The wait is long.

For days partners, relatives and friends have come and gone having paid their last respects to your dying patient.

The same question is asked again and again.

“How long?”

You give the same response to everyone.

“It is hard to know.”

Another shift begins and at handover, you learn that the patient’s condition is the same as yesterday and the day before that.

You are in the middle of a drug round and a visitor stops you and says about their unconscious relative –  “John’s awake and talking to Mum.”

Skeptical, you go in and sure enough John IS talking.

He lapses back into unconsciousness and dies later that day.

Michael Nahm and Bruce Greyson in 2009 called this unexpected event: terminal lucidity.

It is where mental clarity returns in the last minutes, hours or days before the patient’s death.

Hippocrates, Plutarch and Galen wrote about reports of terminal lucidity.

In the nineteenth century, cases of mind clarity shortly before death were reported by medical doctors.

It was interpreted as a sign of impending death.

But in the twentieth century,  the reporting on the phenomenon decreased.

Nahm writes about 83 accounts of terminal lucidity written over 250 years ago.

In close to ninety per cent of these cases, terminal lucidity occurred within a week of death.

And nearly a half of the cases occurred on the last day of life.

Nahm documented accounts of patients with brain abscesses, brain tumours, strokes, Alzheimer’s disease and other dementias, meningitis, schizophrenia and affective disorders having terminal lucidity.

He has suggested the severe weight loss in patients with brain tumours could cause the brain to shrink leading to relief of pressure on the brain.

The fleeting relief of pressure may allow for clear thinking.

However, this does not explain instances of terminal lucidity that occurs in dementia and other diseases.

Nahm provides three recent examples of terminal lucidity in patients with Alzheimer’s.

The first case concerned an elderly woman who suffered from the illness for 15 years and was cared for by her daughter. The woman was unresponsive for years and showed no sign of recognizing her daughter or anybody else. However, a few minutes before she died, she started a normal conversation with her daughter, an experience for which the daughter was unprepared and which left her utterly confused.

The second Alzheimer’s case was remarkably similar. In this case it was a woman’s grandmother who had neither talked nor reacted to family members for a number of years until the week before she died, when she suddenly started chatting with the granddaughter, asking about the status of various family members and giving her granddaughter advice. Her granddaughter reported that ‘‘it was like talking to Rip Van Winkle’’.

The third Alzheimer’s case involved an 81-year-old woman who had been demented for a long time and was living in a retirement home in Iceland. Her family took turns visiting her, even though she had neither recognized any of them nor spoken to them for a year. On one occasion, her son Lydur was sitting at her bedside working on a crossword puzzle. Suddenly she sat up, looked him directly in the face, and said, ‘‘My Lydur, I am going to recite a verse to you’’. She then recited clearly and loudly the following verse, thought by her son to be quite relevant to her situation (translated into unrhymed English by E.H.): Oh, father of light, be adored. Life and health you gave to me, My father and my mother. Now I sit up, for the sun is shining. You send your light in to me. Oh, God, how good you are. She then lay back on her pillow and was again nonresponsive, and remained so until she died about a month later. Her son immediately wrote down the verse, thinking it was his mother’s poetry; but he later learned it was the first stanza from a psalm by an Icelandic poet.”

Terminal lucidity is of great importance to significant others.

They may see this as an ‘improvement’ and that death has been kept at bay.

Only for the sudden death that follows to be a cruel surprise.

For nurses, the implications of this are immense.

Ever so gently, those present will need to have explained what it is that is happening.

Because like death itself, terminal lucidity is a mystery.

To learn more about terminal lucidity,

Nahm, Michael, and Bruce Greyson. “Terminal lucidity in patients with chronic schizophrenia and dementia: A survey of the literature.” The Journal of nervous and mental disease 3.12 (2009): 942-944.