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The Nature and Meaning of near death experince for Patients and Critical Care Nurses

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P1: GRA Journal of Near-Death Studies ph167-jond-455246 November 22, 2002 9:37 Style file version September 27, 2002 The Nature and Meaning of the Near-Death Experience for Patients and Critical Care Nurses Linda L. Morris, Ph.D., RN, C Nursing Education Consultants, Darien, IL Kathleen Knafl, Ph.D., FAAN Yale University, New Haven, CT ABSTRACT: This study was designed to develop a conceptual framework for the near-death experience (NDE), reflecting its nature and meaning for the patient and the critical care nurse. The study used naturalistic inquiry to examine the question: What is the nature and meaning of an NDE and how has it influenced the individual’s view of the self, the future, and feelings and beliefs about life and death? The NDE Scale (Greyson, 1983) was used with patients and semi-structured interview guides were used with both nurses and patients to explore the NDE from a comprehensive perspective. An NDE was defined as the report of “unusual” recollections associated with a period of unconsciousness during either serious illness or injury, or resuscitation from a cardiac or respiratory arrest. The sample included 12 patients who experienced an NDE and 19 nurses who cared for patients who experienced NDEs. This study highlighted the emotional aspects of the NDE. Patients described how the NDE transformed their lives and nurses reported how their experiences with patients changed them personally and professionally. KEY WORDS: near-death experience (NDE); qualitative research; aftereffects; unconsciousness; spirituality; spiritual distress. Linda L. Morris, Ph.D., RN, C, is the President of Nursing Education Consultants of Darien, IL. Kathleen Knafl, Ph.D., FAAN, is a professor in the doctoral program at the Yale University School of Nursing, where she is pursuing a program of research related to family response to childhood chronic illness. This paper is based on a presentation at the International Association for Near-Death Studies Annual Conference, Seattle Pacific University, July 27, 2001. Reprint requests should be addressed to Dr. Morris at 8305 Highpoint Circle, Suite A, Darien, IL 60561. Journal of Near-Death Studies, 21(3), Spring 2003 °C 2003 Human Sciences Press, Inc. 139

140 JOURNAL OF NEAR-DEATH STUDIES Despite the abundance of writings in the lay press on the near-death experience (NDE)and related phenomena, it is a poorly understood event in the intensive care unit. One may wonder why there is such interest in a topic that is so difficult to explain. In the literature the definition of what constitutes an NdE is unclear. Patients may be con- sidered "near-death"as a result of several factors, such as cardiac or respiratory arrest, and severe shock or trauma. However, a common attribute of such states is a period of unconsciousness that is not the result of anesthesia. To the observer, these patients do not (or cannot) respond, but it is during thi od of unconsciousness when some sur- vivors have reported unusual recollections, some of which have been verified by others Many people claim that the NDE is"proof"of an existence beyond death because some survivors claim to have experienced "the here- after. Other researchers claim that the nde is merely the sensory manifestation of a dying brain(Blackmore, 1988, 1991)or produced by erratic electrical misfiring in the brain( Carr, 1982)or chemical im- balances (Jansen, 1990). Still others lie in the middle, convinced that here is something compelling in the stories of those who have expe- rienced another dimension, but unable fully to understand it. despite he wide range of skepticism and sometimes sensationalism, those who have had an NDE are nonetheless, often changed by it. Their expe- riences also affect people who hear the stories of those who have had NDES Although exact numbers cannot be known, many survivors of car- iac arrest have experienced an NDE; however, critical care personnel have inadequate knowledge to manage these patients. And it is clear that these patients need a supportive person to listen to their stories and understand their concerns(garrison, 1989; James, 1994). It is es timated that 1.000 sudden cardiac deaths occur in the united states every day(Emergency Cardiac Care Committee and Subcommittees 1992). Featherston defined sudden cardiac death as"an unexpected witnessed death of an apparently well person resulting from cardiac dysfunction and occurring within 1 hour of the onset of new symp- toms"(1988, p. 242). Results of successful resuscitation in the hospital have not been systematically reported due to several factors; however, several informal sources list survival rates at 53 percent (C Mclane, personal communication, February, 1993), 60 percent(D Knudsen, per sonal communication, May, 2000), or 67 percent (Morris and Fachet 1992). Considering that these figures do not take into account the nu merous factors involved, such as cause or lengths of survival, these

P1: GRA Journal of Near-Death Studies ph167-jond-455246 November 22, 2002 9:37 Style file version September 27, 2002 140 JOURNAL OF NEAR-DEATH STUDIES Despite the abundance of writings in the lay press on the near-death experience (NDE) and related phenomena, it is a poorly understood event in the intensive care unit. One may wonder why there is such interest in a topic that is so difficult to explain. In the literature, the definition of what constitutes an NDE is unclear. Patients may be considered “near-death” as a result of several factors, such as cardiac or respiratory arrest, and severe shock or trauma. However, a common attribute of such states is a period of unconsciousness that is not the result of anesthesia. To the observer, these patients do not (or cannot) respond, but it is during this period of unconsciousness when some survivors have reported unusual recollections, some of which have been verified by others. Many people claim that the NDE is “proof” of an existence beyond death because some survivors claim to have experienced “the hereafter.” Other researchers claim that the NDE is merely the sensory manifestation of a dying brain (Blackmore, 1988, 1991) or produced by erratic electrical misfiring in the brain (Carr, 1982) or chemical imbalances (Jansen, 1990). Still others lie in the middle, convinced that there is something compelling in the stories of those who have experienced another dimension, but unable fully to understand it. Despite the wide range of skepticism and sometimes sensationalism, those who have had an NDE are, nonetheless, often changed by it. Their experiences also affect people who hear the stories of those who have had NDEs. Although exact numbers cannot be known, many survivors of cardiac arrest have experienced an NDE; however, critical care personnel have inadequate knowledge to manage these patients. And it is clear that these patients need a supportive person to listen to their stories and understand their concerns (Garrison, 1989; James, 1994). It is estimated that 1,000 sudden cardiac deaths occur in the United States every day (Emergency Cardiac Care Committee and Subcommittees, 1992). Featherston defined sudden cardiac death as “an unexpected witnessed death of an apparently well person resulting from cardiac dysfunction and occurring within 1 hour of the onset of new symptoms” (1988, p. 242). Results of successful resuscitation in the hospital have not been systematically reported due to several factors; however, several informal sources list survival rates at 53 percent (C. McLane, personal communication, February, 1993), 60 percent (D. Knudsen, personal communication, May, 2000), or 67 percent (Morris and Fachet, 1992). Considering that these figures do not take into account the numerous factors involved, such as cause or lengths of survival, these

LINDA L. MORRIS AND KATHLEEN KNAFL numbers are quite similar. If these figures are representative, then a large number of persons each year are surviving clinical death. Literature review Survivors of NDEs have significant psychosocial issues to resolve af- ter the acute event. One of us (LL M )conducted a preliminary in- tegrative review of the literature on survivors of cardiac arrest and myocardial infarction, concluding that the major issues were linked to resolving the meaning and addressing the emotional sequelae. In other words, survivors of cardiac arrest and myocardial infarction, a large group of patients who experience NDEs, need the support of caregivers ho are well-informed regarding their emotional needs The early literature on the nde, through the early 1980s, described features associated with the experience itself, such as a light a tunnel, and an out-of-body experience(OBE). The literature of the later 1980s reported on the aftereffects of the e experlence he integrative review of the literature included 13 studies that discussed the features associated with an NDe, only two of which( Greyson and Stevenson, 1980; Morse Castillo, Venecia, Milstein, and Tyler, 1986)described examination of medical records as a method to confirm inclusion criteria. eight of the studies used convenience sampling methods, two studies described a purposive sampling approach, and one study(Atwater, 1988)described a random selection of cases from the archives of the international as sociation for Near- Death studies The remainder of the studies did not describe the sampling method Two studies included interview of a secondary source such as a fam ly member or physician to support the primary source. Twelve of the studies used a questionnaire but reliability data were absent in all but two(Greyson, 1983; Ring, 1980) Gender and ethnicity seemed to be factors in reporting NDEs. Stu- rt Twemlow and Glen Gabbard (1984-85)reported that 65 percent of their sample of 339 near-death experiencers were female, and that male respondents tended to have NDEs much more commonly as a re- sult of accident or physical injury than did females, who more often had an NDe as a result of illness. with two exceptions, most authors did not report the ethnic composition of samples. Bruce Greyson and lan Stevenson(1980)reported that all their subjects were Caucasian; and Kenneth Ring(1980)reported that 95 percent of his sample of 102 sub jects were Caucasian and 5 percent were African-American

P1: GRA Journal of Near-Death Studies ph167-jond-455246 November 22, 2002 9:37 Style file version September 27, 2002 LINDA L. MORRIS AND KATHLEEN KNAFL 141 numbers are quite similar. If these figures are representative, then a large number of persons each year are surviving clinical death. Literature Review Survivors of NDEs have significant psychosocial issues to resolve after the acute event. One of us (L.L.M.) conducted a preliminary integrative review of the literature on survivors of cardiac arrest and myocardial infarction, concluding that the major issues were linked to resolving the meaning and addressing the emotional sequelae. In other words, survivors of cardiac arrest and myocardial infarction, a large group of patients who experience NDEs, need the support of caregivers who are well-informed regarding their emotional needs. The early literature on the NDE, through the early 1980s, described features associated with the experience itself, such as a light, a tunnel, and an out-of-body experience (OBE). The literature of the later 1980s reported on the aftereffects of the experience. The integrative review of the literature included 13 studies that discussed the features associated with an NDE, only two of which (Greyson and Stevenson, 1980; Morse, Castillo, Venecia, Milstein, and Tyler, 1986) described examination of medical records as a method to confirm inclusion criteria. Eight of the studies used convenience sampling methods, two studies described a purposive sampling approach, and one study (Atwater, 1988) described a random selection of cases from the archives of the International Association for Near-Death Studies. The remainder of the studies did not describe the sampling method. Two studies included interview of a secondary source such as a family member or physician to support the primary source. Twelve of the studies used a questionnaire, but reliability data were absent in all but two (Greyson, 1983; Ring, 1980). Gender and ethnicity seemed to be factors in reporting NDEs. Stuart Twemlow and Glen Gabbard (1984–85) reported that 65 percent of their sample of 339 near-death experiencers were female, and that male respondents tended to have NDEs much more commonly as a result of accident or physical injury than did females, who more often had an NDE as a result of illness. With two exceptions, most authors did not report the ethnic composition of samples. Bruce Greyson and Ian Stevenson (1980) reported that all their subjects were Caucasian; and Kenneth Ring (1980) reported that 95 percent of his sample of 102 subjects were Caucasian and 5 percent were African-American

JOURNAL OF NEAR-DEATH STUDIES NDE Features The features of the NDe have been a topic of inquiry since 1975, when the popular book Life After Life(Moody, 1975) was published In this work, Raymond Moody first described the NDe after inter- viewing 150 persons resuscitated from cardiac arrest or who other- wise came close to death as a result of severe accident or injury. h found a consistent pattern of features, which later came to be known as the "core experience"(Ring, 1984), including the following features There is an initial sensation of peace and serenity, while seeing the self as separate from the physical body(an out-of-body experience, of OBE). Upon leaving the body, all pain is gone. The disembodied self enters a tunnel or darkness, traveling at great speed and encountering a light at the end of the tunnel, which seems to radiate love. others come to greet and welcome the person to his or her new environment While in the light, the individual experiences a life review or panoramic memory, which is observed objectively, yet experienced with the orig. inal emotions. The person then reaches a border or limit. Some are given the choice to return, whereas for others the decision is made for them. Upon return to the body, the pain, if previously present, Numerous studies have been conducted since this landmark work and most have had consistent findings. Three studies also provided a measurement tool to measure the depth of NDEs, based on the num- ber of characteristics reported(Greyson, 1983, 1985; Ring, 1980). The most notable exception to the consistency in the literature was a study of experiencers in India, who were less likely to have OBEs and had a tendency to have residual marks on the body after the experience (Pasricha and Stevenson, 1986). Other notable exceptions were the re- ports of frightening or"hell-like"NDEs(Bush, 1994; Greyson and Bush, 1992; Rawlings, 1978, 1993; Ritchie, 1978). These experiences are not well reported as the core experience Limitations in the Studies of features There were several limitations that were noted in the studies that re- ported the features of the NDE. First, the method of subject recruitment was often self-selection. In many cases, it was the subjects response to a notice in a magazine that qualified them for the study whether or not they were truly "near death"at the time of the incident. Being near death is very subjective, especially in our common language. To say"I

P1: GRA Journal of Near-Death Studies ph167-jond-455246 November 22, 2002 9:37 Style file version September 27, 2002 142 JOURNAL OF NEAR-DEATH STUDIES NDE Features The features of the NDE have been a topic of inquiry since 1975, when the popular book Life After Life (Moody, 1975) was published. In this work, Raymond Moody first described the NDE after interviewing 150 persons resuscitated from cardiac arrest or who otherwise came close to death as a result of severe accident or injury. He found a consistent pattern of features, which later came to be known as the “core experience” (Ring, 1984), including the following features. There is an initial sensation of peace and serenity, while seeing the self as separate from the physical body (an out-of-body experience, or OBE). Upon leaving the body, all pain is gone. The disembodied self enters a tunnel or darkness, traveling at great speed and encountering a light at the end of the tunnel, which seems to radiate love. Others come to greet and welcome the person to his or her new environment. While in the light, the individual experiences a life review or panoramic memory, which is observed objectively, yet experienced with the original emotions. The person then reaches a border or limit. Some are given the choice to return, whereas for others the decision is made for them. Upon return to the body, the pain, if previously present, returns. Numerous studies have been conducted since this landmark work, and most have had consistent findings. Three studies also provided a measurement tool to measure the depth of NDEs, based on the number of characteristics reported (Greyson, 1983, 1985; Ring, 1980). The most notable exception to the consistency in the literature was a study of experiencers in India, who were less likely to have OBEs and had a tendency to have residual marks on the body after the experience (Pasricha and Stevenson, 1986). Other notable exceptions were the reports of frightening or “hell-like” NDEs (Bush, 1994; Greyson and Bush, 1992; Rawlings, 1978, 1993; Ritchie, 1978). These experiences are not as well reported as the core experience. Limitations in the Studies of Features There were several limitations that were noted in the studies that reported the features of the NDE. First, the method of subject recruitment was often self-selection. In many cases, it was the subject’s response to a notice in a magazine that qualified them for the study, whether or not they were truly “near death” at the time of the incident. Being near death is very subjective, especially in our common language. To say “I

LINDA L. MORRIS AND KATHLEEN KNAFL almost died"can mean anything from acute embarrassment to being in a"near-miss "accident to being hospitalized in intensive care as result of trauma or disease. In most cases the state of near -death was not described. nor was it corroborated. Another limitation of these studies was the skewed sampling of gen- der and ethnicity. Participants tended to be Caucasian and women, and there seemed to be no effort to obtain a representative sample of men and women of varying ethnic backgrounds In addition, there was no description of the instruments, which were presumably interview guides. In qualitative research, the instruments of data collection provide the basis for understanding the nature of the interview. Without a description of the instruments, it was impossible to determine whether the interview protocols were appropriate for the Studies of Meaning and Aftereffects There were eight studies of meaning and aftereffects included in the integrative review of the literature. All of them used an interview or questionnaire method of obtaining data. All of the studies described a positive outcome of the NDE. Three studies described a decreased fear of death(Bauer, 1985; Grey, 1985; Noyes, 1980). Half of the stud ies found that the subjects had a calmer and more accepting attitude toward others and life in general. Other studies reported a strength ened belief in life after death, a renewed sense of purpose in life, or a re-evaluation of priorities( Bauer, 1985; Ring, 1984; Ring and valarino 1988). Taken together, these studies of the meaning and aftereffects of the nde pointed toward a process of changed values and beliefs as a result of the experience. There was less concern with material things and more concern with relationships following the NDE. another term that could describe this outcome was increased spirituality, which is defined as pertaining to the"spirit or soul as distinguished from the body or material matters"(Guralnik, 1980, p. 1373). This view coin- cided with an interesting concept analysis of spirituality(Haase, Britt, Coward, Leidy, and Penn, 1992), which found that the three outcomes of spirituality were a purpose and meaning in life guidance of values and behavior, and self-transcendence, which reaches out beyond reality and allows the individual to rise above personal and material concerns. This description of spirituality fits well with the studies of meaning and aftereffects of NDEs. The present study was built on these studies of meaning and aftereffects

P1: GRA Journal of Near-Death Studies ph167-jond-455246 November 22, 2002 9:37 Style file version September 27, 2002 LINDA L. MORRIS AND KATHLEEN KNAFL 143 almost died” can mean anything from acute embarrassment to being in a “near-miss” accident to being hospitalized in intensive care as a result of trauma or disease. In most cases, the state of near-death was not described, nor was it corroborated. Another limitation of these studies was the skewed sampling of gender and ethnicity. Participants tended to be Caucasian and women, and there seemed to be no effort to obtain a representative sample of men and women of varying ethnic backgrounds. In addition, there was no description of the instruments, which were presumably interview guides. In qualitative research, the instruments of data collection provide the basis for understanding the nature of the interview. Without a description of the instruments, it was impossible to determine whether the interview protocols were appropriate for the research questions. Studies of Meaning and Aftereffects There were eight studies of meaning and aftereffects included in the integrative review of the literature. All of them used an interview or questionnaire method of obtaining data. All of the studies described a positive outcome of the NDE. Three studies described a decreased fear of death (Bauer, 1985; Grey, 1985; Noyes, 1980). Half of the studies found that the subjects had a calmer and more accepting attitude toward others and life in general. Other studies reported a strengthened belief in life after death, a renewed sense of purpose in life, or a re-evaluation of priorities (Bauer, 1985; Ring, 1984; Ring and Valarino, 1988). Taken together, these studies of the meaning and aftereffects of the NDE pointed toward a process of changed values and beliefs as a result of the experience. There was less concern with material things and more concern with relationships following the NDE. Another term that could describe this outcome was increased spirituality, which is defined as pertaining to the “spirit or soul as distinguished from the body or material matters” (Guralnik, 1980, p. 1373). This view coincided with an interesting concept analysis of spirituality (Haase, Britt, Coward, Leidy, and Penn, 1992), which found that the three outcomes of spirituality were a purpose and meaning in life, guidance of values and behavior, and self-transcendence, which reaches out beyond reality and allows the individual to rise above personal and material concerns. This description of spirituality fits well with the studies of meaning and aftereffects of NDEs. The present study was built on these studies of meaning and aftereffects

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