As a physician, I have always been attracted to medical mysteries, phenomena that science can’t easily explain. One of those mysteries is what we term as “the Rally”, also called “Terminal Lucidity” or “pre-mortem surge.” This phenomenon is when our dying loved one suddenly has increased energy before they pass away. It can occur hours to days prior to death but most commonly 24-48 hours prior to their passing. It is a humbling experience when I can’t explain to families why certain phenomena occurs, that is outside traditional medical literature. One description found in medical literature defines The Rally as “The sporadic occurrence of unusually enhanced mental clarity before death has been documented over time and cultures, and reported in patients with and without neurodegenerative diseases, psychiatric disorders, and other neurocognitive deficits, as well as those with other terminal conditions” (Phillip et al, 2024). As a geriatrician, I have witnessed this several times when patients with end stage dementia, who had not recognized their families for years, suddenly a day before death, are “awakened”, recognizing their loved ones, perhaps even eating and partaking in old memories. A common theme that I have seen regardless of the reason of why they are dying, is they often speak about having to travel somewhere “I need to get there”. It’s as if they know they are traveling to some other “dimension” perhaps but are not yet clear of where this place is. It’s also known that sometimes people can regain transient function, they can move their legs or sit on their bed, which they are were not able to do prior. I had one of my patients who was on hospice and actively dying tell me her husband was outside in their car waiting for her. Her husband had passed many years ago. My patient was dying due to end stage COPD. The day prior, her comfort care medications were escalated due to dyspnea and uncontrolled pain. The next day she was awake and eating. I explained to her son, who wanted to send her to the hospital in a desperate attempt to halt her death, that it is common for our deceased loved ones to visit, and that it is also common for us to “awaken” to say goodbye. She died the same night, and her son was grateful he was able to speak to his mom one last time. He was also grateful to know his father was also present and she was not alone. Sometimes the mental clarity that is seen in terminal lucidity gives way for death bed visions where we have the ability to converse with deceased loved ones. In an article I read on terminal lucidity, Anna Katharina “Kathe” Ehmer was a 26-year-old born 1895 and died in 1922. She was born with a mental disability and had lived in an institution for people with mental disorders. Her caregivers reported that she had never spoken a single word during her life due to supposed meningitis as a child. However, just 30 minutes before she died, she was witnessed to be singing songs (Nahm and Greyson, 2013). Per Anna’s facilities director, Friederich Happich: “One day I was called by one of our physicians, who is respected both as a scientist and a psychiatrist. He said: “Come immediately to Kathe, she is dying! When we entered the room together, we did not believe our eyes and ears, Kathe, who had never spoke a single word, being entirely mentally disabled from birth on, sang dying songs to herself. Specifically, she sang repeatedly, “Where does the soul find its home, its peace? Peace, peace, heavenly peace!” For a half an hour she sang, her face, up to then so stultified, was transfigured and spiritualized. Then she quietly passed away. Like myself and the nurse who had cared for her, the physician had tears in his eyes” (Oleszak, 2017). This moment of awareness is transient, but so valuable to their loved ones who are hoping to be able to say goodbye. It also teaches us that death is not only a physical occurrence, but a spiritual one as well. I am always so grateful for my hospice colleagues that can explain “the Rally” to the families who are often confused, thinking that their loved is perhaps doing better. It is an opportunity to engage with our loved ones again, to provide closure. This moment of awareness is transient, but so valuable to their loved ones who are hoping to be able to say goodbye. It also teaches us that death is not only a physical occurrence, but a spiritual one as well.
Chiriboga-Oleszczak, Boris. (2017). Review paper. Terminal lucidity. Current Problems of Psychiatry. 18.https://doi.org/10.1515/cpp-2017-0003.
Nahm, M., & Greyson, B. (2014). The Death of Anna Katharina Ehmer: A Case Study in Terminal Lucidity. OMEGA - Journal of Death and Dying, 68(1), 77-87. https://doi.org/10.2190/OM.68.1.e
Roehrs, Philip MD; Fenwick, Peter MD, FRC Psych; Greyson, Bruce MD; Kellehear, Allan PhD; Kothe, Karalee MA§; Nahm, Michael PhD∥; Roe, Chris PhD; Tassell-Matamua, Natasha PhD; Woollacott, Marjorie PhD. Terminal Lucidity in a Pediatric Oncology Clinic. The Journal of Nervous and Mental Disease 212(1):p 57-60, January 2024. DOI: 10.1097/NMD.0000000000001711
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