Chapter 4
The biology of dying, honestly told
Margaret was eighty-four. Her daughter Sarah sat by the bedside in a small upstairs room at a hospice house in northern Wisconsin. The early light was just touching the windowsill when the nurse — who had done this work for twenty-two years — leaned over and said softly, “Listen to her breathing now. It’s changing.”
Sarah had heard about the death rattle from a friend whose mother had died the year before. She had not yet heard it herself. There was a long pause. Then a few quick, shallow breaths. Then a rasp, deep in the throat. The nurse explained, gently, that this was normal. The muscles in the throat had relaxed. A little fluid had pooled there. The brain stem was sending its last instructions to the lungs, and it was sending them more and more slowly. Margaret was not in pain. She could probably still hear her daughter’s voice. So Sarah talked. Mostly about ordinary things. The apple tree in the back yard. The grandchildren’s last visit. The time her mother had taught her, at a kitchen counter forty years ago, how to make a pie crust.
By mid-morning the breaths were further apart. The nurse reached for the wrist, then for the side of the neck. Sarah watched her mother’s face, already peaceful, settle into a deeper stillness. “She’s gone,” the nurse said. “She left us very gently.”
What, exactly, had just happened?
That is the question this chapter takes up. Not the question of where Margaret has gone — we will come to that question soon enough, through a kind of evidence that did not even exist when most of us were born. The question for this chapter is more modest, but no less real. What happens to the body at death? What does dying actually look like, from the outside, when we lay down our pastoral and theological language for a moment and just watch the thing happen?
I think the answer matters, and I think a great many Christians have been spared the answer for too long. For most of human history the deathbed was at home, in a bedroom, surrounded by family. People had seen dying before. They knew what to expect. Then, in the middle of the twentieth century, we moved the deathbed into the hospital. Nurses learned about dying. Most of the rest of us did not. A whole generation grew up assuming dying was something doctors handled, somewhere out of sight.1
In the past forty years palliative-care medicine and the modern hospice movement have begun to repair the loss. We now have a careful, disciplined description of what the dying body is doing in its last days and hours. That description is what this chapter will give you. It is also the empirical floor on which the rest of the book stands. You cannot weigh what a person reports about their cardiac arrest until you know what a cardiac arrest is. You cannot ask whether a dying patient was perceiving anything before you understand what their dying body was doing.
Hospice nurses are the great recoverers of bedside knowledge in our generation. They have watched thousands of people die, gently, in real rooms, and they know what dying looks like the way midwives know what birth looks like. Pastors and chaplains who learn from them — quietly, humbly, over years — carry into the bedside a kind of wisdom the church had largely lost. The first gift you can bring to a dying parishioner’s family is often the gift of not being afraid of what they are seeing.
A few framing distinctions first.
Doctors and hospice workers usually divide dying into two large patterns. The first is the long decline — death from cancer, congestive heart failure, advanced dementia, advanced lung disease, kidney failure. Months, sometimes years, of slow loss. The body trades pieces of itself for time. Strength goes. Appetite goes. The world shrinks down to a chair, then to a bed, then to a room. The second pattern is the acute crisis — sudden cardiac arrest, severe trauma, massive stroke, drowning. The body is doing well, or well enough, until it is not. Then, in minutes, everything stops.2
The body’s last hours often look similar in either case, because the body has only a few ways to die. Doctors call this the active dying phase. It usually covers the last twenty-four to seventy-two hours of life. Once you have seen it once or twice, you can almost always recognize it again.
The first signs are quiet. The dying person stops eating and stops drinking. This is not a sign that the family has failed to care for them. It is the body itself letting go. The digestive system is shutting down. Forcing food at this stage is not kindness; it can be a small cruelty. The mouth and lips dry. The eyes sometimes hollow. Sleep deepens. The person spends more and more time in it. When they are awake, they may be confused, or strangely lucid, or both within a single hour.3
The blood begins to retreat to the core. The hands cool. The feet cool. A light blue or purple mottling appears on the knees and the soles — what doctors call livedo reticularis, the visible map of failing circulation. The kidneys, no longer well perfused with blood, slow down and then stop. Urine darkens. Then it stops, too.
Breathing changes next. Sometimes it becomes shallow. Sometimes it becomes irregular. A common late pattern is Cheyne-Stokes respiration — named after the two physicians who first described it in the early nineteenth century — a rhythm of deepening breaths followed by a long pause, sometimes thirty seconds or more, before the cycle begins again.4 Families at the bedside often think their loved one has died during one of these pauses, then breathe in relief when the next breath comes. After a while they stop breathing in relief. They simply wait.
The last common breathing change is the so-called death rattle. The dying person is no longer swallowing the small amount of saliva that the throat produces. A little fluid pools at the back of the throat, and the slow remaining breaths move it back and forth. The result is a wet, rough, rasping sound. To families it can sound like distress. It is not. The dying person, by this point, is almost always too deep in unconsciousness to feel it. Hospice nurses spend much of their time, in those last hours, telling the family what they are hearing and why it does not mean what they fear it means.5
The breathing slows further. There is a phase doctors call agonal — a word that comes from the Greek agōnia, “struggle” — though most agonal breathing involves no felt struggle. It is a few last gasping breaths, sometimes minutes apart, the brain stem firing its final instructions even after consciousness has gone. Then the breathing stops. The heart stops, or has already stopped. We have arrived at clinical death: the cessation of breathing and circulation. This is the moment most of the cases the rest of the book will examine begin from. We will pick it up in detail in the next chapter.
Doctors distinguish two stages. Clinical death is the cessation of breathing and circulation. Biological death is the irreversible cessation of every tissue’s biological function — a longer process. The brain’s neurons, deprived of oxygen, last roughly three to six minutes before suffering damage that cannot be reversed. Other tissues last longer; some bone cells live for days. Death, biologically speaking, is a cascade. A person can be clinically dead and not yet biologically dead — which is exactly the window in which a great many of the cases this book will examine occur.
After clinical death the cells of the body live on for some minutes. The brain’s neurons survive, deprived of oxygen, for perhaps three to six minutes before suffering damage that cannot be reversed. Other tissues last longer. Skin can be transplanted hours after death. Some bone cells live for days. The body does not, biologically, die all at once. Doctors mark its beginning at the moment of cardiac and respiratory arrest, but the full biological death of every tissue takes much longer than the news report’s “she died at 9:14 a.m.” suggests.6
So far I have described the well-mapped territory. Most of it is uncontroversial. But two phenomena in the active dying phase deserve a closer look, because they push against the simple picture of what a dying brain can do.
The first is terminal restlessness, sometimes called terminal delirium. Many dying patients, especially those at the end of long illnesses, become restless and confused in the last day or two. They pluck at the bedclothes. They speak unclearly. They reach toward something the family cannot see. Some of this is medication. Some is the brain’s slow loss of oxygen. Some is the metabolic chaos of organs in failure. The medical literature treats it as a manageable, mostly biological phenomenon — though a part of it remains genuinely puzzling.7
The second phenomenon is the strange opposite, and the more striking one. It is called terminal lucidity. Sometimes a dying patient who has been demented for years, unable to recognize their own children, will suddenly — in the final hours of life — sit up clear-eyed and have a real conversation. They will name relatives. They will recall events. They will say goodbye. Then they will lie back down and die.
Michael Nahm, working with the late Bruce Greyson, gathered a careful collection of historical and contemporary cases of this phenomenon and gave it the name terminal lucidity in the medical literature in 2009.8 Alexander Batthyány has continued the research with much larger samples and prospective study designs at the Viktor Frankl Institute.9 The cases include patients with advanced Alzheimer’s disease, Creutzfeldt-Jakob disease, severe schizophrenia, terminal brain tumors, and end-stage strokes — patients whose brains, by every imaging and clinical measure available, were no longer capable of producing the clarity they suddenly displayed.
In their 2009 review and subsequent papers, Nahm and Greyson gathered cases stretching back two centuries. The patterns are familiar to any hospice nurse who has watched for them: a patient with lifelong severe cognitive disability sings clearly in her last hour, in language she has never been heard to use; an Alzheimer’s patient who has not recognized her family for years sits up, calls her daughter by name, and gives a brief farewell; a man silenced for months by a brain tumor opens his eyes the morning of his death and quietly thanks his wife. The cases differ in their details. They share a structure: the brain has been failing, sometimes for years; consciousness has been reduced or absent; and then, briefly, a person whom medicine no longer expected to be there is back. Hours or even minutes later, the body finishes dying.
This is — to put it mildly — not what a strict materialist account would predict. If the mind is the brain, and the brain is in profound structural failure, the mind should not be able to suddenly reassemble itself into coherent personhood for a final hour. The phenomenon is real and well-documented, and even the most cautious researchers admit that no agreed-upon biological mechanism explains it. Some have proposed last surges of neurotransmitter activity. Others have suggested rebound from long-suppressing medication. The honest reading of the literature is that the explanation remains open.10
I do not want to overclaim here. Terminal lucidity by itself does not prove the soul. It is one piece of evidence — a single anomaly in the biology of dying that the standard materialist picture has trouble accommodating. We will see other pieces, much sharper ones, in the chapters ahead. But it belongs in this chapter, because it sits inside the medical staging of dying that this chapter is mapping. The dying brain is not always a brain that quietly and predictably winds down. It is sometimes a brain that, for a few last minutes, lights up with a clarity that ought not to be there.
My own dissertation found terminal lucidity reported in a meaningful subset of the qualitative accounts in the larger 5,278-case dataset — most often in the form of family members noting that their loved one became suddenly clear, recognized people they had stopped recognizing, and described visions of the dying process shortly before passing.11 The conjunction of terminal lucidity with veridical NDE phenomenology is one of the threads the rest of the book will pick up.
It is worth pausing here to engage the major theological alternative reading of what I have just described. Some careful Christian thinkers — including a substantial faction within the contemporary conditional-immortality movement — argue that the body’s death is the death of the person. There is no immaterial soul that separates from the body. There is only the body, and when the body dies, the person ceases to exist. They will be remade, identical-but-new, at the resurrection.12
This is Christian physicalism. It is a serious position, held by serious scholars — Joel Green, Nancey Murphy, and others. It deserves a serious answer. The full answer is the cumulative case the rest of this book will build, especially in Chapter 23. Here, two preliminary observations are enough.
First, the biological account I have just given does not, by itself, settle the question. The medical staging of the body’s death is equally compatible with two readings. The Christian physicalist reads it as: the person is the dying body, and the body’s death is the person’s extinction. The historic Christian tradition reads it as: the person inhabits the dying body, and the body’s death is the person’s separation from that body. The medical data, by themselves, point at neither reading.13
Second, terminal lucidity already begins to put pressure on the strict physicalist version. If the person is the brain, and the brain is in late-stage destruction, the sudden return of personhood is hard to explain. It is not impossible to fit into a physicalist framework — a determined physicalist will appeal to unknown neurochemistry — but it is uncomfortable. The phenomenon fits more easily within the historic tradition’s view, in which the soul is not produced by the brain but uses the brain, and which can therefore make sense of the soul gathering itself in its last hours of using a failing instrument.
There is a third reading worth naming and dispatching. The strict secular materialist reads the dying body as a machine running down. There is no person. There is no soul. There never was. There are only neurons, and when the neurons die, that is all.
The Christian — whether physicalist or dualist — should reject this third reading on theological grounds long before reaching any NDE evidence. The dying body is the body of someone made in the image of God. The dying breath is the dying breath of someone Christ died for. The body of Christ Himself was a dying body. The Incarnation is, among other things, the divine commitment that bodies, including dying ones, are not machines. They are us.
That theological commitment is what makes the careful biological description of dying not a reduction but a tribute. We are looking carefully at what is happening to the body precisely because it is the body of a person, made by God, loved by God, and dying.
What can we say, then, by way of assessment?
The medical-biological account of dying is well-established. Generations of hospice nurses, palliative-care physicians, and researchers have mapped the active dying phase, the changes in circulation and respiration, the death rattle, Cheyne-Stokes respiration, the agonal phase, and the cascade of clinical and biological death. Anyone who has sat at a deathbed and been told what to expect can confirm what the textbooks say: this is the rough order of events; this is what it usually sounds like; this is what is normal.
That account is not, however, complete. Two clusters of phenomena push beyond the easy picture. The first is terminal lucidity, which is real, well-documented, biologically unexplained, and — at minimum — uncomfortable for the strict identification of the person with the brain. The second cluster is the one the rest of this book will take up: the increasing body of evidence that some dying persons, during cardiac arrest with documented brain shutdown, are doing something that strict physicalism says they cannot be doing — namely, perceiving, thinking, and remembering. We have not yet examined that evidence. This chapter has only laid down the biological floor on which the case will rest.
The Christian theological tradition has always taken the body’s death seriously. The Apostles’ Creed includes “the resurrection of the body,” not “the resurrection of the soul.” The Incarnation took on a body that died. The disciples buried Jesus’ body. Mary Magdalene came to the tomb expecting a body. Christian funeral practice has always handled the body with reverence — anointing it, washing it, dressing it, burying it. The body is not a husk to be discarded.14
But the Christian tradition has also, with near unanimity, held that the body’s death is not the person’s extinction. The dying soul, on the historic reading, is not annihilated and pending re-creation. It is separated — temporarily, painfully, partially — from the body it has used and animated, awaiting the resurrection that will put body and soul back together in glorified form.15 The biology of the body’s death is the visible side of that separation. What happens on the other side — what the soul is doing while the body is dying — is what NDE research has begun to map, and what this book will spend most of its attention on.
The body is real. The body’s death is real. The body’s death is not the death of the person.
Those three sentences are the conclusion of this chapter, and they are the bridge to everything that follows.
For the pastor, knowing what dying looks like medically is one of the gifts you can bring to the bedside. The death rattle is not pain. The agonal breathing is not the person’s last suffering. The mottling on the legs is not a wound. The drift in and out of awareness is not a sign that they have stopped loving you. Many bedside conversations are made worse, not better, when no one knows what is normal. A pastor who has read this chapter, or anything like it, can sometimes give a family one of the deepest gifts there is: the gift of not being afraid of what they are seeing. We will return to this work in Chapter 33.
For the dying, I want to say something simpler. Your body is doing what bodies do at the end. The shrinking, the loss of appetite, the deepening sleep, the changes in your breathing — these are not signs that you are doing something wrong, or failing some test, or that God has withdrawn. The body is laying itself down. The Lord knew it would. The Lord came, in fact, to share it with you. The body that died on Good Friday was a real body, and it died really, and the One who died in it is the One who walks beside you now.
For those who companion the dying, do not look away from the body. The body in failure is still the body of someone you love. Touch it. Pray over it. Bless it. The body of someone who has just died is still, for a few precious hours, the body of a person you have loved. And on the deepest reading the Christian tradition has ever offered, that person is no longer where their body is.
That is what the next chapters will begin to show.
↑ 1. On the twentieth-century medicalization of dying and its consequences, the standard accessible treatment is Atul Gawande, Being Mortal: Medicine and What Matters in the End (New York: Metropolitan Books / Henry Holt, 2014), esp. ch. 1–2. From the theological side, see Allen Verhey, The Christian Art of Dying: Learning from Jesus (Grand Rapids: Eerdmans, 2011), 1–30, and Lydia Dugdale, The Lost Art of Dying: Reviving Forgotten Wisdom (New York: HarperOne, 2020), introduction and ch. 1.
↑ 2. The two-pattern framing (long decline vs. acute crisis), with sub-trajectories for cancer, organ failure, frailty/dementia, and sudden death, follows Joanne Lynn and David M. Adamson, Living Well at the End of Life: Adapting Health Care to Serious Chronic Illness in Old Age (Santa Monica, CA: RAND Health, 2003), and is now standard in the palliative-care literature: see Robert Twycross, Andrew Wilcock, and Paul Howard, Palliative Care Formulary, 6th ed. (London: Pharmaceutical Press, 2017); Nathan Cherny et al., eds., Oxford Textbook of Palliative Medicine, 5th ed. (Oxford: Oxford University Press, 2015), part 1.
↑ 3. The standard signs of the active dying phase are catalogued in BJ Miller and Shoshana Berger, A Beginner’s Guide to the End: Practical Advice for Living Life and Facing Death (New York: Simon & Schuster, 2019), part 4; see also Margaret L. Campbell, “Caring for Dying Patients in the Intensive Care Unit: Managing Pain, Dyspnea, Anxiety, Delirium, and Death Rattle,” AACN Advanced Critical Care 26, no. 2 (2015): 110–120.
↑ 4. The pattern was first described by John Cheyne in “A Case of Apoplexy in Which the Fleshy Part of the Heart Was Converted into Fat,” Dublin Hospital Reports 2 (1818): 216–223, and subsequently characterized more fully by William Stokes in The Diseases of the Heart and the Aorta (Dublin: Hodges and Smith, 1854). On its modern interpretation in dying patients, see Robert Twycross et al., eds., Hospice and Palliative Care Formulary USA, 5th ed. (Nottingham: palliativedrugs.com, 2014).
↑ 5. On the death rattle (terminal respiratory secretions), see Margaret L. Campbell and Linda L. Yarandi, “Death Rattle Is Not Associated with Patient Respiratory Distress: Is Pharmacologic Treatment Indicated?” Journal of Palliative Medicine 16, no. 10 (2013): 1255–1259, which provides empirical evidence that the death rattle does not correlate with patient distress — a finding of considerable pastoral importance.
↑ 6. Sam Parnia, with Josh Young, Erasing Death: The Science That Is Rewriting the Boundaries Between Life and Death (New York: HarperOne, 2013), develops the cellular-cascade picture in detail; see also Parnia, “Death and Consciousness: An Overview of the Mental and Cognitive Experience of Death,” Annals of the New York Academy of Sciences 1330 (2014): 75–93. The boundary question is the subject of Chapter 6.
↑ 7. On terminal restlessness/delirium, see Augusto Caraceni and Luigi Grassi, Delirium: Acute Confusional States in Palliative Medicine, 2nd ed. (Oxford: Oxford University Press, 2011); William Breitbart and Yesne Alici, “Agitation and Delirium at the End of Life: ‘We Couldn’t Manage Him,’” JAMA 300, no. 24 (2008): 2898–2910. Some episodes are clearly attributable to medication, metabolic imbalance, or hypoxia; others remain less clearly explained.
↑ 8. Michael Nahm, “Terminal Lucidity in People with Mental Illness and Other Mental Disability: An Overview and Implications for Possible Explanatory Models,” Journal of Near-Death Studies 28, no. 2 (2009): 87–106; Michael Nahm and Bruce Greyson, “Terminal Lucidity in Patients with Chronic Schizophrenia and Dementia: A Survey of the Literature,” Journal of Nervous and Mental Disease 197, no. 12 (2009): 942–944; Michael Nahm, Bruce Greyson, Emily Williams Kelly, and Erlendur Haraldsson, “Terminal Lucidity: A Review and a Case Collection,” Archives of Gerontology and Geriatrics 55, no. 1 (2012): 138–142.
↑ 9. Alexander Batthyány, “Complex Visual Imagery and Cognition during Near-Death Experiences,” Journal of Near-Death Studies 34, no. 2 (2015): 65–83; and Batthyány’s ongoing work at the Viktor Frankl Institute and the International Network for Terminal Lucidity Research, including prospective protocols for identifying and documenting cases as they occur.
↑ 10. The proposed biological mechanisms (last surges of neurotransmitter activity; rebound from chronic medication suppression; transient compensatory changes in cerebral perfusion) are surveyed in Nahm, “Terminal Lucidity” (2009), and in subsequent literature. None has yet been demonstrated to be the cause; the phenomenon’s biological basis remains an open research question.
↑ 11. Matthew Friend, Near-Death Experiences as Evidence for Substance Dualism within the Conditional Immortality Debate (Th.D. diss., Trinity College of the Bible and Trinity Theological Seminary, 2025), ch. 4, qualitative analysis of 4,446 NDERF and IANDS cases. The full cumulative-case synthesis appears in Chapter 14.
↑ 12. The principal contemporary expositions are Joel B. Green, Body, Soul, and Human Life: The Nature of Humanity in the Bible (Grand Rapids: Baker Academic, 2008); and Nancey Murphy, Bodies and Souls, or Spirited Bodies? (Cambridge: Cambridge University Press, 2006). Within the conditional-immortality movement, Glenn Peoples and Edward Fudge have advanced compatible (though distinct) physicalist anthropologies; see Edward William Fudge, The Fire That Consumes: A Biblical and Historical Study of the Doctrine of Final Punishment, 3rd ed. (Eugene, OR: Cascade, 2011), and Glenn Peoples’ published essays at the Rethinking Hell project.
↑ 13. The most thorough Christian engagement with the dualism-physicalism question, defending substance/holistic dualism against Christian-physicalist alternatives on biblical and theological grounds, is John W. Cooper, Body, Soul, and Life Everlasting: Biblical Anthropology and the Monism-Dualism Debate, rev. ed. (Grand Rapids: Eerdmans, 2000). On the philosophical side, see J. P. Moreland, The Soul: How We Know It’s Real and Why It Matters (Chicago: Moody, 2014); Moreland and Scott Rae, Body and Soul: Human Nature and the Crisis in Ethics (Downers Grove, IL: InterVarsity, 2000).
↑ 14. See Thomas G. Long, Accompany Them with Singing: The Christian Funeral (Louisville: Westminster John Knox, 2009); Verhey, Christian Art of Dying, ch. 4–6; Dugdale, Lost Art of Dying, ch. 7. The Apostles’ Creed’s “resurrection of the body” (carnis resurrectionem) underwrites the tradition’s reverence for the body.
↑ 15. The classic biblical-theological case for the historic dualist reading — the soul as separable from the body but awaiting resurrection — is developed at length in Cooper, Body, Soul, and Life Everlasting; see also Stephen Jonathan, Grace Beyond the Grave: Is Salvation Possible in the Afterlife? A Biblical, Theological, and Pastoral Evaluation (Eugene, OR: Wipf and Stock, 2014), ch. 3, on the biblical (rather than Greek-philosophical) provenance of the conscious-intermediate-state tradition. The intermediate state itself is the subject of Chapter 24.