AURAS AND PREMONITIONS: Intimations of Mortality

How can someone know if they are really sick? In the emergency department, life-threatening illness is often spotted as easily as pornography and poor fashion sense--we know it when we see it. But for most people, in most situations, sorting out true illness can be difficult. Many healthy folks cycle through EDs for nothingitis because they are anxious about disease, while some exceedingly unwell people stick it out at home, in full-on denial or stoically convinced that they can will themselves better. Others get so worked up with worry that they cause their coronaries to spasm them into right into a cardiac cath lab, while others just can’t understand why their chest aches so deeply when they walk up stairs.

What’s the difference between a mind that causes illness and one that can detect sickness early? This would seem to be an important question not only for emergency medicine, but also for every single living and thinking patient in the world. As physicians, we’ve all seen scores of panicky patients who have initiated their own domino effect of self-inflicted pathology. Take, for instance, the worried hypertensive, who takes his blood pressure reading at home again and again until it reaches an ischemic stroke climax.

Admittedly, patients seem much better at causing their own illness than they are at sensing illness before it occurs. But, there are some people out there who can reliably predict when they are getting ill. I find this intriguing. Do we, as humans, have a muted and under-recognized sense of our own sickness? With better recognition skills, could our patients serve as their own triage nurses? Phone advice lines are great, but wouldn’t it be nice if our patients had a reliable sense of sickness--an epiphany of medical impairment?

Skeptical? Well, consider some examples. Let’s start with the aura:

“[The aura that] precedes the headache of migraine is very mysterious. … There is a process of intense activity which seems to spread, like the ripples in a pond into which a stone is thrown. … The most frequent among the many forms is that of a small star near the fixing point; it enlarges towards one side, its rays expanding into zigzags.”

So wrote British neurologist Sir William Gowers in 1906 in the British Medical Journal. Gowers was fascinated with the aura, so much so that he just couldn’t help himself from describing it in exquisite detail:

“The most frequent prodroma is visual, as you all know. It is so characteristic as not to lead to confusion with epilepsy. But its features should be noted. The most frequent among the many forms is that of a small star near the fixing point; it enlarges towards one side, its rays expanding into zigzags, often coloured--the “fortification spectrum.” Within it vision is dimmed by bright scintillation. It becomes faint when it has almost reached the periphery, and ends in various ways which are not relevant to our present object.”

Auras, as we know, are also common in people with epilepsy. They come in a wide variety of forms--a kaleidoscope of lights, the smell of burnt toast, the sound of a public-address announcer booming--and may occur seconds to hours before the onset of a headache or seizure. For an epileptic or a migraineur, the aura is an extremely reliable indicator of impending symptoms, far more accurate than clinical evaluation or testing. Absent continuous fMRI or EEG monitoring, auras could be considered a gold standard of disease prediction; but we don’t really understand where auras come from. We assume that they are associated with excitation of specific cortical areas preceding the onset of more generalized processes, but we have not yet been able to capture the neural circuitry of this process.

Is it possible that auras are a prominent manifestation of an innate mental ability to detect illness--a sense and premonition of sickness?

Consider some other health-related premonitions. Most or all of us have had some experience with a patient who accurately predicted his or her own demise. When I asked the partners in my home department about such premonitions of death (POD), all but one had a story to share--and the one who demurred gave this response, “Ugh no, but I can tell you about the thousands of anxious patients I’ve had to talk down from the ledge. … I hope you aren’t going to turn this into an article.”

Well, with apologies to Dr. Nau, I am. I can recall a patient of mine, a reasonably healthy middle-aged man with a small spontaneous intracerebral hemorrhage--caused, I initially reasoned, by poorly controlled hypertension. This man was neurologically intact, not on anticoagulants, and had no evidence of mass or aneurysm on imaging. It seemed like he would do just fine. Nonetheless, we prepared a transfer to a neurosurgical center for observation. My patient, stable and asymptomatic prior to transfer, asked me in a quite of matter-of-fact manner, “I’m gonna die, aren’t I?” I assured him that this was not likely and that we were just taking a precaution, but he was convinced. “I’m gonna die,” he said once more, softly, right before being loaded on the transport stretcher. And in fact he did die, just a few hours later, from multiple new bleeds caused by a rapidly progressive cerebral vasculitis.

A colleague tells a story of an aunt who suffered for months from headaches and dizziness of unknown etiology. After many visits to her doctor and many failed treatments, she became convinced that she was going to die. So convinced, in fact, that she began preparing and freezing dozens of meals, so her husband would eat well after she passed. Ultimately, her cerebral aneurysm was diagnosed just shortly prior to rupture. She did not die, but she was correct about being on the verge of death.

While POD is not a rich topic in the literature, there is some evidence supporting it as a real entity. For example, pregnant women who miscarry or otherwise lose their pregnancy sometimes experience a premonition beforehand. In a survey of women who suffered a stillbirth in the second trimester or later, 64% reported some premonition that their child was unwell.[1]

There are a also handful of case reports on POD sprinkled through the literature. Joseph Ngeh, in a 2003 letter to the Journal of the American Geriatrics Society, describes one such premonition in the in-hospital death of an elderly patient:[2]

“The patient’s family had arrived by then. Although distraught, they showed no surprise at hearing about the patient’s sudden death. During our conversation, I sensed that they had expected this to happen. Remarkably, the daughter-in-law volunteered that, when they visited the patient at 9 p.m. earlier that night, a mere six hours before the patient’s first cardiopulmonary arrest, the patient had held her hand and mentioned that he would ‘die tonight.’”

Premonitions of death are also common in trauma patients. In a recent survey of more than 300 members of the Eastern Association for the Surgery of Trauma, 95% of the respondents reported encountering patients who expressed POD, and 50% agreed that patients expressing such premonitions had a higher mortality rate.[3] Fifty-seven percent also agreed with the belief that patient willpower affects outcome, while 44% were on board with the notion that patients an innate ability to sense their ultimate outcome after injury.

Now, such “evidence” must be considered in the light of its limitations. Recall bias is an obvious limitation: there are surely many pregnant women and trauma patients who thrive or recover despite premonitions to the contrary. We must also distinguish POD from the ancient Chinese phenomenon of hui guang fan zhao, also called “Lazarus premonition.” Screenwriters have made liberal use of this phenomenon for decades: the transient revival of the dying person before death. This situation is clearly different from POD because it is not so much a premonition as the recognition of a process that is nearly complete, like a song in its last chorus.

Absent a biologic explanation, it’s impossible to prove that humans have an innate sense of sickness. I would argue, however, that we should not be overly skeptical. We accept the fact that animals may intuit when they or others are ill. Oscar the therapy cat, for example, has to date correctly foretold the deaths of more than 50 patients in a nursing home, curling up beside them within hours of their death.[4]

We also accept that certain animals--and my family’s recently departed black Labrador was one of these--will innately put themselves out to pasture near the time of their death. (In the case of our Lab, this did not work, as my wife kept carrying her back inside from the bushes.)

It seems biologically and intuitively plausible that we humans have an innate sense of sickness. I think we can all agree that such a skill--maybe we could call it an aurascope--would be quite useful. Wouldn’t it be nice to have as much faith in the word of a patient who intuitively predicts the onset of a heart attack or stroke as we would with an epileptic aura? Sure would save us emergency physicians a lot of stress--not to mention unnecessary testing.

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Dr. Ballard is an emergency physician at Kaiser San Rafael.

Email: dustin.ballard@kp.org

References

1. Erlandsson K, et al, “Women’s premonitions prior to the death of their baby in utero,” Acta Obstet Gynecol Scand (June 13, 2011).
2. Ngeh J, “The phenomenon of premonition of death in older patients,” J Am Ger Soc (Oct. 24, 2003).
3. Miglietta MA, “Premonition of death in trauma,” Am Surgeon, 75:1220-26 (2009).
4. “Oscar (therapy cat),” www.wikipedia.org (2013).