“Terminal Lucidity”: How to Discuss a Topic So Barely Studied?

The purpose of this article is to debate the issue of “terminal lucidity”. Although there are clear records of its occurrence for over 250 years, the concept is not yet well established in the literature. Only in 2009, the correlation between the term itself and the fact that there was spontaneous remission of the symptoms of certain patients close to the moment of death is more intense. The subject has been debated within two visions: the first from the philosophical-spiritual perspective and the second from the medical-scientific perspective. The second is increasingly gaining ground as publications are emerging worldwide, often involving patients with neurological and / or psychiatric disorders. The technical gap on the subject reveals, on the one hand, the understanding in the popular imagination about the investigated problem and, on the other, the methodological difficulties in giving a scientific treatment to the object of analysis.


Introduction
In clinical practice, professionals are often exposed to cases in which terminally ill patients suddenly improve their clinical condition and then die. Despite its relative frequency, the concept of "terminal lucidity", "health visit", "pre-death improvement", "pre-death remission", among other terms, is rarely found in the literature. In addition to the effect on the prognosis of the individual, is to consider its impact on the family experiencing this event, which can sometimes be misunderstood due to lack of knowledge and negligence of medical staff [1].

Objective
Discuss the scientific knowledge about "Terminal Lucidity" and its citations in the literature.

Methods
The study was conducted from a literature review in PubMed and Google Scholar databases, looking for articles that somehow tried to explain and / or exemplify the term "Terminal Lucidity". The topic was also researched in a textbook dealing with the discussion of death and its nuances [2].

Discussion
Palliative care is becoming increasingly present in medical education and publications and, therefore, terminal patientfocused care makes health professionals increasingly face situations in which scientific knowledge alone is not able to explain.
The recognition of the death process is considered one of the most difficult tasks in the medical field. Although this concept is not accurate in the literature, its about a moment in the evolution of a patient from which the irreversibility of the disease makes any treatment aimed at prolonging life, prolonging suffering. Typically, during the final phase (last 48 hours) anorexia and no fluid intake, immobility, cognitive impairment, myoclonus, pain, peripheral collapse, functional failure and final snoring are observed [3].
It was not until 1975 that another detailed article on terminal lucidity was published in a medical journal, thus becoming the only publication on the subject in the twentieth century. It was only in 2009 that Dr. Michael Nahm, one of the leading researchers in the field, first used the term "Terminal Lucidity", which has since been widely disseminated [2].
Despite the least attention in the recent decades, the unexpected mental clarity and memory recovery shortly before death is a curious phenomenon at least and it has been reported in the medical literature over the last 250 years. The scientific term used by the very first time in 2009 and already widespread by Dr. Michael Nahm, one of the leading researches in the field, is known as terminal lucidity. In one of the views on death lucidity and its process, we have the following description: When each one of the cells realizes that their time here is ending, they strive to show, for one last time, their best state of functioning. Then, you leaver cells will be exemplary hepatocytes, those in your lungs incredibly adept at gas exchange, your brains cells awaken, and those unsed neurons all wake up and curiously look at the scene and say 'Let me see what is going on.' Suddenly, your whole body works well [1].
There are numerous reports of its presentation. The fact that a patient suddenly recover his consciousness, say goodbye to his family, remember their names and events after a long period of inability to learn, with progressive short-and long-term memory loss, is a complete mystery. However, it is undeniable that in some cases the spontaneous remission of symptoms occur.
After the first half of the nineteenth century, however, the scenario showed a significant drop in the academic interest in the area. The cases came to be published by authors more interested in the philosophy of mind and brain, and not necessarily by doctors. It was not until 1975 that another detailed article on death lucidity was published in a medical journal, thus becoming the only publication on the subject in the twentieth century. It was only in 2009 that Dr. Michael Nahm, one of the leading researchers in the field, first used the term "Terminal Lucidity", which has since been widely disseminated [2].
Despite the least attention in the last decades and the scarcity of scientific articles -five publications found in the databases-the unexpected mental clarity and memory recovery shortly before death is a curious phenomenon at least. In one of the views on terminal lucidity and its process, we have the following description: "… When each of the cells realizes that their time here is ending, they strive to show, for the last time, their best state of functioning. Then your liver cells will be exemplary hepatocytes, those in your lungs incredibly adept at gas exchange, your brain cells awaken, and those unused neurons all wake up and curiously look at the scene and say, 'Let me see what is going on.' Suddenly your whole body works well… " [4].
The fact that a patient suddenly regains consciousness, says goodbye to his family, remembers their names and events after a long period of failure to learn with progressive memory loss, is a complete mystery. However, it is undeniable that in some cases spontaneous remission of symptoms occurs. In his study of endof-life experiences with caregivers in a nursing home, Brayne observed that 70% of respondents confirmed the frequent occurrence of this phenomenon in patients with dementia. That is, near death, these individuals became more lucid [2].
The most well-known cases involve patients whose brains degenerated from diseases such as Alzheimer's but recovered with an intact memory shortly before they died. However, reports of terminal lucidity are not restricted to this "disease class" alone. Its appearance has been reported in patients with schizophrenia, mood disorders, meningitis, central nervous system tumors and stroke [1]. In the early nineteenth century, Burdach noted that there are two ways in which terminal lucidity manifests itself. At first, the severity of the mental disorder may slowly decrease, as opposed to the decline of the body's vitality. And in the second, total mental clarity may come abruptly and unexpectedly moments before death [5].
The phenomenon may have a wide range of levels and varieties, but it is always characterized by the unexpected return of long-lost mental faculties. Still, there are only preliminary data on its prevalence and no data on the assessment of the psychological and physiological conditions that may favor it [2]. Despite the potential to initiate the development of new forms of therapy and contribute to an advanced knowledge of the cognition, memory process and nature of the human mind, terminal lucidity has been and still is largely ignored by professionals and family members involved. In addition, it comes as a complete surprise to those who watch death, so it is possible to miss the last opportunity to relate better to a beloved one who was previously unresponsive for a long time and sometimes, for years [6].
It is currently thought that it is not possible to affirm the definitive mechanism of terminal lucidity. It can result from different processes depending on the etiology of the underlying diseases. Cachexia in chronic patients, for example, can cause considerable shrinkage of brain tissue, relieving the pressure exerted by intracranial lesions and thus allowing the fleeting return of some brain functions. However, it is unclear whether this would explain the complete remission of cognitive deficits reported during terminal lucidity. Some patients who have their life support removed may experience an unexplained transient onset of electroencephalographic activity as blood pressure decreases moments before death [7]. These findings suggest that the neuroscience of terminally ill patients is far more complex than commonly thought. There is also no clarity about how severely mentally affected patients can sometimes recognize their family members and recall their lives shortly before death, suggesting that the memories in these cases became only inaccessible and were not erased at all [2].

Conclusion
Although there is a common sense about its real existence, the rare articles that address the subject often involve cases of psychiatric and neurological patients whose underlying pathologies would theoretically prevent an abrupt improvement from occurring. In confronting the strange, even if we have no perception, we have our actions molded from this interaction. The "I" particular to each one and the "other", beyond me, is what we call alterity. From this assumption, one way of looking at this phenomenon would be to credit the health team itself the biased analysis of certain end-of-life event.
But on the other hand, although scarce, the literature brings reports that occurred all over the globe, which allows us to understand that, regardless of the culture in which the health professional was created, the phenomenon is described. Because it is a subject beyond technical knowledge, difficult to prove effectively, controversial and even subjective, it is of paramount importance that the subject be addressed more frequently.