From the Journal of Near-Death Studies, Volume 43-1
Alternative Link: https://doi.org/10.17514/JNDS-2025-43-1-p62-68
LETTER TO THE EDITOR
Reaffirming Definitional Clarity in Terminal and Paradoxical Lucidity: Reply to Michael Nahm
To the Editor,
I appreciate the opportunity to address Michael Nahm’s (2024) recent critique. Unfortunately, Nahm’s Letter contained factual inaccuracies and, in my view, reflected a misunderstanding of the consensus-based definitions established within our discipline. After addressing these topics, I conclude by emphasizing the common ground between Nahm and me.
Rectifying Factual Inaccuracies
Nahm (2024) asserted that the “alleged definition of terminal lucidity (TL) that Batthyány presented in his Letter (2023a) and his book (2023b) conspicuously lacks, of all things, a mention of the proximity to death” (p. 73). I found this assertion quite surprising. Regarding my Letter, the second sentence explicitly stated: “Terminal lucidity is the unexpected return of mental clarity shortly before death in patients suffering from severe psychiatric and neurologic disorders” (Batthyány, 2023a, emphasis added).
Regarding my book, two points seem relevant. First, the title—Threshold: Terminal Lucidity and the Border of Life and Death—clearly referenced the centrality of the timing of TL as being on the verge of death. Second, in the opening pages of the book, I described TL as occurring “at the hour of death” (p. 5)—and I sustained this focus throughout the book. Indeed, the proximity to death is the defining theme of the work; the entire theoretical framework rests upon the explicit significance of the “pre-mortem” window. The theme of Nahm’s (2024) Letter was the need for greater accuracy in the scholarship of our shared field of study, so it is difficult to fathom how a central tenet so plainly evident—inscribed in the very title of my monograph and the second sentence of my Letter—could have been overlooked.
Functional vs. Fundamental Distinction: The Consensus Framework
Although Nahm (2024) frequently referenced his co-authorship of the Mashour et al. (2019) white paper, it may be clarifying to provide some context regarding the origins of that framework. The white paper arose from an expert workshop convened by the National Institute on Aging (NIA) of the National Institutes of Health, of which one of the explicit aims was to produce a consensus document. Although Nahm contributed to the final paper, he was not among the participants at the summit, which included, alphabetically by last name, myself, Lori Frank, Bruce Greyson, Jason Karlawish, Ann Marie Kolanowski, George A. Mashour, Serguei Pakhomov, Dena Schulman-Green, and Raj C. Shah, and, from the NIA, Basil Eldadah, Elena Fazio, and Kristina McLinden.
Much of the data evaluated at the workshop originated from case studies subsequently published as statistical analyses in Batthyány and Greyson (2021). As an attendee of those discussions, I can attest that the resulting paper’s definition was intended to integrate, rather than isolate, terms. The white paper hence explicitly referenced case studies “focused on the time around death,” noting that “the phenomenon [paradoxical lucidity] in this context is sometimes called terminal lucidity” (Mashour et al., 2019). The operative context here is the proximity to death rather than a categorical separation. Had a categorical distinction been intended, the paper would have articulated one.
In this sense, terminal lucidity is not a separate phenomenon, but, rather, is a temporal designation for paradoxical lucidity occurring near death. As the team of Professor Karlawish—himself a workshop participant and co-author of the Mashour (2019) white paper—recently confirmed in a similar exchange with Nahm: “Terminal lucidity should be regarded as an instance of paradoxical lucidity, but not all instances of paradoxical lucidity should be regarded as terminal” and that terminal lucidity is thus properly understood as a “special subtype of paradoxical lucidity” (Peterson et al., 2022).
The Problem of “Clinical Noise:” The Fallacy of Non-Paradoxical “Unexpectedness”
I concur with Nahm (2024) that restricting paradoxical lucidity or terminal lucidity, as in our white paper and some of my and his work, to severe chronic neurological, psychiatric, or neurodegenerative disease may prove too narrow, because the phenomenon also appears in acute-onset neurological disorders or secondary neurological involvement (Batthyány & Greyson, 2021; Batthyány, 2023b). However, I have doubts that Nahm’s current proposal to, therefore, extend the definition to include patients who were merely “dull” (2024, p. 76) or “drowsy or confused .. with healthy brains” (2022b, p. 270) is advisable. There is still a substantial difference between shifting the focus from neurodegenerative diseases to include acute neurological disorders—or neurological involvement in systemic diseases—and further opening the definition to admit such mild fluctuations as dullness or drowsiness “with healthy brains” into the definition of TL. I fear that this proposal introduces a degree of clinical noise that is scientifically unfounded and that threatens to seriously undermine the term’s discriminant validity.
To illustrate: Under Nahm’s proposal (2022a, 2022b; 2024), a patient who had been “dull” or “drowsy” and “with healthy brain” but then—after a prolonged period without adequate rest—finally enjoyed a restorative night’s sleep, unbeknownst to caregivers, would qualify as exhibiting “terminal lucidity.” The mere fact that such a patient, having thereby replenished previously depleted cognitive resources, engaged in meaningful communication before passing away within 24 hours would suffice. But such an event would merely represent a normal, albeit perhaps subjectively “unexpected,” physiological fluctuation. To place minor clinical variations without pathological brain involvement—such as a subjectively unexpected improvement in a patient’s cognitive state following a good night’s sleep or adequately nutritious food—in the same scientific category as an end-stage Alzheimer’s patient who, after months of mutism and profound cognitive decay, suddenly recognizes family members and speaks coherently hours before death, is, in my view, untenable.
If all such cases are admitted into the catalogues of terminal lucidity, the category loses its scientific validity and usefulness. Without a requirement for a neurological baseline, case collections would become overcrowded with minor clinical fluctuations that happened to occur before a patient’s death, effectively obscuring the profound neurobiological mystery of true terminal lucidity under an accumulation of clinical noise. Hence, the proposed expansion of the spectrum—from pathological brain involvement to merely “drowsy” or “dull” in the explicit absence of brain pathology under a single conceptual umbrella—obscures these clinically significant distinctions and engenders confusion rather than clarity, thus elevating the risk of artifacts that contaminate the data.
It is possible that Nahm (2024) sought to pre-empt this objection by retaining the criterion “unexpected” (2024) in his definition of terminal lucidity. But this retention does not resolve the problem; it merely makes it more visible: namely, that the word “unexpected” becomes uncertain and potentially arbitrary when not understood in a clearly diagnostic or clinical sense—that is, not as a function of the disease itself, but as a function of the expectations of third parties who happen to find this or that turn in the patient’s condition surprising. In other words, this matter involves distinctions between fundamentally different forms of what it means for an event to be “unexpected.” In the first case, the improvement may only remain unexpected until one becomes aware of all the factors that contributed to the temporary amelioration—such as a restorative night’s sleep—which effectively reduces this criterion to a criterion of lack of information. In the second case, however, the word “unexpected” carries an altogether different, namely clinical, weight.
Furthermore, by expanding the scope of TL to encompass minor fluctuations—from “dull” to “alert” within neurologically intact populations, the construct becomes ontologically tethered to the timing of death. This association creates a circular dependency wherein the diagnosis is contingent upon a possibly entirely unrelated outcome. This conceptual elasticity facilitates a post-hoc fallacy, conflating two potentially decoupled phenomena—a transient, if unexpected, physiological surge and the subsequent death of the patient—into a single, teleological construct. Expanding the scope of TL in this way would, in effect, conflate a temporal sequence with a biological consequence.
On Scientific Maturation and Semantic Revision
Naturally, as in any evolving field, definitions and case evaluations evolve and sometimes remain in flux; my own usage of the term has developed with further research, as indeed has Nahm’s—one need only compare his earlier definition of TL as lucid episodes in patients with “severe neurological and psychiatric disorders” (Nahm et al., 2012, p. 138) with his current, considerably more expansive formulation (Nahm, 2022, a, b; 2024).
As already pointed out, I grant that I may have, at times, placed excessive emphasis on the role of neurodegenerative diseases. I suspect, however, that some of Nahm’s criticism somewhat misses the genre of the respective chapters of my book (Batthyány, 2023b), for in these chapters I first described the historical development of my research: my grandmother’s case, our early attempts as a working group at the University of Vienna in the winter semester of 2009, our first study, the NIA workshop, and so forth. To extract remarks from these intermediate steps and pin them down as inconsistencies seems not entirely appropriate.
Having said that, Nahm is not wrong to observe that in my earlier publications, I may have included accounts in which the neurological component appeared unclear, or where I speculatively considered such involvement likely. I am not certain, however, that Nahm’s criticism here is entirely justified. For example, he took issue with my mention in Threshold (Batthyány, 2023b) of the case of Queen Dagmar of Denmark—though he omitted the fact that I made this mention as an attributed quotation from Macleod to illustrate that unexpected lucidity attracted attention as early as the 13th century.
Contrary to Nahm’s claim that Queen Dagmar was merely giving birth (Nahm, 2024, p.74), however, her critical state—described as being taken for “dead”—suggests a profound physiological crisis with at least some neurological involvement. Whether the underlying cause was puerperal sepsis or eclampsia, both pathways necessarily involve significant cerebral impairment: In the case of advanced sepsis, the systemic inflammatory response and subsequent septic shock would trigger sepsis-associated encephalopathy, whereby bacterial endotoxins and global hypoxia due to hypotension cause acute brain dysfunction and coma. Alternatively, if the condition arose from eclampsia, the “coma” would represent a primary neurological catastrophe characterized by hypertensive brain edema and a deep postictal state following tonic-clonic seizures. Consequently, given that both sepsis-induced hypoxia and eclamptic cerebral edema fundamentally disrupt the central nervous system, the presence of significant neurological damage remains entirely plausible, making the claim of a condition without neurological involvement physiologically unlikely.
Yet Nahm also took issue with the fact that, in my earlier work, I did not include cases involving diseases such as cancer. I handled the matter thus, however, for a different reason than Nahm appears to have assumed. I made this distinction as a matter of basic scientific hygiene for the very same reason that I consider it inadvisable to regard neurologically healthy “dull” or “drowsy” patients as candidates for TL. In many such cancer cases, including terminal cases, cognitive fluctuations can be explained as, in principle, predictable clinical recovery following, for example, the cessation of chemotherapy or high-dose analgesics with cognitively relevant side effects. Although such improvements may be impressive—even “unexpectedly” robust to attending physicians or family members—they represent a well-understood replenishment of resources and are fully explicable within existing conceptual frameworks.
On the other hand, I am not certain that the “peritonitis” case that Nahm (2024) cited truly serves as good evidence for a non-neurological definition: The patient’s confusion and unconsciousness are clinical features likely pointing to sepsis-related encephalopathy (Shuliatnikova & Shavrin, 2018), which would make it a classic example of TL under the neurological definition.
Common Ground
To again emphasize our common ground and narrow down our differences, I concur with Nahm that restricting paradoxical lucidity or terminal lucidity to chronic or neurodegenerative disease is too narrow. Hence, my earlier exclusion of cancer and other cases may have been too cautious. Point taken. However, I consider Nahm’s expansion to cases in which individuals felt “dull” or “drowsy” prior to a lucid episode to compromise the conceptual integrity of the phenomenon.
In any case, time will tell which concepts and taxonomies or nosologies better accommodate the observed phenomena. My recent work with colleagues (Gilmore-Bykovskyi et al., 2021; Griffin et al., 2024), for example, demonstrates a diverse spectrum of lucidity requiring precise, data-driven categorization, and it seems likely that typologies—though not necessarily categories of unexpected lucid episodes will require expansion or further narrowing. I suspect Nahm and I would agree that any expansion of our conceptual framework must be driven by empirical data and rigorous typologies rather than by semantic dilution that robs the term of its scientific utility. Ultimately, this debate will not be settled by terminology alone. Only further empirical work will resolve these questions and is, in any case, already in the process of doing so.
References
Batthyány, A. (2023a). Terminal lucidity: The need for accuracy and integrity [Letter to the Editor]. Journal of Near-Death Studies, 41(1), 67-71. https://doi.org/10.17514/JNDS-2023-41-1-p67-71
Batthyány, A. (2023b). Threshold: Terminal lucidity and the border of life and death. St. Martin’s Essentials.
Batthyány, A., & Greyson, B. (2021). Spontaneous remission of dementia before death: Results from a study on paradoxical lucidity. Psychology of Consciousness: Theory, Research, and Practice, 8(1), 1-8. https://doi.org/10.1037/cns0000259
Gilmore-Bykovskyi, A., Block, L., Benson, C., & Griffin, J. M. (2021). The importance of conceptualizing and defining episodes of lucidity. Journal of Gerontological Nursing, 47(4), 5. https://doi.org10.3928/00989134-20210326-01
Griffin, J. M., Kim, K., Finnie, D. M., Lapid, M. I., Gaugler, J. E., Batthyány, A., & Frangiosa, T. (2024). Developing and describing a typology of lucid episodes among people with Alzheimer’s disease and related dementias. Alzheimer’s & Dementia, 20(4), 2434-2443. https://doi.org/10.1002/alz.13667
Mashour, G. A., Frank, L., Batthyány, A., Kolanowski, A. M., Nahm, M., Schulman-Green, D., Greyson, B., Pakhomov, S., Karlawish, J., & Shah, R. C. (2019). Paradoxical lucidity: A potential paradigm shift for the neurobiology and treatment of severe dementias. Alzheimer’s & Dementia, 15(8), 1107-1114. https://doi.org/10.1016/j.jalz.2019.04.002
Nahm, M. (2022a). Terminal lucidity versus paradoxical lucidity: A terminological clarification. Alzheimer’s & Dementia, 18(3), 538-539. https://doi.org/10.1002/alz.12574
Nahm, M. (2022b). The importance of the exceptional in tackling riddles of consciousness and unusual episodes of lucidity. Journal of Anomalous Experience and Cognition, 2(2), 264-296. https://doi.org/10.31156/jaex.24028
Nahm, M. (2024). Defining terminal lucidity: Taking the need for accuracy and integrity seriously [Letter to the Editor]. Journal of Near-Death Studies, 41(2), 70-78. https://doi.org/10.17514/JNDS-2024-42-1-p70-78
Nahm, M., Greyson, B., Kelly, E. W., & Haraldsson, E. (2012). Terminal lucidity: A review and a case collection. Archives of Gerontology and Geriatrics, 55(1), 138-142. https://doi.org/10.1016/j.archger.2011.06.031
Peterson, A., Clapp, J., Harkins, K., Kleid, M., Largent, E. A., Stites, S. D., & Karlawish, J. (2022). Is there a difference between terminal lucidity and paradoxical lucidity? Alzheimer’s & Dementia, 18(3), 540-541. https://doi.org/10.1002/alz.12579
Shuliatnikova, T. V., & Shavrin, V. O. (2018). Sepsis associated encephalopathy and abdominal sepsis: Current state of problem. Art of Medicine, 3(7), 158-165.
Alexander Batthyány, PhD, Director and Chair
Institute for Theoretical Psychology and Personalist Studies Pázmány Péter Catholic University
Budapest, Hungary
alexander.batthyany@gmail.com