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THE UNREAL WORLD

Turmoil inside the mind of a mother on her deathbed

July 16, 2007|Marc Siegel | Special to The Times

"Evening" is a film by Focus Features, written by Susan Minot and Michael Cunningham.

The premise: Ann Lord (Vanessa Redgrave) is lying on her deathbed at home, attended by her daughters. Wracked with pain, she appears to be dying of some kind of cancer and is receiving intravenous narcotics. Ann begins to talk about events of 50 years earlier, reliving the untimely death of her former beau Buddy at the wedding of his sister, as she, Ann, jilts Buddy and spends the night with his best friend, Dr. Harris Arden. For the rest of her life, she has blamed herself for Buddy's death and, in a feverish state on her deathbed, relives that fateful night. The nurse in attendance tells her daughters that the characters Ann is talking to and about "might be real people and they might not" -- she seems to doubt that the memories are real. Indeed, Ann is frequently confused and delirious as death approaches and, among other things, hallucinates that she is visited by Dr. Arden wearing a stethoscope and that her night nurse is in a formal gown.

The medical questions: Is it possible for someone to be delirious and hallucinating and yet able, at the same time, to accurately recall events from the past? Are pain and fever contributing factors to confusion, as the patient's daughters and nurse maintain? Is it common to be revisited, at life's end, by intensely felt past experiences? And is it, as the movie suggests, an easy matter for family and nurses to predict a sinking patient's likely time of death?

The reality: According to the bible of psychiatry, the Diagnostic and Statistical Manual of Mental Disorders, fourth edition (DSM-IV), "The essential feature of a delirium is a disturbance in consciousness that is accompanied by a change in cognition that cannot be better accounted for by a preexisting or evolving dementia." It leads to a reduced but fluctuating awareness of her environment as well as a diminished ability to focus.

Delirium is associated with life-threatening illness and is frequently characterized by preservation of long-term memory while short-term memory is disturbed. Ann Lord's experiences are consistent with this state. Thus, the nurse is wrong -- it is quite realistic and usual that Ann can vividly remember remote events while mixing up the identity of her daughters and nurse and experiencing psychotic hallucinations. Pain, pain medications, fever and underlying illness are all contributing factors to delirium.

Research on the organ of fear and terror -- the amygdala -- has shown that traumatic memories are especially well-ingrained in the brain and resurface easily when a person experiences a traumatic trigger; it is not unrealistic that the stress of dying might cause these emotional memories to quickly resurface. However, research also shows that these powerful emotions may alter perception and the accuracy of memory, although this is not the case in the film. Ann appears to be an unerring narrator of her past tragedy.

Less accurate is the unwavering expectation in the movie that Ann's death is imminent. The family has assembled for a deathwatch to say their final goodbyes -- when in fact, dying, delirious patients often linger, unpredictably, for days or even weeks, especially when they appear as vital as Ann does.

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Dr. Marc Siegel is an internist and an associate professor of medicine at New York University's School of Medicine. He is also the author of "False Alarm: The Truth About the Epidemic of Fear." In The Unreal World, he explains the medical facts behind the media fiction. He can be reached at marc@doctorsiegel.com.

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