among ten images. However, eleven patients reported memories or perceptions suggestive of consciousness. Some recalled coming out of coma, with medical interventions either recalled accurately or misinterpreted. Others described inner experiences, either random dream-like experiences, or what the authors term ‘recalled experiences of death’ (RED), which correspond to the typical NDE. The latter type was recalled by six patients out of the 28 interviewed.11Parnia et al (2023), 1. All information in this section and the next is drawn from this article except where otherwise noted.
These six patients underwent further interviews and took Greyson’s NDE scale. For the most part their recollections broke down into five categories: perception of separation from body, perception of heading towards a destination, returning to a place that felt like home, undergoing an educational re-evaluation of their life and, finally, returning again. The patients are quoted:
a) Perception of separation from the body
“I was no longer in my body. I floated without weight or physicality. I was above my body and directly below the ceiling of the intensive therapy room. I observed the scene that was taking place below me … I, who no longer was the body that had belonged to me just a moment prior, found myself in a position which was . . . more elevated. It was a place that had nothing to do with any kind of . . . material experience.”
b) Perception of heading towards a destination
“I remember entering a … tunnel. The feelings I experienced … were much more intense than [usual]. The first feeling was a feeling of intense peace. It was so calm and serene with an incredible amount of tranquility. All of my … worries, thoughts, fears, and opinions were gone. The intensity of the tranquility was so incredible and overwhelming that there was no fear in what I was experiencing. I had no fear about where I was going and what to expect when I arrived there. Then I felt warmth … Then there was the desire to be home.”
c) Undergoing a purposeful, meaningful and educational re-evaluation of life
“I do remember a being of light … standing near me. It was looming over me like a great tower of strength, yet radiating only warmth and love … I caught glimpses of my life and felt pride, love, joy, and sadness, all pouring into me. Each image was of me, but from the standpoint of a being standing with me or looking on. … I was shown the consequences of my life, thousands of people that I’d interacted
with and felt what they felt about me, saw their life and how I had impacted them. Next I saw the consequences of my life and the influence of my actions.”d) Returning to a place that felt like home
“I went directly to a place of light. It was calm and immediate … The place where I was I perceived to be analogous in a way to the exterior of an entry way … There was one major being of love and many other beings of love … There was nothing but love, goodness, truth, and all things to do with love. There was no room for fear or evil or anything but this love. It was more wonderful than any of my best hopes or experiences [in this place]. It was beyond perfect and loving, as we in our human state know it. There are no words to describe it. I was so happy to be there.”
e) Returning
“I was asked if I wanted to come home (meaning there) or wanted to come back here. I told them that my two sons needed me and I had to go back. I was suddenly in my body again feeling my achy joints flaring in pain. I really don’t remember what was going on around me at that point, just that I hurt.”12Parnia et al. (2023), 5.
Discussion
Drawing on earlier findings of surprising cortical activity at or after death, Parnia and co-authors combine these with their own findings of apparent consciousness to theorize as follows:
Ischemic depolarization may initiate brain disinhibition – leading to activation of dormant pathways – observed as transient electrocortical biomarkers of lucidity. Although of unknown evolutionary benefit, instead of being hallucinatory, illusory or delusional, this appears to facilitate lucid understanding of new dimensions of reality – including people’s deeper consciousness – all memories, thoughts, intentions and actions towards others from a moral and ethical perspective.13Parnia et al. (2023), 9.
The authors go on to argue that findings of lucidity and heightened perception during catastrophic disorder or cessation of brain activity requires consideration of alternatives to the idea that mind is purely a product of brain processes, and state that further research is necessary.
KM Wehrstein
Literature
Greyson, B. (1983). The Near-Death Experience Scale: Construction, reliability and validity. Journal of Nervous and Mental Disease 171, 369-75.
Parnia, S., Fenwick, P., Spearpoint, K., Devos, G., Goldberg, D., Yang, J., Zhu, J., Baker, K., Killingback, H., McLean, P., Wood, M., Zafari, A.M., Dickert, N., Beisteiner, R., Sterz, F., Berger, M., Warlow, C., Bullock, S., Lovett, S., McPara, R.M., Marti-Navarette, S., Cushing, P., Wills, P., Harris, K., Sutton, J., Walmsley, A., Deakin, C.D., Little, P., Farber, M., Greyson, B., & Schoenfeld, E.R. (2014). AWARE – AWAreness during REsuscitation – A prospective study. Resuscitation 85/12, 1799-1805.
Parnia, S., Keshavarz Shirazi, T., Patel, J., Tran, L., Sinha, N., O’Neill, C., Roellke, E., Mengotto, A., Findlay, S., McBrine, M., Spiegel, R., Tarpey, T., Huppert, E., Jaffe, I., Gonzales, A.M., Xu, J., Koopman, E., Perkins, G.D., Vuylsteke, A., Bloom, B.M., Jarman, H., Tong, H.N., Chan, L., Lyaker, M., Thomas, M., Velchev, V., Cairns, C.B., Sharma, R., Kulstad, E., Scherer, E., O’Keeffe, T., Foroozesh, M., Abe, O., Ogedegbe, C., Girgis, A., Pradhan, D., & Deakin, C.D. (2023). AWAreness during REsuscitation – II: A multicenter study of consciousness and awareness in cardiac arrest. Resuscitation 191: 109903, 1-12.
Parnia, S., Keshavarz, T., McMullin, M., & Williams, T. (2019). Abstract 387: Awareness and cognitive activity during cardiac arrest. Circulation 140: A387 (11 November). [Online poster abstract presentation.]
Parnia, S., Waller, D., Yeates, R., & Fenwick, P. (2001). A qualitative and quantitative study of the incidence, features and aetiology of near death experiences in cardiac arrest survivors. Resuscitation 48, 149-56.
Stony Brook School of Medicine (n.d). Research [Item] 2. AWARE II (AWAreness during REsuscitation). [Web page.]
UK Clinical Trials Gateway (n.d.). AWARE II (AWAreness during REsuscitation): A multi-centre observational study of the relationship between the quality of brain resuscitation and consciousness, neurological, functional and cognitive outcomes following cardiac arrest. [Web page preserved on Internet Archive.]
University of Southampton News (2014). Results of world’s largest near death experiences study published. (7 October.)
Van Lommel, P., Wees Van, R., Meyers, V., & Elfferich, I. (2001) Near-death experience in survivors of cardiac arrest: A prospective study in the Netherlands. Lancet 358, 2039-45.