What’s it all about? – Check out the introduction page linked above.
Dr Parnia was a guest speaker at a fairly recent 2018 resuscitation update seminar hosted by the European Resuscitation Council. YouTube link
In his presentation he covers the concept of the AWARE study, reconfirming the aims of analysing the flatline period of cardiac arrest. The key parameters of the monitoring are brain oxygenation levels alongside electrical activity (EEG). He presented a slide picture of the equipment designed into a portable unobtrusive all in one stand unit, including a mounted I Pad for image projection.
The data collection period is said to finish by the end of 2020, thus I suspect any report or release of findings will not likely appear before mid 2021. The data pool target is the recording of 1500 in hospital cardiac arrest patients. Concerns have been raised previously in this blog about data pool size, but inevitably resources and practicality must dictate limits.
The relationship of brain oxygenation levels with corresponding EEG measurement is still mooted as the key investigation of the study, with the noted proposition that better oxygenation during cardiac arrest resuscitation leads to not only better recovery but also increased likelihood of any experience recollection.
Oxygenation and these associated relationships are discussed in previous blog articles.
There is allusion and brief discussion of memory in the talk. In my opinion a relationship worthy of much discussion and analysis is indeed that of memory and the self, especially in the scenario of near/actual death experiences.
The other guest speakers in the session are also well worthy of a listen / watch, giving an insight into the past and future of resuscitation / life saving protocols.
Is the AWARE study starting all over again, or being expanded, or integrated into something else?
Thanks to one of the regular contributors for this reminder, but Dr Parnia tweeted for the first time in a very long time:
I use the word illusive since he doesn’t really clarify what this means. Is this AWARE II, surely not as that is well under way now. Are these sub-studies of AWARE II? Are they completely new studies, and if so how will they differ?
Anyway, hopefully we will learn more before long.
The Aware study team have set up a web portal for news and general project information on the Stony Brook University hospital website. (www.stonybrookmedicine.edu/sbuh)
Stony Brook is a New York teaching and research hospital, specialising in, among other fields, neurosciences, organ surgery and transplantation. It is a tertiary care and ‘Level 1’ trauma centre.
The resuscitation section (https://medicine.stonybrookmedicine.edu/medicine/sleep/resuscitation) is now the home of the AWARE study as it continues into the second phase, as part of the ‘Resuscitation Research Group’.
The copy content covers the aims of the study, summarised pretty much as Dr Parnia did in the “Dr Oz” interview discussed in the last article. It focuses heavily on the aim of improving resuscitation methodology and monitoring systems. To improve post cardiac arrest outcome, the group as a whole, including the study, is working on a standardisation of procedure that monitors oxygenation and CPR quality. The spreading or ‘education’ of this procedure so far is claimed to have had measurable success.
There is comparatively little description of the more esoteric aspect of AWARE, that being the probing of possible consciousness in cardiac arrest situations. There is an intriguing paragraph that raises similar thoughts that I have already mused upon in previous articles:
“we will be testing the hypothesis that by limiting ischemia during resuscitation, higher cerebral oxygenation leads to improved cortical function during CPR and is associated with improved survival as well as favourable neurological, functional and neuropsychological outcomes. We further hypothesize that mental and cognitive activity and awareness during CPR may reflect verifiable events and is associated with the quality of brain resuscitation.”
What is unclear here is, does this refer to the duration of ‘flatline’ EEG? If so, is this not a conflict of current medical understanding? Maybe the implication is rather that better recovery leads to better memory storage, but the wording as expressed could be taken to mean that the CPR quality is in fact itself directly enabling the possibility of awareness, rather than the memory of it.
Is it also then being suggested that verifiable memories, due to cognitive activity, will be based on functional human physiology, and thus any reported ‘out of body experiences’ are presumed to be illusional rather than actual external witness?
That latter point is quite crucial to the scope of the study, even if OBE verification is only presented as a lesser exploration.
I would like the study team to clarify their hypothesising in these regards.
The study has once again been publicly registered in the UK on the NHS research domain. (http://www.hra.nhs.uk/news/research-summaries/aware-ii)
As an extra, there is a good list of resource papers linked that are worth looking at.
Of particular note are the papers concerning oximetry during cardiac arrest, clinical outcomes, and consciousness and death experience.
It is good to see the study in full progress, and I among followers look forward to further updates.
Dr Sam Parnia, key organiser of the AWARE studies, is now on a Twitter account, of interest to those who wish to keep updated of his activities. (@SamParniaMDPhD). He indicates that there will be a web site or central portal of some sort to hold news and information on the AWARE II study, which is good news again for those following.
He has announced that the study will now go on until 2020, when a results presentation will be made to the Canadian Association of Emergency Physicians. This planned time extension can only be good for the study. It will be bring it in line to match the length, and hopefully breadth of the first AWARE. A larger data pool and more analysis means better observations and deductions. Many followers thought from the outset that a 2 year study was too ambitious.
There are currently 8 participating hospitals in the study, with an option to extend to 25. Dr Parnia is on the look out for more participants, presumably with a view to recruiting towards the higher number. This could be what the discovered PowerPoint slides in the ‘intervention presentation’ as discussed in the last article were about.
Again, this is encouraging. It would seem there is ongoing enthusiasm and support from the medical community at large, especially from the emergency resuscitation field. The study is accepted as a viable project with worthy aims.
Last year, October 2016, Dr Parnia made an appearance on the American television show Dr Oz, in a feature about the experience of dying. It can still be viewed at – http://www.doctoroz.com/episode/oz-investigates-final-7-minutes-death-what-does-it-really-feel-die?video_id=5170234436001
He spoke enthusiastically of the study and it’s aims, which in short, he says are:
1) Improve resuscitation techniques to achieve a better outcome for cardiac arrest patients.
2) Learn more of the subjective experience patients go through in such situations, with a view to educate at large possible expectations to have of the dying process.
3) Explore the relationship between consciousness and the dying brain, examining further the details of memories in near death experience.
Dr Parnia believes that the experiences are a universal phenomenon which everyone undergoes through the dying process. Depending on the quality of resuscitation, and thus the recovery speed of the patient post cardiac arrest, there is a ‘spectrum’ of recollection. The spectrum would start from remembering absolutely nothing at all at one end, to a full vivid account of apparent witness at the other.
The suggestion is that the post arrest ‘tsunami’ of brain cell inflammation and chemical shock quite often destroys any memory of experience, unless mitigated by better oxygenation throughout the arrest, thus reducing post event damage.
It is a proposed relationship that the study is geared to explore.
Analysis of these variables at the end of the study will certainly give insight and open debate on the states of physiological functionality during cardiac arrest, as well as question the relationship between consciousness and memory, and indeed memory storage, physiological or otherwise.
At what point do these experiences and the memorising of them occur? I feel this will have to be discussed and conjectured upon if the idea of better recovery contributing to recollection is going to become the focus.
There is of course still the holy grail as far followers of AWARE are concerned, will there be a confirmed veridical visual out of body experience? Can there be?
We watch with interest, and wish the practitioners and indeed the patients the best in their endeavours.
Towards the end of last year 2016 the details of the second aware study, and its ongoing recruitment progress, were removed from the public database at UKCRN. This led to some worry and speculation among followers as to what was going on with the study. An interesting piece was put up by fellow blogger and clinician Ben Williams.
There is reference made to some discovered PowerPoint / presentation slides that appear to infer a necessary intervention in the study to improve the patient recruitment.
Without official news or statements, we can only wait for the original published study end date to pass, considered to be May. I expect some form of update in the summer.
It is worth noting that in October, Dr Sam Parnia (chief clinical coordinator in the study) was interviewed on American talk show “The Dr Oz show”.
Dr Parnia’s demeanour and enthusiasm would suggest that he is buoyed by the AWARE study progress so far. There are interesting points put across by Parnia in this show, not least his belief that all people entering clinical death have similar special experiences with only some actually remembering.
More on the implications of this another time….
Our experience of the world is as for every different animal species, unique, not just due to our brain complexity, but also due to the nature of our sensory detection equipment. How we experience the world is down to the presentation given to us by our mental processing ability of all the sensory data from our senses and their range of detection.
The data starts as physical interaction between the atomic nature of our surroundings and the biological construct of our sensory equipment. Scientific understanding has an extremely good grasp of our bodily interactions with the atoms, photons and electromagnetic waves that make up our environment. Our sensors take in a bombardment from the physical world that is in essence (at a quantum level) an interaction of electrical forces.
The data feeds to our brain from our sensory organs as electrical impulses producing a picture for us to monitor and interact with.
Our world is the way it is to us because of (a) it’s construct, (b) our own biological construct to sense it, and (c) our brain’s processing ability to create a mental sensory picture of it.
Our body is part of the physical world it inhabits and follows the same rules of construct, producing the mental sensory picture. This picture is reasonably conjectured to be different for different species of animal based on varying sensory equipment and processing ability.
So what of consciousness?
Perhaps our consciousness can be described as the entity that is looking, hearing, and feeling this picture. Our personality and sense of who we are is built on the development of this consciousness through experience and memory. We are our own history. The accumulation of experience and memory makes us, even if the essential consciousness itself can arguably be separated from these.
Out of body experiences
When considering an out of body experience, or in other words a consciousness without the physical sensory equipment, how and why would a physical world still be pictured? Furthermore, if then the consciousness is free from the physical brain, why does the picture still build as a physical construct? How is the physical world still seemingly interacting with consciousness, even if only in an observation / perception manner?
The Aware study led by Dr Sam Parnia and others is putting out of body experience anecdotes to the test, using controlled monitoring and observation environments. A truly verified experience of this nature is yet to be discovered, but it would be wrong to assume that this is the sole objective of the study. There appears to be a direction in questioning the assumptions from measurements of when a brain is capable of conscious activity, and in what state.
Apparent evidence of consciousness in a ‘dead’ brain does not automatically infer the separation of consciousness. Exploration of possible activity in hitherto considered ‘impossible’ states would have to be exhausted. Only more convincing evidence, such as the verified veridical visual experience would suggest a separation.
How would separation fit in our understanding of the universe?
How is our understanding of our place in the universe now, without separation? We are biological matter with complex brains that process inputs to then direct function of our bodies within environments. As alluded to at the beginning of this article, physically this can be reduced to the interaction and exchange of electricity, as can all physicality. In quantum field theory all matter is the ‘excitation’ or movement of energy within fields of fundamental forces.
Perception of the universe is a picture, assembled with electricity. It is a picture because our consciousness makes it so, we ‘see’ it and interact with it, but the picture itself is produced by our brain through its electrochemistry.
If consciousness is removed from normal physical inputs, would it still be possible to ‘see’ a picture? In the debate of what consciousness actually is, most conjectures still put it in the realm of physical existence, albeit in a yet to be understood manner.
The brain based point of view would say that a picture can still be created, with compensations made for the lack of sensory data. The picture may not be veridically accurate, but will still be based on whatever input is available, including memory.
A separation conjecture could argue that a picture can still be created independent of the brain or any bodily sensors, by using inputs on a level deeper than atomic contact. That is, perhaps, the electrical interaction that goes on within the brain and between the body and the environment, could still happen at a smaller quantum level, without the bigger manifestations of body matter. The picture could then still be built in a similar way as though the bodily senses were still there.
Modern science at a microcosmic level puts all existence, or all matter at least, down to a consequence of electromagnetic forces and energy. It is not that far fetched then to suggest that the phenomenon of consciousness, however linked to brain matter itself, is likely to be of the same. What it is the consequence of, is the big question.
The exploration of possible consciousness separation from the brain could lead to three major paradigm shifts:
Is our understanding of brain functionality in ‘dead’ states shortcoming?
Does our existence, through our consciousness, go beyond manifest biology?’
Is our understanding of the fundamental forces of the universe in need of revision?
As of writing Jan 2016, the UKCRN website (http://public.ukcrn.org.uk/search/StudyDetail.aspx?StudyID=17129) states that 3% of the study data pool has been achieved, or in the exact wording “global recruitment to date”. (EDIT: Please note as of late 2016 the details of this study outline have been removed and the link is no longer valid. There is a new official briefing page on the NHS Research portal http://www.hra.nhs.uk/news/research-summaries/aware-ii). The study start appears to have been started in May 2015, meaning that if the proposed time duration has to be adhered to, as stated ending May 2017, the likely final pool will only be 12% of what was hoped for, or approximately 180 patients recruited. I take this to infer the number of survivors of cardiac arrest through resuscitation under the controlled conditions of the study.
This may seem disheartening, especially in the light of statistical probabilities of patient recall, but there may well be good reason for optimism.
One aspect of this study, much discussed on this blog, is the monitoring of oxygen during resuscitation to better assist CPR efforts and give more survivable outcomes. A correlation between better oxygen and NDE recall is part of the research. This should mean that better resuscitation is implemented in the pool of this study, thus hopefully producing better patient outcomes, and maybe then, if the oxygen / recall correlation does exist, a richer rate of experiences is recorded.
So whereas the study from it’s outset is small, the useful data return could still be substantial.
The possible pattern of higher oxygen producing more recall experiences is good for this and future studies, but in itself will have to at some point be questioned and explored for any causality factors. It could be postulated that better recovery and less post arrest damage allows an experience to be imbedded in memory at an earlier stage in recovery, when it is less likely to be lost. But then some of the wording from Dr Parnia and the AWARE team could be read as somewhat leading down a physiological understanding.
“Perhaps the people who had experiences simply had higher oxygen levels of blood flowing into the brain and hence oxygen delivery.” (Erasing Death)
“It is possible that patients who are able to recount these experiences may have better patient outcomes in terms of reduced brain damage, improved functional ability and better psychological adjustment to the event. We think that these patients may have had better blood flow to the brain during cardiac arrest, leading to consciousness and activity of the mind.” (UKCRN study outline)
Of course what will help steer this quandary is what could be seen as the holy grail of the whole AWARE project, that is, an experimentally verified visually veridical experience recall. Such a result will have to lead to more than physiological hypotheses. At the very least it would question our understanding of measurable brain activity in relation to actual conscious activity. Indeed, a specifically external visual recall would question the convention of consciousness as a physiological phenomenon entirely.
Having started in May 2015, the current phase of study should finish data collection in May 2017.
Then we wait…..
The AWARE study of cerebral oxygen
The monitoring and study of cerebral oxygen (rsO2) during cardiac arrest has been a planned aspect of the AWARE study from the outset of it’s conception, and has seen implementation through the completed first phase, and now into a second ongoing phase, it is under further scrutiny.
Dr Sam Parnia asserts this and refers to the monitoring in some detail in his book Erasing Death (The Lazarus Effect).
“To measure the changes in oxygen levels in the brain during cardiac arrest, we obtained a highly sophisticated brain monitoring device, called a cerebral oximeter, that could measure oxygen levels in the brain continuously and record the levels every few seconds during a cardiac arrest and allow us to see if any relationship exists.”
“The results so far have been very promising and have demonstrated that almost all the patients in our study who have suffered with cardiac arrests start out with very low brain oxygen levels.”
“Today, we are also continuing our efforts with respect to the use of cerebral oximetry, both in terms of the relationship that it may have with patient’s experiences and, more important, as a unique way to determine the quality of resuscitation; we hope to identify novel ways to improve oxygen delivery to the brain with a view to ensuring more people survive and have less brain injury.” *
The purpose of studying rsO2 in the first phase appears chiefly to have been investigating the relationship between oxygen levels during a cardiac arrest, and the longer term physiological outcome of the patient.
It may seem obvious that a better maintained bloodflow level is going to be conducive to better patient recovery, but exactly what level as the critical threshold during the resuscitation process has hitherto never been that extensively explored, with just one or two small scale studies in the published domain.
Dr Parnia is keen to set a standard of rsO2 monitoring and targeting as a routine element of the resuscitation process in emergency medicine, with a view as ever to improving the overall success and survival rate.
So what of NDEs?
In the UKCRN outline of the study’s second phase, and indeed in Erasing Death, it is suggested that there may be a similar relationship between better rsO2 levels during cardiac arrest, and the apparent patient recollections of experience during the arrest.
“Maybe patients were able to recall specific memories because physicians had achieved better blood and oxygen delivery to the brain without realising it.” *
Dr Parnia has previously asserted an accepted science that low level oxygen in cardiac arrest means brain functionality is lost, being in an EEG flatline state until the heart is restarted. He may now be reconsidering this assumption. It is worth remembering here that the one ‘verified’ case of interest described in the first study phase results paper discusses apparent recall from well after 30 seconds into the arrest.
“There have been many scientific studies that have examined what happens to the brain immediately after the heart goes into VF (ventricular fibrillation) and stops. These studies have all demonstrated that brain electrical activity stops and the brain itself flatlines” *
By suspecting higher rsO2 levels as a factor in NDEs, Dr Parnia and the team must be suggesting one of a few scenarios:
- In some cases of resuscitation, even though the heart is not pumping, there is enough blood flow and oxygen to cue a minimal level of brain activity, perhaps close to consciousness, that may even be measurable on an EEG, to give rise to experiences stimulated by environmental sensory input.
- There maybe possible activity levels that though allow no consciousness, not even being measurable by EEG, do however allow external stimuli data to be stored and retrieved later in recovery, that then give rise to memories.
- Higher blood flow and oxygen aids a better path of recovery and a quicker resumption of conscious awareness, but the patients’ recalled experiences are confused illusions based on external stimuli in the recovery stage, with a working heart and restored blood flow, rather than from during the actual arrest and resuscitation period.
Either way, it becomes apparent that connecting experiences with a part functioning brain implies that the visual aspect of any such recollection must be illusionary, perhaps as the brain makes sense of external audio stimuli.
So are the AWARE team by suggesting higher rsO2 therefore suggesting some level of functionality during the arrest / resuscitation period?
Is there an implied suggestion then that NDE recalls are in fact from explainable physical brain activity?
“This is a possibility that has to be considered. Although previous research had indicated that, in general, during cardiac arrest, doctors cannot get enough blood into the patient’s brain, there was no way to rule out the possibility that some individuals who had recalled specific experiences had not somehow received better resuscitation. Maybe there were exceptions to the rule.” *
(*all quotes from The Lazarus Effect / Erasing Death by Dr Sam Parnia. Ch10)
Apparently the collection of new data began in May.
The second phase of the AWARE study is outlined as a two year observational study of 900 – 1500 patients. This is a shorter study than the first phase, which lasted four years, and no doubt this will be welcomed in most quarters who are following the project. The expected study pool of patients is of course significantly smaller, which is possibly surprising given the limited results of the first phase study.
In the first phase, only 2 patients out of the 2000 pool claimed to have had an apparent veridical OBE recall. Cutting the study pool in half makes the chance of another such case less likely. Dr Parnia himself said of the results back then “it was not possible to absolutely prove the reality or meaning of patients’ experiences and claims of awareness due to the very low incidence of explicit recall……and more work is needed in this area.”
However, reading the UKCRN outline, the focus appears to be relaxed more onto the 10% of survivors with general apparent memories / experiences, rather than just the veridical cases.
Now at first to me, this appears to be going off target as a research endeavour, for surely it is only the apparently veridical OBEs that can corroborated to substantiate any discovery. But then, the outline goes on to suggest brain oxygen levels as a dimension to be explored, which as a piece of background data to NDEs, does make the specifics of recollection less important in this phase of study.
That is not to say that OBEs are not still being watched out for, because visual stimuli are still going to play a part in the experiment environment.
The monitoring of brain oxygen levels is going to play a key role. I believe a number of factors have determined this as a path to follow. Monitoring oxygen will at least rule in or out this aspect as a factor, in both survivability and memory recollection. It could lead to a question or reanalysis of brain functionality in compromised blood flow / cardiac arrest circumstances, for some people. Also, there may be other details less publicly discussed in the first study that led to a suggestion of greater oxygen in the brains of the 10% that remembered varying experiences. Dr Parnia after the publication of the first study results reasserted that “the brain typically ceases functioning within 20 – 30 seconds of the heart stopping and doesn’t resume again until the heart has been restarted.” The brain oxygen monitoring would appear to be looking for the possibility of exceptions to this.
The visual stimuli of projecting upward facing random images will continue, but this time in a portable manner, so as to suit the mobile location nature of cardiac arrest events. It is stated that a tablet device will be used to do this. I would hope that a large screen tablet will be used, so as to gain a better chance of images being ‘seen’, with the images both vivid and simple in nature.
The post event and recovery interviews with patients will be audio recorded. It was unclear as to whether this was done in the first study. Real time recording of data like this is I believe important for future peer analysis and comparison. It helps take the study results away from being purely anecdotal.
There is no mention of any attempt to record the actual arrest events in a similar manner. I believe if this could be done, the data from the study in the future would hold considerably more value, again for peer analysis and data credibility. There would indeed be an amount of administrative legal preparation and authority agreement required to do this, but it should be noted that this has in fact on numerous occasions been done before. Recording (both audio and video) of emergency resuscitation situations is carried out from time to time by various hospitals and institutes for medical / professional overview and improvement studies. An example of the planning documentation of such recording can be seen here: http://accs.wustl.edu/en/~/media/Files/ACCS/Trauma-Resuscitation-Recording-2014.ashx
In conclusion, the study as it goes on can only positively contribute to the data pool for studying near death experiences. The brain oxygen analysis may or may not lead to further understanding of brain viability during cardiac arrest. Another veridical recall is a real possibility in the 1000+ monitored cases, and who knows, that ever elusive visual recall may yet be found.
I maintain my belief that this is the first and only study of it’s kind that actively monitors near death situations, subsequently exploring patient outcomes and experiences. The AWARE team are to be congratulated and supported in carrying on with this endeavour.
“The AWARE study researchers are to be congratulated on a fascinating study that will open the door to more extensive research into what happens when we die” (Dr Jerry Nolan, Editor-in-chief of Resuscitation Journal)
(All quotes from : University of Southampton. “Near-death experiences? Results of the world’s largest medical study of the human mind and consciousness at time of death.” ScienceDaily. ScienceDaily, 7 October 2014. http://www.sciencedaily.com/releases/2014/10/141007092108.htm)
UKCRN outline publication : http://public.ukcrn.org.uk/Search/StudyDetail.aspx?StudyID=17129
Incidentally, the UKCRN publication of the AWARE 2 proposal is the only such information I have come across. I have heard or seen no other news or commentary regarding this second phase of the study. As to when and if this has started yet is not known. (EDIT: Please note as of late 2016 the details of this study outline have been removed and the link is no longer valid. There is a new official briefing page on the NHS Research portal http://www.hra.nhs.uk/news/research-summaries/aware-ii).