Death: The secret teacher hiding in plain sight

Paul McNamara is a GP in Glasgow and honorary clinical lecturer at the University of Glasgow.

Ayanfeoluwa Olowoyo is a 3rd year medical student at the University of Glasgow.

Shaha Alajeel is a 3rd year medical student at the University of Glasgow.

General practice offers a unique window into what it means to be human. Every day, patients entrust us with their fears, griefs, hopes, and stories.

Over time, I have come to see death as a secret teacher hiding in plain sight. Medicine places us in constant proximity to mortality, yet the lesson is not simply about dying. It is about living.

It is often only when we confront life’s fragility that we fully appreciate how precious it is.

Perhaps that is partly why peri death phenomena feel so arresting to clinicians and families alike. In the hours or days before death, some patients unexpectedly regain clarity, recognition, humour, or a desire to communicate after prolonged decline. Others describe vivid visions, speak of deceased relatives, or display moments of lucidity that seem disproportionate to their underlying disease.

These experiences are often deeply moving, sometimes unsettling, and not always easily explained within our current understanding of consciousness and the dying brain.

I have sat with families in those moments. Not often, but often enough that the memory stays. A patient who had not spoken coherently in months suddenly asks after a grandchild by name. Another, bed bound and seemingly unreachable, laughs at something only she can see.

Terminal lucidity refers to the unexpected return of mental clarity in those approaching death.¹ It has been documented across the palliative landscape, in patients living with advanced cancer, organ failure, and neurodegenerative disease alike. Despite appearing in medical literature as early as the nineteenth century, it remains marginal in clinical training and is rarely discussed in palliative education.¹ Most clinicians encounter it before they have a name for it.

Terminal lucidity sits uneasily within our usual understanding of illness. We are trained to think of advanced disease as a progressive narrowing of function and awareness. Decline follows damage. Cognition fades as neural structures fail. Yet terminal lucidity appears to briefly interrupt that trajectory. Patients who seemed unreachable sometimes return, however fleetingly, to themselves.

Various neurobiological explanations have been proposed, including transient shifts in neurotransmitter activity, cerebral perfusion, or neural network reorganisation, yet none adequately account for what is observed.¹˒³ The mechanisms remain speculative. Terminal lucidity is recognised. It is not explained.

That gap matters.

Modern neuroscience has made extraordinary progress in mapping the neural correlates of consciousness. Yet how subjective experience arises from neural activity remains one of the most contested questions in science and philosophy.³ Terminal lucidity does not necessarily undermine existing models so much as expose their edges, particularly at the threshold between life and death. It sits at the intersection of neurobiology, phenomenology, and something we do not yet have adequate language for.

In clinical practice, these moments arrive less as theoretical puzzles and more as human encounters that ask something of you. Families may interpret sudden clarity as a sign of recovery. Clinicians recognise it as transient. Navigating that tension requires something rarely taught: the ability to hold hope and honesty in the same breath.

I have seen relatives begin planning for more time, only for death to arrive hours later.

Dismissing these moments too quickly risks diminishing their emotional weight. Encouraging unrealistic hope deepens the grief that follows. What is asked of us is not a definitive explanation, but sensitivity, honesty, and comfort with ambiguity.

For families, these brief returns of recognition can profoundly shape how the dying process is remembered. A final conversation. A shared joke. The simple act of being recognised by someone who had seemed lost. These moments often become the ones that endure, carrying more meaning than months of careful clinical care.²˒⁴ Allowing them to retain that meaning, without forcing them into a narrow medical category, is part of the quiet work of end of life care.

The significance of terminal lucidity may not lie in identifying a precise mechanism. Its value lies in what it reveals about the limits of our knowledge, and perhaps about the limits of our categories. We speak of irreversible decline. We speak of consciousness as though we fully understand what it is and where it resides. And then a patient who has not known your name in two years looks at you clearly and asks how you are.

Medicine does not have a good answer for that. And perhaps that is the point.

Emily Dickinson wrote, “That it will never come again is what makes life so sweet.” These brief returns of self, warmth, and recognition carry that same quality. They are unrepeatable. And in their very transience, they remind clinicians and families alike how much about the mind, and about being human, remains beautifully unknown.

References

1. Nahm M, Greyson B, Kelly EW, Haraldsson E. Terminal lucidity: a review and a case collection. Archives of Gerontology and Geriatrics 2012; 55(1): 138–142.
2. Lim CY, Park JY, Kim DY, et al. Terminal lucidity in the teaching hospital setting. Death Studies 2020; 44(5): 285–291.
3. Silva TO, Levy K, Kerr CW. End-of-life experiences in patients: a scoping review of types, characteristics, and implications for the mind-brain relationship. Int RevPsychiatry 2025; 37(2): 142–156.
4. Chiriboga Oleszczak BA. Terminal lucidity. Current Problems of Psychiatry 2017; 18(1): 34–46.

Featured photo by Gábor Szűts on Unsplash