Older Homeless People Are At Great Risk of Dying

Research Describes a “Health Shock” from Losing Housing Later in Life

By Laura Kurtzman

A quarter of the participants in a long-term study of older people experiencing homelessness in Oakland died within a few years of being enrolled, UC San Francisco researchers found.

The study, funded by the National Institute on Aging, recruited people who were 50 and older and homeless, and followed them for a median of 4.5 years. By interviewing people every six months about their health and housing status, researchers were able to examine how things like regaining housing, using drugs, and having various chronic conditions, such as diabetes, affected their risk of dying.

They found that people who first became homeless at age 50 or later were about 60 percent more likely to die than those who had become homeless earlier in life. But homelessness was a risk for everyone, and those who remained homeless were about 80 percent more likely to die than those who were able to return to housing.

Becoming homeless late in life is a major shock to the system.

The median age of death was 64.6 years old, and the most common causes of death for people in the study were heart disease (14.5 percent), cancer (14.5 percent), and drug overdose (12 percent).

“Becoming homeless late in life is a major shock to the system,” said Margot Kushel, MD, who directs the Benioff Housing and Homelessness Initiative and is a professor of Medicine at UCSF and senior author of the study published August 29, 2022 in JAMA Internal Medicine.

“These untimely deaths highlight the critical need to prevent older adults from becoming homeless – and of intervening and rehousing those that do, quickly,” she said.

The study is unique for its prospective design. Previous studies of mortality in homeless populations were retrospective and drew information from medical records. By contrast, the current study – Health Outcomes of People Experiencing Homelessness in Older Middle agE (HOPE HOME) – followed a group of people, whether or not they received health care.

Many study participants had serious conditions that went untreated.

“We looked at how frequently people reported diagnosis of heart disease or cancer before dying of these diseases. It was really low,” said Rebecca Brown, MD, affiliated assistant professor of medicine in the Division of Geriatrics at UCSF. “We think this represents a lack of access to care and delayed diagnosis. Often, we didn’t even know people were ill because they didn’t report it in their six-month interviews. But we found it on their death certificates.”

Researchers went to great lengths to track down what happened to the people in the study when they missed check-ins and couldn’t otherwise be accounted for, including looking at photos of unidentified deaths at the coroner’s office, reviewing California state death records to match their participants’ names and dates of birth, querying emergency contacts, searching social media, and reading online obituaries.

They found that as of Dec. 31, 2021, 117 of the 450 people had died since the study began enrolling in 2013. Nearly 40 percent (45) occurred after the pandemic started in March of 2020, but just three of those deaths were from COVID-19. Participants entered the study in two waves, with 350 enrolled in 2013-14 and another 100 enrolled in 2017-18; 101 of the deaths were from the first wave, and 16 were from the second.

Mortality rates were high compared to the general Oakland population. The risk of dying was 3 times higher for men and 5 times higher for women, compared to people of the same age and sex in Oakland. The median age for participants entering the study was 58, and 80 percent were black; 76 percent were male, and 24 percent were female.

The study also contained detailed information about people’s use of drugs and alcohol, as well as their mental health. But drug and alcohol use itself was not independently associated with death.

“The streets are just no place to live,” said Johná Wilcoxen, 72, who spent more than a decade living in his car when he lost Section 8 housing because his children moved out. Through his ordeal he continued working as a plumber, which gave him a place to go during the day and money for food. “The more people as we can get off the street, the better,” he said.

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When and why did humans start using tombstones?


As grave markers, tombstones offer a focus for mourning and commemoration. Typically made of stone and usually engraved with the deceased’s name, date of birth and death, they also often carry inscribed tributes. They’ve been around a long time, across a wide variety of cultures.

“Numerous Neolithic stone statues called stelae, associated with Kurgan culture burials about 5,000 years old, were found in Ukraine and Moldova,” reveals Čaval. “We also have Bronze Age stone and wooden markers on mounds. The Greeks buried commoners and elites in marked graves. There’s the pre-Roman Vulci in Italy, followed by the abundant Roman tombstones, with statues, reliefs and inscriptions telling stories,” she adds.

Why deaths are written in stone

As Čaval explains, the first epitaphs as we now know them, especially the formula “Here lies…”, comes from the Greek tradition. Adopted by the Romans, thanks to the spread and influence of their empire, this became the standard in the West.

More than just words, the aesthetics of tombstones also tell us about the beliefs of their creators. “The specifics tell us something unique about the times in which they are made—about communities, their identity, values and beliefs, about both life and the afterlife,” says Čaval.

Most obviously, a tomb’s location can reflect the deceased’s personal attachment to a specific location, while craftmanship and materials can reflect social status, especially if rare. Inscriptions are indications of literacy, while decorative motifs can suggest religious affiliations.

“Even without decoration or inscription, the tombstone’s shape, position within a cemetery, type of cemetery, all help build a picture of what a society values and how individuals fit into these values,” adds Čaval.

The stećci enigma

Čaval’s expertise and interest in understanding the past through burial practices and their material culture, were sparked by the Western Balkans’ little known stećci, gigantic stone monuments found at gravesites.

Decreed a UNESCO World Heritage Site in 2016, the stećci are medieval tombstones, preserved across the landscapes of Bosnia and Herzegovina, Croatia, Montenegro and Serbia.

“Remarkably, these are not attributed to any ethnic or religious group and so have always been considered enigmatic. But their numbers, with over 70,000 preserved, alongside their monolithic character reflect their importance, many centuries ago,” says Čaval.

Some tombstones have inscriptions written in Glagolitic and Bosnian Cyrillic scripts, both extinct today. This speaks to local ethnic and religious diversity, substantiated by prehistory decorations mingling with Roman Christian or Islamic elements.

“We’re using modern digital techniques like to explore this phenomenon and I’m proud to help publicize them,” reflects Čaval.

Are the cracks showing in tombstones?

The simplest reason for tombstones’ success is that they are fit for purpose. Suitable has been relatively easy to find and transport to gravesites. It can be decorated. Stone is hard-wearing, enduring and the passage of time—ensuring a lasting tribute. Which also explains why other grave markers, whatever they might have been, are lost to time.

With the rise of humanist funerals and with cemeteries facing overcrowding, accompanied with increasing sustainability concerns—are tombstones falling out of favor? “There is definitely a trend for alternatives but I think there will always be a place for tombstones. Their reassuring solidity literally represents a life, keeping it present and so relevant,” concludes Čaval.

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Psychedelic trips and near-death experiences result in strikingly similar attitude shifts

The two experiences alter a person’s core beliefs in a comparable way and scientists want to understand why.

By Katie MacBride

In 2014, Tracy Morgan was in a car accident that nearly took his life. The former Saturday Night Live and 30 Rock cast member suffered near paralyzing injuries in the accident that killed his friend James McNair. In 2019, he told Oprah Winfrey how the crash fundamentally changed his attitude.

“The way I am with people, something’s just different. I find myself saying, ‘I love you’ 200 times a day to strangers.”

Such shifts in attitude about life and death are common among people who have had near-death experiences. Studies have found that those who describe themselves as having experienced near-death events have lower ratings in metrics assessing fear of death and higher ratings for belief in a happy afterlife.

Similar changes in attitude are often described by people who have psychedelic drug experiences. For example, a pivotal 2016 study that looked at the effect of psilocybin treatments in terminal cancer patients found that patients who took the drug had dramatic “increases in quality of life, life meaning, and optimism, and decreases in death anxiety.”

But what do near-death events and psychedelic experiences have in common? That’s what Johns Hopkins University School of Medicine researchers sought to parse. Their results, published Wednesday in the journal PLOS One, raise intriguing questions about what shifts our attitude toward life and death.

Here’s the background — Roland Griffiths is the director of the Center for Psychedelic and Consciousness Research at Johns Hopkins University School of Medicine. He was the first author on the 2016 psilocybin cancer patient study and has long been interested in attitude shifts resulting from psychedelic experiences.

What that study showed, Griffiths tells Inverse, is that “a single dose of psilocybin produced remarkable decreases in anxiety and depression that endured.”

What predicted these positive outcomes, he explains, was “a constellation of features of the experience.” These are classically defined as mystical experiences, though Griffiths cautions that some people may misunderstand what that means. “It’s not a supernatural thing; these have certain features that we can define empirically.”

Those features include “Sacredness, deeply felt peace and joy, transcendence of time and space,” and “internal unity and external unity.” The cliche but accurate way to describe that unity is feeling “one with the universe.” A psychedelic experience with those qualities is predictive of decreased anxiety and depression, as well as shifts in attitude about death and dying.

“If you look at the phenomenological features of near-death experiences, there’s something called a near-death experience questionnaire, it looks again suspiciously like the mystical experiences, there are so many features in common,” Griffiths says. “So that prompted us to wonder, ‘do we have a model [with psychedelics] that is very similar — in terms of brain mechanisms or psychological changes — to experiences that occur naturally.”

Griffiths and his colleagues decided to hone in on that question by directly comparing a group of people who claim to have had a near-death or “non-ordinary” experience that altered their attitudes about death and dying with a group who reported similar changes after taking a psychedelic drug.

What the researchers did — Researchers administered a survey to 3192 people. There were 900 in the near-death or other non-ordinary experience group; the remaining participants were sorted into groups based on the drug responsible for the experience in question: LSD, DMT, psilocybin, or ayahuasca — a psychoactive brew derived from specific shrubs that have traditionally been used in spiritual ceremonies by indigenous peoples in the Amazon basin.

Participants were given a series of questionnaires designed to parse different aspects of their experience and the enduring effects. To quantify the “cognitive, affective, paranormal, and transcendental” aspects of their experience, participants were given the Greyson Near-Death Experience Scale. These questions revolved around the thoughts, perceptions, and feelings that defined the person’s experience. The subjective aspects of the experience, as well as the attitude shifts following it, were evaluated using several other surveys.

What they found — One of the most striking findings is how similar the two groups were to each other.

“Almost 90 percent of both groups reported decreased fear of death following the experiences,” Griffiths says. “Both groups rated the experience very high for personal meaning and spiritual significance, and both groups reported persistent positive changes in personal well-being, life satisfaction, life purpose, and life meaning.”

Slight deviations occurred between the two groups; for example, those in the near-death experience group were more likely to report the experience as the single most meaningful of their life. The one exception was the ayahuasca subgroup, those participants rated the experience more closely to the near-death group: as the most meaningful of their life.

Interestingly, the psychedelic drug group rated the experience higher on the mystical and near-death experience questions than the participants in the actual near-death experience group.

Digging into the details — The reasons behind some of the slight discrepancies between the near-death and psychedelic groups were fairly obvious. For example, the near-death group was more likely to believe their life was in danger during the experience because, as Griffiths says, “they clinically were.”

Other differences, especially those among the psychedelic drug subgroups are less clear, though Griffiths offers some possible factors.

The ayahuasca subgroup being so similar to the near-death experience group on the singular meaningful experience metric may be the result of different demographics, or different contexts.

“The Ayahuasca group tended to be older, more affluent, and female,” Griffiths says. “And ayahuasca is more likely to be taken in a ceremonial setting. So there’s a set and setting difference there that’s distinct from psilocybin or LSD.”

While he can’t say for sure those account for the differences, they “may be very important to how those effects are interpreted.”

The answers likely won’t elude the researchers at the Center for Psychedelic and Consciousness Research for too long. They’re studying many different aspects of psychedelic-assisted therapy.

“We’re looking at different therapeutic indications for these drugs. We have studies on alcohol use disorder, OCD, anorexia, Alzheimer’s, Lyme disease, and PTSD,” Griffiths says. “We’re also looking at the brain mechanisms involved in psychedelic experiences. We have a whole line of investigation in healthy volunteers aimed at more fully understanding the longer term implications of some of these profound experiences.”

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Don’t Forget the Death Workers

Hayley Campbell on the hidden labor after life

The Repentant Magdalen (c. 1635/1640) by Georges de La Tour

By Stephanie Bastek

Anglo-American attitudes toward burial have changed significantly over the past half century: today, most people choose to be cremated, and alternatives like natural burials and human composting are on the rise. Margareta Magnusson’s The Gentle Art of Swedish Death Cleaning, about the importance of getting your affairs in order, was a surprise bestseller, and American mortician Caitlin Doughty is but one of several popular YouTube personalities who speak about death. But largely absent from the conversations at so-called Death Cafes (coffee, crumpets, and the inevitable!) is any discussion of the people who devote their lives to caring for the dead. These death workers are the focus of Hayley Campbell’s new book, All the Living and the Dead. Campbell speaks to people doing jobs we tend not to consider: embalmers and executioners, of course, but also crime scene cleaners, mass fatality investigators, bereavement midwives, and others. What makes these people choose to surround themselves with death tells us a lot about what the rest of us lose when we relegate death to the shadows.

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Ashes to Ashes

Turning the dead into soil in Washington State.


Micah Truman, founder of Return Home, uses the word beautiful many times during our conversation about his company’s unique burial process.

Terramation—what Return Home calls human composting—a two-month-long process that turns deceased bodies into soil, is new to the world. So new, in fact, that the service is offered in only a few places on the entire planet, and Washington State happens to be one.

Washington became the first place in the world to legalize human composting, thanks to a small, dedicated group of funeral directors led by Katrina Spade, a founder of the nonprofit Urban Death Project. As an undergrad at the University of Massachusetts Amherst, Spade had received the prestigious Echoing Green Fellowship and worked with scientists and biologists to develop a process that turns human remains into soil. In 2018, Spade pushed for human-composting legislation in Washington, later signed by Governor Jay Inslee in 2019. After it became law, she opened the world’s first human-composting center, Recompose, located in Seattle.

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Currently, there are only three states that provide this service: Washington, Colorado, and Oregon. Other states, including California, are working on similar legislation. In 2021, California Democratic assembly member Cristina Garcia, from Bell Gardens, introduced Assembly Bill 501, which would legalize “natural organic reduction.” It successfully passed out of the California State Assembly, the Senate Health Committee, and the Senate Business and Professions Committee, but it is currently tabled.

Return Home is located in Auburn, a suburb 20 miles south of Seattle. Speaking with me on a sunny spring morning, Truman recalls the story of a California family who recently used Return Home’s service.

The woman’s son had died suddenly, and she’d decided that because he hadn’t liked to fly when he was alive, she would transport him in a car herself. She drove from Northern California to Washington, her son’s body cooled and packed according to Return Home’s instructions. Once she arrived, Truman recalls, “She was able to sit with him and talk with him. We were able to place him in his vessel with his mom there.”

“It was one of the most beautiful things I’ve ever seen,” Truman says.

An entrepreneur and investor, Truman saw the Washington legislation as not just a business opportunity but an environmental one. The funeral industry isn’t particularly innovative: most people opt for either burial or cremation, and neither of those are good for the planet, he explains.

“Cremation has long been considered the environmental alternative. It’s the one that people use. It’s what I would have used, or my family, because we consider it the least environmentally impactful,” he says.

But, he points out, “Cremation uses about 30 gallons of fuel, spews about 540 pounds of CO2 into the air per cremation.”

The burial service Truman offers is different from a green burial, which, at its simplest, involves placing an unembalmed body directly into the ground without a box. Though green burial is also more natural than cremation, it presents the same problem that traditional cemeteries often face: limited space.

The idea of human composting might seem weird at first. Some “conservative religious groups” have reservations, says Truman, but he points out that the Catholic church was also once averse to cremation and is now on board. And if you think of human composting as slow burial, it’s less odd. Return Home uses a custom-made, heavily insulated plastic polycarbonate vessel; the body is placed inside with alfalfa, straw, and sawdust. After 30 days, the body disintegrates, leaving only bones, which are crushed and returned to the vessel to sit for another month. At the end of the cycle, 500 pounds of dense, nutrient-rich soil are created and can be used anywhere.

“We have to tell our families that it is extremely nutritionally dense,” Truman says. “So a lot of people would think, ‘OK, I will take a large pile of this and plant a tree in it,’ but there’s an enormous amount of nitrogen. It’s incredible. It’s the stuff of life.”

Joanna Ebenstein is the founder and creative director of Morbid Anatomy, an organization based out of New York City that has classes and lectures that encourage thinking differently about death and using creativity to explore the end of life. (Sample class: Make Your Own Memento Mori.) “We’re really about bringing death to the forefront,” says Ebenstein. A Bay Area native, she says that many people in the death-positive community are younger women and are more open to embracing natural burials, like human composting.

“A lot of them are focusing on trying to change attitudes about death so that we can live, so we can have better deaths. And that includes dying with more dignity, being able to choose when you die. And that also includes what you want done with your body and help people get to spend time with your body after you die,” Ebenstein says. “I certainly have seen many, many more people interested in this in the last 10 years than I ever have before.”

Though Return Home’s is the largest facility in the state—11,000 square feet, housing 70 vessels at a time, at full capacity—Truman is composting only 900 bodies a year.

With so few places offering the service in the country, Truman says 20 percent of his customers are from out of state: “Colorado, California, Missouri, Oregon. So we’ve had people come from all over there, and a number of them from California.”

Truman is still moved by the memory of the California family who came to Return Home.

At the end of the two-month process, the woman’s other sons made the drive up to gather the enriched soil made from their brother’s remains and brought him back to California.

“It was one of the most remarkable experiences I’ve ever had in my life,” Truman says.

You might even say it was beautiful.•

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Is Alexa’s voice of the dead a healthy way to grieve a loved one?

By Riya Anne Polcastro

Amazon’s Alexa is getting an update that may soothe some grieving souls while making others’ skin crawl. The AI enhancement will enable the device to replicate a deceased loved one’s voice from less than a minute of recording, allowing users the opportunity to connect with memories in a much more extensive manner than simply listening to old voicemail messages or recordings might provide.

Still, there are reasonable concerns regarding how this technology could impact unprocessed emotions or even be used for unscrupulous purposes.

The ‘why’ behind the new AI

Rohit Prasad, senior vice president and head scientist for Alexa, told attendees at this year’s Amazon re:MARS conference  that while AI cannot take away the grief that comes from losing a loved one, it can help keep the memories around by providing a connection with their voice. A video played at the conference featured a child asking Alexa to have his grandmother – who had already died – read a book. The device obliged and read from “The Wonderful Wizard of Oz” in the grandmother’s voice. It was able to do so by analyzing a short clip of her voice and creating an AI version of it.

At the conference, Prasad mentioned “the companionship relationship” people have with their Alexa devices:

“Human attributes like empathy and affect are key to building trust,” he said. “These attributes have become even more important in these times of the ongoing pandemic, when so many of us have lost someone we love.” By giving the voice those same attributes, his plan is for the voice to be able to connect with people in a way that helps maintain their memories long after their loved one is gone.

What does the research say?

While it’s yet to be proven whether an AI facsimile of a loved one’s voice has the potential to assist in the grieving process, there’s hope there could be a real benefit to the application. Research into how hearing a mother’s voice can ease stress among schoolchildren suggests the potential is there.

Leslie Seltzer, a biological anthropologist at the University of Wisconsin–Madison, determined that talking to Mom on the phone can have the same calming effects as receiving in-person comfort—which included hugs. In a follow-up study that demonstrated the same effects don’t hold for students conversing with their mothers through instant messages, the researcher explained that speaking with someone trustworthy has the power to reduce cortisol and increase oxytocin.

There is, however, a fundamental difference between talking to a living relative on the phone and interacting with an AI imitation of someone who is gone. Anecdotal evidence of friends and family listening to old recordings of their loved ones suggests that what is healing for some may be devastating for others. While some people report that listening to old voicemails, for example, help them reconnect and process their grief, others have said it made the pain worse.

What about the experts?

Dianne Gray, a certified grief specialist, also pointed out it could go either way. She explained the Alexa feature could “be immensely helpful or, conversely, act as a trigger that brings grief back up to the surface.”

She suggested regardless of the situation, the mourner should be in a safe space that will allow them enough time and support to work through any unexpected emotions that come up.

Likewise, Holly Zell, a licensed clinical professional counselor intern specializing in death and grief, agreed:

“Every person’s grief experience is unique, and each grief experience a person has across their life is unique,” she said. “What might be helpful in one situation might feel distressing or harmful in another.”

Zell is concerned the AI could interfere with the grieving process, particularly with the example given at the conference of a child listening to their grandmother read a story.

“One of the most challenging and also important aspects of grief is acceptance, which involves acknowledging that the death has happened and that certain things change in relationships after death,” she said. “It can be healthy to have a sense of a ‘continued’ relationship after death, but this is not meant to be in conflict with acceptance.”

Zell instead encourages having loved ones record messages before they pass. Those messages can also provide that connection that can be so crucial, Gray explained.

“This connection via sound can continue long after the loved one has died,” she said. “A common fear of the bereaved is that they will forget what a loved one’s voice sounded like.”

She’s hopeful that by hearing the voice of the deceased without their physical body, the feature can help people navigate acceptance.

“Research will be interesting on this topic.”

Additionally, Gray sees potential benefit for seniors with low vision who may find it easier to use the 100% voice-activated device than if they were trying to pull up recordings on their phones.

That doesn’t mean the AI is risk-free, she explained.

“What if there are things left unsaid, disharmony or abuse between the voice on the Alexa device and the beloved? What if the message on the Alexa device is not as kind, gentle or loving as it should or could be?”

Gray pointed to the unfortunate reality that people often die with close relationships still in tatters—and that their voice could have a negative impact on survivors.

Zell said she also remains unconvinced at this point.

“I’m sure there are people who will find this comforting or helpful. I personally and professionally feel skeptical of this as a useful tool, and would strongly encourage people to find their own meaningful ways to include their lost loved ones into their lives through photos, stories, videos/recordings and other experiences.”

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After death, you’re aware that you’ve died, say scientists

Your subjective experience might not end the moment your heart stops, research on near-death experiences suggests.

By Philip Perry

Time of death is considered when a person has gone into cardiac arrest, which is the cessation of the electrical impulse that drives the heartbeat. As a result, the heart locks up. This moment when the heart stops is considered by medical professionals to be the clearest indication that someone has died.

But what happens inside our mind during this process? Does death immediately overtake our subjective experience or does it slowly creep in?

Scientists have studied near-death experiences (NDEs) in an attempt to gain insights into how death overcomes the brain. What they’ve found is remarkable: A surge of electricity enters the brain moments before brain death. One 2013 study, which examined electrical signals inside the heads of rats, found that the rodents entered a hyper-alert state just before death.

Some scientists are beginning to think that NDEs are caused by reduced blood flow, coupled with abnormal electrical behavior inside the brain. So, the stereotypical tunnel of white light might derive from a surge in neural activity. Dr. Sam Parnia is the director of critical care and resuscitation research, at NYU Langone School of Medicine, in New York City. He and colleagues have investigated exactly how the brain dies.

Our cerebral cortex is likely active 2–20 seconds after cardiac arrest.

In previous work, Dr. Parnia has conducted animal studies looking at the moments before and after death. He’s also investigated near-death experiences. “Many times, those who have had such experiences talk about floating around the room and being aware of the medical team working on their body,” Dr. Parnia told Live Science. “They’ll describe watching doctors and nurses working and they’ll describe having awareness of full conversations, of visual things that were going on, that would otherwise not be known to them.”

Medical staff confirm this, he said. But how could people who were technically dead be cognizant of what’s happening around them? Even after our breathing and heartbeat stop, we remain conscious for about two to 20 seconds, Dr. Parnia says. That’s how long the cerebral cortex is thought to last without oxygen. This is the thinking and decision-making part of the brain. It’s also responsible for deciphering the information gathered from our senses.

According to Dr. Parnia, during this period, “You lose all your brain stem reflexes — your gag reflex, your pupil reflex, all that is gone.” Brain waves from the cerebral cortex soon become undetectable. Even so, it can take hours for our thinking organ to fully shut down.

Usually, when the heart stops beating, someone performs CPR (cardiopulmonary resuscitation). This will provide about 15% of the oxygen needed to perform normal brain function. “If you manage to restart the heart, which is what CPR attempts to do, you’ll gradually start to get the brain functioning again,” Dr. Parnia said. “The longer you’re doing CPR, those brain cell death pathways are still happening — they’re just happening at a slightly slower rate.”

Other research from Dr. Parnia and his colleagues examined the large numbers of Europeans and Americans who have experienced cardiac arrest and survived. “In the same way that a group of researchers might be studying the qualitative nature of the human experience of ‘love,’” he said, “we’re trying to understand the exact features that people experience when they go through death, because we understand that this is going to reflect the universal experience we’re all going to have when we die.”

One of the objectives is to observe how the brain acts and reacts during cardiac arrest, throughout both the processes of death and revival. How much oxygen exactly does it take to reboot the brain? How is the brain affected after revival? Learning where the lines are drawn might improve resuscitation techniques, which could save countless lives per year.

“At the same time, we also study the human mind and consciousness in the context of death,” Dr. Parnia said, “to understand whether consciousness becomes annihilated or whether it continues after you’ve died for some period of time — and how that relates to what’s happening inside the brain in real time.”

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