State of the heart: A brief look at Lazarus Syndrome‬

Back in the late 1990s and early 2000s I used to write regularly for the British magazine Bizarre. One of the articles of mine that they published was on ‘near death experiences’ and it was during my research on that topic that I first came across what has been termed the Lazarus syndrome (sometimes referred to as the Lazarus Phenomenon). The syndrome takes its name after Lazarus (who according to the New Testament was raised from the dead by Jesus), and refers to the spontaneous return of blood circulation after the person has been declared dead. The condition is very rare and there have been less than 30 documented cases in the medical literature over the last 30 years. The term ‘Lazarus Phenomenon’ is relatively recent and was first used by Dr. J. Bray in a paper published in a 1993 issue of the journal Anesthesiology.

Earlier this year, a story appeared in the British press about a Scottish woman who came back from the dead after collapsing while gardening (February 10, 2012). The newspaper reported:

“A woman declared dead after she suffered a massive heart attack astonished doctors and her grieving family when she suddenly came back to life. Relatives of Lorna Baillie were devastated when a team of medics withdrew treatment after spending three hours trying to revive her. The family gathered around her hospital bed to say their goodbyes after doctors told them the 49-year-old grandmother was ‘technically dead’… It was then, 45 minutes later, that Mrs Baillie’s disabled husband John, 58, whispered ‘I love you’ to his wife. And when Mrs Baillie’s eyelids flickered and she appeared to squeeze her eldest daughter Leanne’s hand, the nurse again assured the family that ‘involuntary movements’ were to be expected. Unconvinced, the family demanded the nurse call in a doctor, who found a pulse and rushed Mrs Baillie to intensive care. Mrs Baillie’s miraculous signs of recovery followed, but medics warned that her chances of survival remained slim because her kidneys had failed and she was in a coma. But Mrs Baillie’s condition continued to improve and [was] moved from intensive care to a medical ward. An MRI scan yesterday revealed no obvious brain damage”.

The causes of how seemingly dead people to come back to life are not clearly understood among the medical community. One explanation that has been suggested is that as a consequence of cardiopulmonary resuscitation, there is the buildup of pressure in the chest as a result of cardiopulmonary resuscitation (CPR), and that the relaxing of the pressure (post-CPR) initiates electrical impulses that restart the heartbeat. Other physiological factors that have been suggested include the affected individuals having elevated levels of (i) potassium electrolytes (i.e., hyperkalemia) or (ii) adrenaline (epinephrine). Here are a few ‘typical’ examples reported in the medical literature:

• Case 1: After suffering an abdominal aneurysm, a 66-year-old American man was declared dead after 17 minutes of failed treatment. However, 10 minutes later, one of the doctors felt a pulse, and he made a full recovery with no long-lasting medical problems (Reported in Anesthesia and Analgesia, 2001).
• Case 2: After renal failure secondary to embolism of the superior mesenteric artery, a 93-year old American woman was pronounced dead after 6 minutes of failed resuscitation treatment. Five minutes after being declared dead cardiac activity was observed on the heart monitor, and she made a full recovery (Reported in Anesthesia and Analgesia, 2001).
• Case 3: Following a drug overdose-related heart attack, 27 year-old British man was declared dead after 25 minutes of failed treatment. Shortly after death had been declared, a nurse noticed the heart monitor was again showing heart rhythms so the resuscitation attempt continued and the man made a full recovery with no long-term medical complications (Reported in Emergency Medical Journal, 2001).
• Case 4: A 65-year-old male with congenital deafness and dumbness was found unconscious in his room at a public home. After 35 minutes of resuscitation treatment he was declared death. Approximately 20 minutes later, a police officer found the man moving in the mortuary. He lived for a further four days (Reported in Forensic Science International, 2002)

In 2010, Dr. K. Hornby and colleagues (all at McGill University, Montreal, Canada) published a systematic literature review of auto-resuscitation after cardiac arrests in the journal Critical Care Medicine. They started from the position that there was a lack of consensus as to how long after circulation has topped for death to be determined after cardiac arrest. At present, and because of the Lazarus Syndrome, the medical literature recommends that death should not be certified until 5-10 minutes after failed CPR has taken place. The condition also raises questions and interesting ethical issues as to when post-mortem procedures should occur (e.g., organ harvesting, autopsies, etc.)

The authors located 32 cases (aged 27-94 years of age across 16 different countries) published in the medical literature (from 27 different articles, so most were single case studies). They then systematically collated all data relating to a number of different factors including (i) patient characteristics, (ii) duration of cardio-pulmonary resuscitation, (iii) terminal heart rhythms, (iv) time to unassisted return of spontaneous circulation, (v) monitoring, and (vi) outcomes.

The authors considered the papers to be of “very low quality” (all were case reports or letters to the editor). All of the 32 cases reported auto-resuscitation following failed CPR. The times ranged from just a few seconds up to 33 minutes. They also noted that there was a lot of inconsistency in reporting methods and that only eight of the cases reported continuous electrocardiogram monitoring and exact times. In these eight cases, auto-resuscitation did not occur beyond the 7-minute barrier. They also noted that there were no cases of auto-resuscitation in the absence of CPR. The findings of their review therefore suggest that the provision of CPR may influence the occurrence of auto-resuscitation. Their study concluded that there was insufficient evidence to support or refute the current recommended waiting period of 5-10 minutes to determine death following a heart attack. Similar conclusions were reached by Dr. Vedamurthy Adhiyaman and colleagues, in a 2007 literature review published in the Journal of the Royal Society of Medicine. They looked more widely at auto-resuscitation and located 38 cases published in the medical literature. They also examined the longer-term outcome and reported:

“Seventeen patients (45%) achieved good neurological recovery following ROSC [return of spontaneous circulation]. Three of these patients subsequently died during their hospital stay due to sepsis and pulmonary embolism and 14 (35%) were eventually discharged home with no significant neurological sequelae. Seventeen patients (45%) did not achieve neurological recovery following ROSC and died soon after. The outcome is not known in four patients (10%). There was no significant correlation between the outcome and duration of CPR, time interval for ROSC or the diagnosis”.

The paper most importantly points out that “death is not an event, but a process…a process during which various organs supporting the continuation of life fail”. As their review points out, the ceasing of circulation and respiration is a good example. Obviously, the absence of heartbeat and respiration are the “traditional and the most widely used criteria” to certify that someone has died, but the Lazarus phenomenon demonstrate that on their own they are not a sign of definitive death.

(Footnote: The paper by Adhiyaman and colleagues also notes the many other medical contexts and conditions in which the word ‘Lazarus’ has been used to describe many other unexpected and scientifically unexplained phenomena. For instance: “Lazarus complex describes the psychological sequence in the survivors of cardiac arrest, near-death experiences and unexpected remission in AIDS. Lazarus syndrome is described in paediatric palliative care, when a child is expected to die but unexpectedly goes into remission. Spontaneous movement in brain dead and spinal cord injury patients has been described as Lazarus sign. Survival of species after mass extinction has been called Lazarus effect. The term Lazarus phenomenon was also used for unexpected survival of renal graft patients”).

Dr Mark Griffiths, Professor of Gambling Studies, International Gaming Research Unit, Nottingham Trent University, Nottingham, UK

Further reading

Abdullah, R.S. (2001). Restoration of circulation after cessation of positive pressure ventilation in a case of “Lazarus Syndrome”. Anesthesia and Analgesia, 93, 241.

Adhiyaman, V., Adhiyaman, S. & Sundaram, R. (2007). The Lazarus Phenomenon. Journal of the Royal Society of Medicine, 100, 552-557.

Ben-David, B., Stonebraker, V.C., Hershman, R., Frost, C.L. & Williams, H.K. (2001). Survival after failed intraoperative resuscitation: A case of “Lazarus Syndrome”. Anesthesia and Analgesia, 92, 690-692.

Bray, J.G. (1993). The Lazarus phenomenon revisited. Anesthesiology, 78, 991.

Hornby, K., Hornby, L. & Shemie, S.D. (2010). A systematic review of autoresuscitation after cardiac arrest. Critical Care Medicine, 38, 1246–1253.

Maeda, H., Fujita, M.Q., Zhu, B.L., et al (2002). Death following spontaneous recovery from cardio-pulmonary arrest in a hospital mortuary: “Lazarus phenomenon” in a case of alleged medical negligence. Forensic Science International, 127, 82-87.

Walker, A., McClelland, H. & Brenchley, J. (2001). The Lazarus phenomenon following recreational drug use. Emergency Medical Journal, 18, 74–75.