Chapter 4

What Happens to the Body at Death

The visible side of a person whose other side is withdrawing

The hospice nurse had worked for twenty-three years, and she had learned, she told me once, to read a body the way some people read a page.

We were sitting on a porch outside a small Catholic hospice in central Indiana on a warm Saturday in August. Her name was Janet. The man she had been with that morning, whom she had cared for through the previous week, was named Roger. He was eighty-one. He had been a steel-mill foreman for thirty-eight years and had a long, quiet face and large hands that had grown thin in the last six months. His lungs were almost finished. He had refused intubation, very calmly, and he had asked his daughter to call hospice. Now he was, as Janet put it, in the last mile.¹

What that meant, in her language, was very specific. His feet were already cool to the touch and lightly mottled — the skin marbled with bluish patches as the smaller blood vessels lost their last instructions. The fingertips were the same. His urine output had dropped to almost nothing in the last day. His breathing had begun the long, irregular pattern that experienced hospice nurses know on sight: deep, shallow, deep, long pause, deep, deep, shallow, longer pause. He was no longer eating. He had not taken anything to drink in eight hours. His pupils responded slowly to light. His blood pressure, which they were no longer measuring, had been falling for two days.

But he could still talk. That morning he had told his daughter that he loved her. He had asked, twice, where his wife was. (His wife had been dead for eleven years.) He had said something in Slovak — Janet did not know what — that had made him smile and close his eyes for a long moment.

"He is pulling in," Janet said, watching a hummingbird at a feeder hanging from the eaves of the porch. "That is how I think of it. He is pulling in from the edges. The body is already letting go of the edges. The blood pressure tells you. The kidneys tell you. The hands and the feet tell you. They go first. The center holds longest."

She had seen this — by her own count — somewhere between three and four hundred times.²

"What about the mind?" I asked her.

She turned to look at me with the kind of patience that hospice nurses develop after a few hundred dying patients have asked them every conceivable question.

"The mind is the strange one," she said. "Sometimes the mind goes first, long before the body. Dementia. You know. Sometimes the mind stays clear right to the end and you can talk with the person until the very last hour. And sometimes — this is the part I never got used to — sometimes the mind comes back. People who have not spoken in months, who have not recognized their own children in years, come back for an hour or a day before they die. They wake up. They know everybody's name. They say what they need to say. Then they go."

She paused, watching the hummingbird hover and then dart away.

"I don't know what that is," she said. "Nobody really does."

I want to begin this chapter with Janet's testimony — the hospice nurse on an Indiana porch, watching a steel-mill foreman do what bodies do at the end — because what she had learned over twenty-three years of bedsides is what palliative medicine has been learning, slowly and carefully, for about the last fifty years. And what she had learned is also what the historic Christian tradition learned a long time ago. The body has its own way of dying. The body is not random when it dies. The body is doing something. And what the body is doing is patterned, observable, and — in some respects — strange enough that the strict mechanistic explanations have to strain hard to cover the data.³

This chapter is about the body at death. The next chapter, immediately following, is about the brain at death — and that is a deeper and stranger story, because the moment a body's heart stops, the brain's electrical activity collapses on a precise timetable that we will examine in detail. Before we go there, though, we have to look honestly at the visible thing. The body in its last hours. The hands that grow cool. The breathing that changes. The consciousness that flickers in patterns medical science is only beginning to chart. We have to look honestly because the rest of this book — its claims about the soul, about what is happening at the moment of death, about what the dying are reporting from the boundary — rests on a careful description of what is happening on this side of the line first.

Janet's name has been changed. Roger's name has been changed. Their stories are real, and so is what their bodies were doing.

The Body Has Always Been the Question

The Christian tradition has been answering questions about dying for two thousand years, and for most of those years it has done so without the help of a stethoscope, an electrocardiogram, or a single peer-reviewed clinical study. A medieval village priest carrying the viaticum — the bread of the dying⁴ — to a thatched cottage where a tanner was breathing his last had no monitoring equipment and no medical training. He had a Bible, a prayer book, his own experience of having sat with maybe three or four hundred dying people in his career, and the Ars Moriendi, the "Art of Dying," a tradition of pastoral wisdom that the Western church had been refining since at least the fourteenth century and whose roots go all the way back to the patristic deathbed liturgies.

What that priest saw, over the long years, was very nearly what Janet sees: the long approach, the active phase, the agonal phase, the moment the breath stopped and the body became still. He had names for parts of the process. So did the physicians of his day. The body's signs of dying were not unknown to medieval Christianity. They were known the way a farmer knows the signs of weather — without instruments, but with deep accumulated attention.⁵

What was lost, in the long centuries between the medieval Ars Moriendi and the contemporary recovery of a theology of dying, was not the knowledge of how the body dies but the integration of that knowledge with a serious theology of the dying soul. In the twentieth century, dying moved from the home to the hospital. The dying body became a medical event. The dying soul became, for many physicians, an awkward metaphysical residue that did not appear on any chart they had been trained to read. The pastor and the physician went separate ways. The patient's death became the failure of the medicine, not the passage of a person. Atul Gawande's Being Mortal, published in 2014, is the contemporary century's most-read description of what that separation cost — and of how the hospice and palliative-care movements have begun, painstakingly, to put the pieces back together.⁶

I am writing this chapter for two kinds of reader. The first is the Christian who wants to know what the body is actually doing in those last days and hours, because she will be in the room when her mother dies, or her husband, or her child. The textbooks know more than her grandmother knew. She wants the textbook knowledge — and she wants it told plainly. The second reader is the pastor, the chaplain, the theologian, the seminarian. He has read the Ars Moriendi traditions; he has the historic Christian theology of dying in his bones. What he sometimes lacks is fluency in the medical phenomenology that the contemporary palliative literature has mapped. Both readers need the same thing: a careful, accessible, honest account of what dying — bodily dying, the visible kind — actually looks like.

And I am writing it from a particular place, which I want to name. I write as a Christian who believes that the body is the visible side of a person whose other side, in dying, is withdrawing. The medical-biological story is real. The body's collapse is real. The grief is real. But the body is not the whole. What you are watching, when you watch a beloved person die, is not the running-down of a machine. It is the slow withdrawal of a person from the matter through which she has, for many years, made herself known to you. The biology is true; it is just not the whole truth.

That theological frame should be visible from the start. I am not going to keep it hidden and then surprise you with it in the last paragraph. I think the medical and theological accounts are integrated. I think they have always been integrated. I will give you the medicine straight. But you should know what I think.

The Two Trajectories: The Long Slope and the Short Cliff

People die in two main shapes. Palliative medicine has known this for several decades, and the shapes are now well-described in the literature.⁷ Knowing them changes what you see at a bedside.

The first shape is the long slope. Someone has a chronic illness — cancer that has metastasized, advanced heart failure, end-stage chronic obstructive pulmonary disease (COPD), end-stage liver or kidney disease, or one of the slow neurodegenerative dementias. For weeks or months or years, the person becomes gradually weaker, eats less, sleeps more, requires more help with the basic acts of being alive. The slope is not always smooth. Sometimes there are rallies, where the person feels better for a few days and the family begins to hope. Sometimes there are cliffs within the slope, where things suddenly get worse and then level off again. But the overall shape is a slow descent. The body is winding down. The dying nurse Janet was watching with Roger had been on this slope for two years.

The second shape is the short cliff. Someone is well one day and gone within hours or days. A massive heart attack. A stroke. A car accident. A pulmonary embolism. A sudden severe infection. The transition from full life to death is fast — sometimes minutes, sometimes a few days. There is no time for the family to gather. There is no slow goodbye. The body stops abruptly.

There is also a third pattern, which the medical literature calls the frailty trajectory: an old person becomes more and more diminished over a long stretch, with no single illness in the foreground, until at some point a small infection or a simple fall starts a cascade and the person dies a few weeks later.⁸ But the two main shapes, for our purposes, are the long slope and the short cliff.

I name the trajectories because they shape what we see. The book is going to talk a great deal about NDEs that happen during cardiac arrest — the short-cliff event par excellence. But many NDEs also happen during prolonged illness, during the long slope, during the active dying phase that many readers of this book will have witnessed at the bedside of a parent, spouse, or friend. The biology of dying is not one biology. It is a family of related processes, and the active dying phase — the last twenty-four to seventy-two hours, which is where the visible biology becomes most striking — looks broadly similar across both shapes, even when the path that led there was very different.⁹

The Active Dying Phase

What hospice nurses call "active dying" is the body's last twenty-four to seventy-two hours, sometimes a little longer. It is, for the family, the part that begins to look unmistakably like dying. Before that, the person was sick and frail. Now the person is going.

What happens during the active phase is, in the contemporary palliative literature, fairly well-characterized. The Oxford Textbook of Palliative Medicine, the standard reference work in the field, devotes detailed sections to the recognized signs.¹⁰ Janet, on the porch, was naming them as a senior nurse names them, in working language. Let me lay them out one by one.

Circulation pulls in. The heart, even when it is not yet failing acutely, begins to give priority to the central organs over the peripheral ones. Blood pressure falls. The hands and feet grow cool, and then sometimes mottled, with bluish-purple marbling that hospice nurses call livedo reticularis — the body's small blood vessels relinquishing their grip. The pulse is weaker at the wrist than at the neck. By the last hours, the peripheral pulses may be very faint or undetectable, even when the heart is still beating audibly under the chest. The body is concentrating its dwindling resources where they will do the most.

The kidneys slow and then stop. Urine output drops, often dramatically, in the last day. The urine, when it is still being produced, becomes dark and concentrated. By the final hours there is usually almost none. This is one of the markers experienced hospice nurses will name when a family asks how long there is — not as a precise predictor, but as a sign that things have crossed a threshold.

Eating and drinking stop. The dying body very commonly loses interest in food and water in the last days. This is one of the things families have the hardest time accepting. We have been feeding our beloved person all his life. Now we want to feed him still. But the body, in the active phase, does not want food. The hunger and thirst signals fade. Forcing fluids at this point — through an IV, through a feeding tube — does not, on the current palliative-medicine evidence, prolong life or make the dying person more comfortable.¹¹ It often makes things worse: more fluid in the lungs, more secretions in the airway, more discomfort. The body is letting go of its appetites in good order.

Sleep deepens. The dying person sleeps more, often through most of the day. Wakefulness becomes intermittent and brief. The sleep is not always restful in the ordinary sense; it can be punctuated by stirrings, mumblings, half-awakenings. But the trajectory is unmistakable: more sleep, less waking.

Breathing changes. This is the change families notice most, because they hear it in the silence between sentences, between visits to the room. Breathing in the active phase is no longer steady. It becomes shallow, then deep, then shallow, with pauses. The pauses lengthen. By the agonal phase, which I will describe in its own section, the breathing has its own distinctive shape.

Consciousness fluctuates. The dying person may be lucid in one hour and confused the next. Some confusion is medical — a low oxygen level, a urinary infection, a buildup of waste products the kidneys are no longer clearing. Some is part of dying itself, as we will see when we come to terminal restlessness. And some is the strange, inexplicable rallying that Janet named, which the literature now calls terminal lucidity.

The remarkable thing, for someone reading this list for the first time, is how predictable it is. Hospice nurses who do this work for years — Janet, the staff at the great hospices like Christopher's in London, the workers at the small Catholic hospice in central Indiana where I sat with Janet — speak of these signs the way a sailor speaks of clouds and wind. The signs are not infallible. The body sometimes does unexpected things. But the general pattern, when the active phase is unfolding, is recognizable enough that an experienced clinician can usually tell the family, with reasonable confidence, that the time is short.¹²

One of the gifts of the modern hospice movement, beginning with Cicely Saunders and the founding of St. Christopher's in 1967, has been the careful documentation of these signs and the steady transmission of that knowledge to families.¹³ A hundred years ago every village had three or four older women who had attended dozens of deathbeds. Then we put dying in hospitals and the older women lost the apprenticeship; the doctors did not have it because they had been trained to cure rather than to companion. The hospice movement is, in a deep sense, a recovery: the bedside skill that the church once carried is being relearned, this time inside a medical specialty that takes the dying seriously again.

I want to underline this point because it matters for the rest of the book. Much of what experienced hospice clinicians know about the active dying phase was lost from common Christian pastoral knowledge during the twentieth century. The pastor who arrives at a hospital bedside today, in much of the West, has often had no formal training in what he is looking at. He has not been taught to read mottling, or to distinguish agonal breathing from struggling breathing, or to explain to a panicked family that the rattle is not what it sounds like. He brings prayer and presence, which are not nothing — but he is missing a working bedside literacy that, for most of Christian history, the parish clergy possessed as a matter of course. The recovery of dying-well theology that Chapter 3 traced is not just a recovery of liturgy and doctrine; it is also, at the level of bedside competence, a recovery of the skill of watching. The pastor who knows what the body is doing can, with the same prayer and the same presence, give a family a steadier and more truthful kind of help.

Terminal Restlessness, Terminal Lucidity

Two specific phenomena of the active dying phase deserve their own treatment, because both bear on what we will be asking, in the rest of the book, about the relationship between the dying body and the dying mind. The first is terminal restlessness. The second is terminal lucidity.

Terminal restlessness is the agitation, sometimes severe, that some dying people exhibit in the last hours or days. The patient may pluck at the sheets, try to climb out of bed, cry out, pull at lines and tubes, mumble incoherently, refuse to be comforted. It is one of the hardest things for a family to watch. It looks, to the bedside, as if their beloved is suffering deeply.

Some of terminal restlessness is straightforwardly medical. An undiagnosed infection. Pain that has not been adequately controlled. A full bladder. The buildup of metabolic waste — uremia, hepatic encephalopathy — that throws the consciousness off its hinges. Hospice clinicians are now well-trained to look for these treatable causes first, and the contemporary literature has improved considerably the management of restlessness.¹⁴ Adjusting medications, attending to comfort, sometimes a small dose of a sedating drug, almost always brings relief.

But not all terminal restlessness has a clean medical explanation. The dying brain is doing something complicated in the last hours, and some of the agitation may be the brain's last waves of organized activity colliding with sensory inputs and unprocessed memory. We do not yet know all of it. What hospice nurses tell families is, on the whole, true: it usually looks worse from outside than the patient feels from inside, and most of the time it can be managed. The patient is not, in most cases, in the kind of pain the family imagines.

The second phenomenon, terminal lucidity, is the one Janet named on the porch and the one that has fascinated me for years. Terminal lucidity is the sudden, unexpected return of clear consciousness in a dying person whose mental life had previously been severely impaired — by advanced dementia, by long-standing severe psychiatric illness, by stroke, sometimes by deep brain disease. Hours or days before death, the lights come back on. The person speaks clearly, recognizes loved ones, says what needs to be said. Then, very often within twenty-four hours, the person dies.¹⁵

The phenomenon was carefully documented by the German psychologist Michael Nahm and, with him, by the American psychiatrist Bruce Greyson, in a series of papers beginning in 2009. Nahm coined the term terminal lucidity in its current usage and surveyed the historical literature, going back to nineteenth-century clinical case reports.¹⁶ One of the most striking historical cases — and the one Nahm and Greyson have made widely known in the contemporary literature — is the case of Anna Katharina Ehmer.

The Ehmer case is unusual for its dramatic clarity, but it is not unique. Nahm's literature surveys identified, by the time of his 2012 review, more than eighty historical case reports of comparable phenomena.¹⁸ A more recent study by Sandeep Batthyány at the Viktor Frankl Institute, working with hospice and nursing-home staff, has begun the systematic prospective documentation of contemporary cases.¹⁹ Hospice clinicians, when polled, very commonly report having seen at least one or two cases over a long career — though the phenomenon is rare enough that no individual nurse will see many.

Now, terminal lucidity is not by itself an argument for substance dualism. There may turn out to be neurological mechanisms that account for it — perhaps a final surge of certain neurotransmitters, perhaps the temporary suppression of inflammatory processes that had been damaging cognition, perhaps something subtler. The phenomenon is genuinely puzzling on the standard physicalist account, because the normal state of advanced dementia is permanent neuronal loss; lost neurons do not, on the conventional account, suddenly resume function. But it is not impossible to imagine a physicalist explanation.

What terminal lucidity does, for the larger argument of this book, is something more modest and more interesting. It tells us, with documentary force, that the relationship between the dying brain and the dying consciousness is not a simple, one-way story of progressive shutdown. The brain can be, by all medical assessment, severely and permanently damaged — and yet, at the threshold of death, the person can come back, whole and clear, for a final hour. Whatever is happening in those final hours is more complicated than the brain-as-machine story will easily accommodate.

I will mention terminal lucidity again only briefly in later chapters; the full development of its theological significance lies in the cumulative case. For now, I want only to note that it belongs alongside the other puzzling phenomena — alongside veridical NDEs, alongside the deathbed visions we will discuss when we come to welcoming-party encounters — that fit awkwardly into the strict mechanistic account of dying.

The Agonal Phase

The word agonal comes from the Greek ἀγών (agōn), which means a contest, a struggle. The agonal phase, in modern medical usage, is the body's last, most distinctive phase before death — the phase during which the breathing pattern becomes unmistakable and the heart begins to fail in the final way.²⁰

The agonal pattern is most often what is called Cheyne–Stokes respiration, after the Irish physician John Cheyne (who described it in 1818) and the Irish physician William Stokes (who described it again in 1854).²¹ The pattern is rhythmic but not regular: progressively deeper and faster breaths build to a peak, then progressively shallower and slower breaths trail off, then a pause — sometimes long enough that the family thinks the person has died — then the cycle begins again. The pause may last fifteen, twenty, even thirty seconds. Then a deep breath, then another, then the build, and the cycle repeats.

Cheyne–Stokes is not unique to dying. It can occur in heart failure, in some sleep disorders, in some neurological conditions. But in the active dying phase, when other signs are converging, it is often the unmistakable signature of the body's central regulators losing coordinated control. The brain stem, normally the steady metronome of breathing, is no longer issuing the smooth instructions it has issued for the patient's whole life. The respiratory drive is becoming choppy.

Often, in the last hours, the breathing pattern shifts again, into agonal breathing proper — a slower, gasping, irregular pattern sometimes called "fish breathing" or "mandibular breathing" because it can look like a fish out of water, the jaw opening and closing in a slow rhythm with each gasp. Agonal breathing is, despite how it sounds, not a sign of the patient suffering. The patient at this point is generally beyond conscious experience of distress; agonal breathing is the brainstem's last reflex pattern before respiration stops.²²

The other distinctive sound of the agonal phase is what hospice has long called the death rattle. As the patient becomes too weak to swallow saliva and other respiratory secretions, fluid pools in the upper airway, and each breath produces a wet, rattling sound. It is one of the most disturbing sounds for families. It can be partly managed with positioning and, if needed, with medications that reduce secretions; but it cannot always be eliminated. Hospice clinicians explain to families, gently and repeatedly, that the rattle does not mean the person is choking or struggling. It is simply the sound of breath moving past unswallowed fluid in a body that has nearly finished its work.²³

When the Heart Stops

At some point, the agonal phase ends. The breathing slows and becomes more irregular. The pauses lengthen further. There is a last breath — sometimes a deep one, more often a shallow one almost indistinguishable from the breaths that preceded it. There is a last beat of the heart. There is a moment when no further breath comes, and then a moment when the family realizes that no further breath is going to come.

The medical name for this is cardiopulmonary arrest: the simultaneous cessation of circulation and respiration. In a hospital with monitors, it appears as the flat-lining of the cardiac trace. In a hospice or a home, it appears as the long pause that finally does not end.

What follows the moment the heart stops is a cascade of biological events with their own precise timetable. Within seconds, blood stops moving through the tissues. Within ten to twenty seconds, the brain — for reasons we will examine in the next chapter — loses its organized cortical electrical activity. Within thirty to sixty seconds, the EEG, if one is being recorded, becomes effectively flat. Within two to four minutes, neuronal damage from oxygen deprivation begins to become irreversible. Within five to ten minutes, the brain has typically suffered damage from which recovery, even with full resuscitation, would leave permanent impairment. Within minutes more, the cells throughout the body begin the long, slow biochemical descent that will end, hours later, in the final stillness of the body's chemistry.²⁴

This is the cascade of somatic death: the death of the body as an integrated, functioning organism. It is followed, on a slower timetable, by biological death: the death of the body's individual cells and tissues, which continues for hours after the heart has stopped. Some cells last longer than others. The cornea and the heart valves remain transplantable for a while after death. Hair and fingernails do not "continue to grow," as folklore has it; they only appear to, because the surrounding skin retracts as it dries. But the cellular life of the organs, slowly and relentlessly, fades.²⁵

The medical determination of death has, in modern hospitals, become a more carefully regulated thing than people sometimes realize. A patient is declared dead either by cardiopulmonary criteria (the heart and lungs have stopped, and a clinician confirms after a brief period that they will not restart) or by neurological criteria (the brain, including the brain stem, has irreversibly ceased to function — the so-called "whole-brain death" standard). Both standards have their own clinical protocols, and both are objects of careful contemporary medical and bioethical scrutiny.²⁶ The boundary question — when, exactly, is a person dead? — is the subject of the next chapter but one, where it can receive its full treatment.

For our present purposes, the description has to be, on the body's side, this stark: the heart stops; the breathing stops; within seconds the cellular machinery begins to fail; within minutes the damage to the brain's neurons becomes irreversible; within hours the body's organized chemistry has dissolved into the slower chemistry of postmortem decay. The body, on this side, has finished.

And it is precisely here — at the moment when, by the strict physicalist account, all the conditions for consciousness have ceased — that the testimonies the rest of this book examines begin. People who have been declared clinically dead, whose hearts had stopped and whose brains had been measured (in the cases where such measurement was being done) to be electrically silent, return with detailed accounts of what they experienced during the period in which their bodies were not, by any medical measure, capable of having an experience. That contradiction is what the book is about. It rests on the biological description we have just given.

Where the Body Is Honored

Before we come to the alternative explanations, I want to spend a few hundred words on what the Christian tradition says about the body that has just done what we have been describing.

The body matters. Christianity has never taught otherwise, despite charges sometimes leveled at it from outside.²⁷ The body is good. Genesis describes the body as formed from the dust of the ground by God's own hand, animated by the breath that God himself breathes into it.²⁸ The body is part of what God calls "very good" in the seventh verse of Genesis 1. The body is the garment God gave the human; the body is the instrument through which the human acts in the world; the body is the place where the human's love and friendship and service are made visible to other humans.

The Incarnation makes the body's status in Christian theology beyond all dispute. The eternal Word, the Logos, the Son of God, took on a body — a real, weighty, hungry, sleepy, tireable, woundable, mortal human body. He grew tired and slept on a boat. He grew hungry and ate fish. He took children up in his arms. He was beaten and bled and died. And then, after the Resurrection, he ate broiled fish on a beach with his friends. The Christian creed of the resurrection of the body is not an optional addendum; it is the central Christian claim about the destiny of human persons. We are not destined to disembodied existence. We are destined to be reunited, in glorified bodies, with the matter through which our selves have always made themselves known.²⁹

So when I say, in the rest of this book, that the dying body is the visible side of a person whose other side is withdrawing, I am not saying that the body is the unimportant side. The body is real. The body is precious. The death of the body is a real loss, not a stage prop. The grief of the family at the bedside is grief over the loss of something genuinely beloved, not merely the loss of a temporary container. Christian dualism, properly understood — what philosophers and theologians call holistic dualism — is far closer to the biblical anthropology than it is to the disdainful Platonic dualism that disparages bodies as prison houses.³⁰ The body and the soul belong together. They have been one organism for a lifetime. Their separation is a wound in creation that the Resurrection alone will heal.

This is why Christian funeral practice has, from the earliest centuries, treated the body of the dead with reverence. The body is anointed. The body is washed. The body is dressed. The body is buried with prayers and with care. The early Christians braved persecution to recover and bury the bodies of their martyrs. The catacombs are full of inscriptions of love over the bones of the beloved. The medieval church developed elaborate liturgies of commendation for the dying and elaborate liturgies of burial for the dead. The body, as the Apostle Paul wrote, is "a temple of the Holy Spirit"; that the temple has now fallen silent does not mean the Spirit will not in time raise it again.³¹

What I am about to say, in the next section, about the alternative explanations of dying — the strict physicalist account, the Christian-physicalist account — therefore has to be read against this prior commitment. The dualism this book defends is a dualism that holds the body in honor. It is not the dualism of the disdainful philosophers. It is the dualism of the Apostles' Creed: "I believe in the resurrection of the body."

Is the Body the Person? — A Christian-Physicalist Question

The most thoughtful contemporary opponents of the position I am defending are not the secular materialists. They are fellow Christians who hold what is now called Christian physicalism or Christian materialism: the view that the human person is a complex physical organism, with no separable soul, and that what survives death is — strictly — nothing, until God reconstitutes the person at the resurrection.³² The leading defenders of this position in the contemporary discussion include Joel Green, the New Testament scholar at Fuller Theological Seminary, and Nancey Murphy, the philosopher of science at Fuller. Glenn Peoples, working from the conditional-immortality movement, has defended versions of the same position. These are serious Christian scholars writing in dialogue with the church's tradition. They are not to be dismissed.³³

Christian physicalism, as it bears on the topic of this chapter, makes a specific claim about the dying body. The claim is roughly this: when you watch a beloved person die, what you are watching is the failure of the person, not the visible side of the person. The body is the person. There is no other side. When the body's organized functioning ceases, the person ceases — until God, at the resurrection, reconstitutes the person from the same matter (or different matter that God identifies as continuous with the original). On this view, the dying we have been describing is the slow extinction of a human being, full stop. There is no "withdrawal" because there is no second thing to withdraw. The grief of the bedside is grief over a person who, for the period between death and resurrection, has truly ceased to exist.

Christian physicalists do not claim that the New Testament settles this question against them. They argue that the New Testament's apparent dualism — the references to the soul and spirit, the language of "departing to be with Christ," the imagery of disembodied martyrs under the heavenly altar in Revelation — is either symbolic, or has been misread under the influence of later Greek philosophical categories. Their case has been made with care; it deserves a careful response, which the book offers in Chapter 23 and in Chapter 24.³⁴

What I want to do in this chapter is much more limited. I want to ask: does the biological description of dying — by itself, without yet bringing in the NDE evidence the rest of the book will examine — sit comfortably with the Christian-physicalist account, or with the historic dualist account, or with neither, or with both? My answer is that the biology alone is consistent with both readings, but with different degrees of strain.

Where the dualist account fits the biological data without strain. The dying body progressively withdraws from the periphery toward the center. The visible signs are signs of withdrawal, not of pure mechanical breakdown. The hands grow cool because the circulation is being concentrated centrally; the kidneys slow because the body's resources are being conserved; the eating and drinking stop because the body is letting go of its appetites in good order; the consciousness fluctuates and sometimes, just before the end, suddenly clarifies. These are not the signs of a machine running down. They are the signs of an organism doing something — something with shape, something with rhythm, something that looks (to the experienced observer) intentional in its sequencing. The dualist tradition has always read those signs as the visible signs of the soul preparing for departure.³⁵

Where the physicalist account fits the biological data, but with more strain, the strain is this: the strict physicalist has to render terminal lucidity, in particular, as the brain's surprising final flourish before total collapse. This is not impossible. But it is a hard story to tell. A patient whose brain has been measurably and progressively damaged for years, whose neurons have been counted on autopsy or imaging studies and found to be greatly reduced, whose cognition has been impaired by every available behavioral measure — that patient suddenly, in the hours before death, displays clear, articulate, integrated consciousness. A physicalist account has to explain how the brain that could not produce coherent speech for eight years suddenly, with even fewer functional neurons, produces coherent speech at the threshold. The dualist account has the resource of saying: the soul is still all there. What was failing was the brain's ability to mediate the soul's expression. As the soul prepares to depart from the body, perhaps for a moment the mediation is briefly transparent again. The physicalist has to tell the same story without that resource.

The biology alone does not settle the question. I want to be honest about that. But the biology, read carefully, is more friendly to the dualist reading than the physicalist literature usually admits. The phenomena of the active dying phase — and especially the puzzling ones, terminal lucidity above all — have a certain shape that the dualist tradition has always recognized: the organism letting go, the soul preparing to leave, the body finishing its long, faithful work and being allowed to rest.

And there is a second alternative I should briefly name, since it is sometimes invoked by Christian physicalists in the conditional-immortality movement: the doctrine of soul sleep. On this account, the dead are unconscious, in a kind of deep sleep, between physical death and resurrection. Soul sleep has had defenders in church history — Martin Luther sometimes flirted with versions of it; some early Adventist writers held it; Edward Fudge, in The Fire That Consumes, treats it sympathetically.³⁶ Soul sleep is not, strictly, a physicalist position; it allows that there is a soul, but holds that the soul is unconscious until the resurrection.

The biological data of this chapter does not rule out soul sleep. What rules out soul sleep, if anything does, is the NDE evidence the rest of the book will examine — together with the New Testament texts on the conscious intermediate state (Luke 23:43; 2 Corinthians 5:8; Philippians 1:23; Revelation 6:9–11), which the historic Christian tradition has read with remarkable consistency.³⁷ I will not attempt that argument here. I name soul sleep because it is one of the views in the conversation; the chapter that handles it directly is Chapter 24.

What the Biology Tells Us — and What It Does Not

It is worth stepping back and asking, plainly, what we have so far established and what remains for later chapters.

We have established that dying, in the body, is a patterned process. The body does not collapse randomly. The body collapses according to a recognizable sequence: peripheral first, central last; the kidneys early, the brainstem reflexes very near the end; circulation pulling in toward the heart, then failing; respiration becoming irregular, then shifting into the agonal pattern, then stopping altogether. The pattern is not absolute; individual cases vary. But the pattern is real, and well-described in the contemporary palliative literature, and predictable enough that experienced clinicians can read the body's progress with considerable accuracy.³⁸

We have established that the dying body sometimes does things that fit awkwardly into the strict mechanistic description. Terminal lucidity is the most striking instance, but there are others — the deathbed visions some dying patients describe of relatives they did not know had died; the rallying clarity in the hours before the end; the curious peacefulness that hospice workers regularly observe in the last hours, even in patients whose earlier course was anguished. None of these phenomena, by itself, is decisive. But all of them, taken together, suggest that the dying body is not a closed system whose behavior is fully predictable from its physical states alone.³⁹

We have established that the historic Christian tradition's reading of the dying body — as the visible side of a person whose other side is preparing to depart — is fully consistent with the biological data, and arguably handles the puzzling phenomena (especially terminal lucidity) more naturally than the strict physicalist alternative.

We have not established that substance dualism is true. That argument requires the NDE evidence the rest of the book will examine — particularly the cases of veridical perception during cardiac arrest, the cases involving congenitally blind NDErs, the cases of encounters with deceased relatives the patient did not know had died. The biology alone is suggestive; the biology together with the NDE evidence is, in my judgment, decisive. But that case has yet to be made.

We have not yet examined what happens to the brain at death. Chapter 5 takes that up. The brain's collapse, on the strict physicalist account, should mean the cessation of consciousness within seconds of cardiac arrest. The fact that consciousness sometimes manifestly persists — and sometimes, on the testimony of NDErs, includes detailed perception of the surrounding environment that is later verified — is what makes the brain story so much more difficult than the body story. We have to walk that road carefully, and Chapter 5 walks it.

We have not yet examined the question of when, exactly, a person is dead. The contemporary medical and bioethical conversation about the criteria for death — cardiopulmonary criteria, neurological criteria, the relationship between them — is a serious one and bears directly on the question of what is happening at the moment a person crosses from one side to the other. Chapter 6 handles that question.

We have not yet entered the NDE evidence proper. The case files begin in Chapter 7, with a brief history of NDE research, and the major evidential chapters begin in Chapter 10. The 5,278 cases I analyzed in my doctoral dissertation, of which 1,618 met the dissertation's "Exceptional" or "Strong" thresholds for evidential weight, are still ahead of us. The cumulative case is what those chapters build.⁴⁰

What this chapter has been doing, then, is foundational. We have set the visible scene. The body dies in patterned ways. The Christian tradition has long read that dying as the separation of soul from body. The physicalist alternative is intelligible but, on at least one set of phenomena, strained. Now we are ready to turn to the brain — where the strain becomes much more difficult for the physicalist to manage — and from there into the NDE evidence itself.

Before we close this chapter, one more piece of the biological story is worth flagging — though it is a piece I am only flagging, and not developing. The body does not, in most cases, give up easily. The body fights to live. The body's design — and I use that word advisedly — is for life. Even the dying body, in the active phase, is doing a great deal of work to keep its central functions going as long as it can. Hospice clinicians frequently remark on how much harder the body works in its last days than people realize. The pulse may be thready, but the heart is laboring. The breathing may be irregular, but the respiratory drive is still firing. The body fights, in a real sense, to the last hour.⁴¹

And then, near the end, the fighting stops. Sometimes the dying person becomes very peaceful — not because the body's struggle has been suppressed by medication (though medication can certainly help) but because the struggle simply yields. The breathing slows. The face relaxes. The hands, which had been tense, open. The dying person settles. Hospice nurses speak of this as the body "letting go" in its own time. It is one of the gifts of dying well — and it is, in the dualist tradition's reading, the moment when the work of separation is nearly complete and the soul is preparing for its passage.

Why This Matters

I want to close with the pastoral horizon — because I am writing this book not only for scholars but for pastors, for chaplains, for the children of dying parents, for the wives and husbands and friends of dying people, for those facing their own death.

The body that you are watching die is not a defective machine. It is a person. The visible side of a person. The other side, on the reading of this book, is preparing to depart — but the visible side is no less real, no less precious, and no less worthy of your full attention while it is still in front of you.

Sit with the body. Hold the hand. Speak to the person. The current state of medical and pastoral evidence suggests strongly that a dying person retains some degree of awareness much longer than the family imagines, including the awareness of voices, the awareness of touch, the awareness of presence. Hearing is, on the clinical literature, often one of the last senses to fade.⁴² Speak the names of those who are present. Speak the names of those who have gone before. Speak, if your tradition gives you the words, the name of Christ. The dying person may give no visible response. That does not mean she does not hear.

Be patient with the changes. The mottling of the hands is not painful. The death rattle is not, for the patient, the choking sound it sounds like. The agonal breathing is not the suffering it appears to be. Hospice clinicians have learned, slowly and at the cost of long pastoral attention, that what looks distressing from outside is very rarely as distressing from inside as the family fears. Trust the people who do this work for a living. Their experience is not nothing. Their experience is the recovery of an ancient bedside wisdom.

If you have time, learn the rhythm of the dying day. The active phase has its own pacing. There are stretches of stillness, and then a flurry — a stirring, a half-spoken sentence, a hand reaching out — and then more stillness. There may be visitations: the dying person speaking to someone you cannot see, or naming a person long dead, or smiling at the empty corner of the room. These moments may unsettle you; do not be quick to dismiss them. The deathbed-vision literature, which we will examine in a later chapter, is by now substantial. Whatever else is going on, what your beloved person is reporting in those moments is real to her. Receive it with seriousness. Do not correct her. Do not try to bring her back to your version of the room. She is, on the reading of this book, in the process of leaving the room — and the leaving has its own integrity.

Honor the body afterwards. Wash the body. Sit with the body. The body is not, the moment after death, a thing rather than a person. The body has been a person all its life and remains, in the Christian view, the person's bodily side — soon to be raised, finally to be glorified, awaiting the resurrection. Christian funerals have, from the earliest centuries, treated the body with reverence; that practice has good theological reasons behind it. Resist the cultural pressure to whisk the body away as quickly as possible. The body's last gift is to teach you something about the weight of incarnate existence — and about the weight of the loss when an incarnate person departs.

Grieve the loss. The death of the body is real. The grief is real. The Christian tradition has never asked the bereaved to pretend otherwise. Jesus wept at the tomb of Lazarus, even knowing what he was about to do.⁴³ The Apostle Paul did not say, "Do not grieve"; he said, "Do not grieve as those who have no hope" — a very different instruction.⁴⁴ Christian grief is not stoic. Christian grief is grief in the company of hope.

And then — when the body is still, when the breathing has stopped, when the long work of dying is done — turn the question. The body has finished. What about the person? What about the side that, on the reading of this book, has been withdrawing as the body's signs gathered? What is happening to the person now? That is the question the rest of the book is built to ask. The chapters ahead will examine, with careful attention to the medical data and the testimony of those who have come back, what the dying are doing in those moments and minutes after the body has finished its work.

Janet, the hospice nurse on the porch in Indiana, said to me at the end of our conversation: "The body knows what it's doing. Mostly. The body is doing something at the end. You can read the body. But the body is not the whole story. I have been doing this for twenty-three years and I'll tell you — there is something else there. I don't know exactly what. But I know there is something."

That, in the end, is what this chapter has tried to say. The body's death is real and patterned and meaningful. The body's death is also not the whole story. There is something else there. The chapters ahead will tell you what some of it looks like.

The dead body lying in the room you are sitting in is not the failure of medicine. It is not the failure of love. It is not even, on the reading I am defending, the failure of the person. It is the visible side of a passage. The Christian tradition has known this for two thousand years. The contemporary palliative literature has confirmed, on its own terms, much of what the tradition saw. The NDE evidence the rest of the book examines provides, I believe, the strongest empirical confirmation we have ever had of what the tradition was looking at. And the person whose body has just finished — whom you have loved, and whom you are now mourning — is, on the historic Christian reading, on the next step of a journey whose first chapter is now complete.

The body has finished. The person has not.

That is what the rest of this book is about.