Jewish Ethical Choices at the End of Life: Where Judaism and

1
Jewish Ethical Choices at the End of Life Where
Judaism and Medicine Meet

• Rabbi Barry M. Kinzbrunner, MD
• Executive Vice President
• Chief Medical Officer
• Vitas Innovative Hospice Care
• Miami, FL

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Melting Pot Society

• Associated with US society in the 1950s and
  before through 1970s
• Model Immigrant Groups
• Shed their historic identities and adopt the ways
  of their new country
• Assimilation into one amalgamated culture with
  shared values and norms

3
Multiculturalism

• More recent phenomenon
• Started in late 1970s following popularity of
  Roots
• Increased interest in identifying with ones
  roots or cultural/ethnic origin
• Has become increasingly important in US
• African American --Hispanic
• Asian --Eastern European
• Religious groups

4
Hospice Perspective

• Original concept resembled Melting Pot Society
• Currently about 40 of dying patients receive
  hospice before death
• Generic Chaplain to meet Spiritual needs
• Ethnic and cultural barriers identified
• Mistrust of healthcare system
• Informing individual may hasten death
• Mandate to preserve life at all costs
• Proscription to concept of giving up

5
Hospice Perspective

• Attempt to reach out to patient groups not
  already accessing hospice
• Chaplains of multiple faiths available either on
  staff or contracted
• Understanding needs of specific ethnic, cultural,
  and religious groups
• Diversity and access programs
• Inner City
• Language specific
• Teams for specific ethnic/cultural/religious
  groups

6
Medical Ethical Values

• Autonomy
• Beneficence
• Non-Maleficence
• Justice
• Social
• Distributive

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Autonomy

• The right of an individual to choose between
  various alternatives presented to them
• Jewish Law
• Autonomy is voluntarily limited
• Decisions are made that are consistent with Gods
  law
• The Rabbi, the expert in Gods law, provides
  advice and counsel regarding health care
  decisions.

8
End of Life Decision Making

• Only applies to patients who are terminally ill
• Guidelines Decisions in Judaism, like hospice
  care in general, are made on a case-by-case basis
• Involvement of a Rabbi who is knowledgeable in
  the area

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Terminal Illness in Jewish Law

• Prognosis of one year or less
• Goses
• Actively dying
• Presence of death rattle
• Some describe as last 3 days of life
• Only basic needs may be provided
• Other interventions are prohibited

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Assisted Suicide/Euthanasia

• Absolutely prohibited
• Deliberate hastening of death is considered an
  act of murder

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Refusal of Medical Treatment

• Patients may refuse treatment if the treatment
• is not proven to be efficacious
• is clearly futile
• entails great suffering or significant
  complications
• Steinberg, A A Jewish perspective on the four
  principles. Chapter 7. Principles of Healthcare
  Ethics, John Wiley Sons, Ltd, 1994.

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Withdrawing and Withholding

• Secular Medical Ethics Withdrawing and
  Withholding are the same.
• Some secular ethicists are now promoting the idea
  that withdrawing is ethically superior to
  withholding.
• Jewish Medical Ethics Withdrawing and
  Withholding are different.

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Withdrawing and Withholding

• WITHHOLDING is permissible when the active
  intervention will delay the dying process or the
  terminally ill patient is experiencing pain and
  suffering that will not be relieved by the
  intervention
• WITHDRAWING of life support and other
  interventions is generally not permissible
  according to Jewish law, unless the intervention
  is clearly viewed as an impediment to death.
• Iggros Moshe, Choshen Mishpat II74 in Tendler
  MD Responsa of Rav Moshe Feinstein, NJ, Ktav
  Publishing, 1996.
• Lamm M Commentary in NIJH Jewish Living Will,
  California, NIJH, 1992.

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CPR

• CPR may be withheld from or refused by terminally
  ill Jewish patients because
• CPR is ineffective therapy for terminally ill
  patients
• CPR may cause harm in terminally ill patients

15
Pain and Suffering

• Judaism does not espouse pain and suffering as a
  virtue
• One may not hasten death, however one may
  withhold treatment or remove impediments to death
  that prolong life in the face of pain and
  suffering

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Pain and Suffering

• Treatment of physical pain with opioids and other
  medications is mandatory
• Opioids should NOT be withheld in the face of
  intractable pain, even if there is a concern that
  death may be hastened
• Judaism also recognizes the importance of
  treating mental anguish and suffering

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Nutrition and Hydration

• Food and fluid are considered basic care by most
  Rabbis
• Therefore, even when provided by artificial
  means, most Rabbis do not consider their
  provision to constitute a medical intervention

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Nutrition and Hydration

• Rabbi Moshe Feinstein
• Iggros Moshe, Choshen Mishpat II74
• Translation I Quite clearly, providing food to
  the patient is beneficial.
• Translation II Clearly, we must feed him food
  that will cause him no harm.
• I Tendler MD Responsa of Rav Moshe Feinstein,
  NJ, Ktav Publishing, 1996.
• II Berman A From the legacy of Rav Moshe
  Feinstein, zl. Journal of Halacha and
  Contemporary Society 135, Spring, 1987.

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Nutrition and Hydration

• Food and fluid should be provided in a fashion
  that provides benefit and avoids harm
• Competent patients may refuse artificial
  hydration or nutrition, but caregivers should try
  and convince the patients to accept the
  intervention

20
Nutrition and Hydration

• If it is determined that the food or fluid is
  without benefit or harmful artificial support may
  be avoided after consultation with a Rabbi
• One may not forcibly feed or hydrate a goses

21
Advance Directives

• Health Care Proxy Designates who will make
  health care decisions if one becomes
  incapacitated.
• Living Will instructions by the patient on
  interventions they desire or do not desire should
  they be in a terminal condition and cannot
  express their wishes.

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Advance Directives

• Health Care Proxy
• Permissable by most
• Includes designation of a Rabbi to advise the
  proxy agent on halachic matters
• Living Will
• More controversial
• Not accepted by all because of concern over lack
  of Rabbinic consultation

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Jewish Life and Rituals

• Prayer
• Prayer Quorum
• Minyan 10 men (orthodox) or persons
• Required for certain prayers including Kaddish
• Dietary Laws Kosher
• Sabbath Shabbat Shabbos
• Holidays

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Holocaust Survivor Issues

• Recurring Loss
• Dying Again
• Beating it Again
• Change in body image
• Anger and resentment
• Survivors Guilt

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Holocaust Survivor Issues

• Survivors Syndrome
• Depressive Reactions
• Anxiety states
• Somatic complaints
• Intellectual impairment
• Contact abnormalities
• Sleep disturbances
• Chronic functional gastrointestinal symptoms
• Exaggerated reactions to chronic pain
• Barile A Geriatric study of survivors.
  International Society for Yad Vashem, Martyrdom
  and Resistance. March-April, 2000, p. 14.

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Vidui Confessional Prayer

• Special prayer said when death may be near
• Shulchan Aruch Yoreh Deah 3381
• When a man is about to die, we tell him to say
  Viddui. We tell him, Many have uttered the
  confession and not died, and many have not
  uttered the confession and died. The reward for
  saying the confession is that you shall live, for
  whoever says the confession acquires a place in
  the afterlife.

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Jewish Concepts of the Afterlife

• World of Souls
• Gan Eden Paradise
• Gehinnom Punishment and Purification
• Resurrection of the Dead
• Olam HaBah The World to Come
• The world of resurrected life after the
  Resurrection of the Dead
• Gilgul Reincarnation

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Care at time of Death

• Initial Care
• In last minutes no one should leave unless
  emotions uncontrolled or physically ill
• After death, eyes and mouth are closed, and face
  is covered with a sheet
• Feet should face the doorway, otherwise the body
  should not be moved
• Candle near the head of the deceased or all
  around the room (except on Shabbat)
• Lamm M The Jewish Way in Death and Mourning. NY,
  Jonathan David, 1969

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Care at time of Death

• Initial Care
• Cover mirrors in home
• Recitations of Psalms
• Respect for deceased
• Ask deceased for forgiveness
• No eating, drinking, or smoking
• Contact Rabbi and/or Chevra Kadisha
• Shomer Watcher, a friend or family member who
  remains with the body until burial
• Lamm M The Jewish Way in Death and Mourning. NY,
  Jonathan David, 1969

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Care at time of Death

• Chevra Kadisha Burial Society
• Jews who are knowledgeable in the proper care of
  the deceased prior to burial
• Physical cleansing and preparation of the body
• Prayers for the deceased
• Preparation should not be performed by non-Jews
• Lamm M The Jewish Way in Death and Mourning. NY,
  Jonathan David, 1969

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Care at time of Death

• Autopsy limited by Jewish law
• Governmental Jurisdiction
• Hereditary diseases for benefit of survivors
• Help another specific person
• All body parts must be returned for burial
• Embalming generally prohibited
• Cremation generally forbidden
• Lamm M The Jewish Way in Death and Mourning. NY,
  Jonathan David, 1969

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Mourning and Bereavement

• Mourning Customs for Immediate Relatives
• Parents
• Siblings
• Children
• Spouse
• Lamm M The Jewish Way in Death and Mourning. NY,
  Jonathan David, 1969

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Mourning and Bereavement

• 5 Stages of Mourning
• Aninus period between death and burial
• Shiva 7 day period after burial
• Days 1-3 Intense mourning
• Days 4-7 Somewhat less intense mourning
• Shloshim 30 day period after burial
• includes Shiva
• 12 month period after burial
• includes Shiva and Shloshim
• Lamm M The Jewish Way in Death and Mourning. NY,
  Jonathan David, 1969

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Mourning and Bereavement

• Aninus
• Period between the death and burial
• Bereaved focuses final arrangements for the
  deceased.
• Bereaved is not obligated to participate in
  certain religious observances related to prayer.
• Bereaved refrains from the social and personal
  activities that are traditionally forbidden
  during shiva
• Lamm M The Jewish Way in Death and Mourning. NY,
  Jonathan David, 1969

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Mourning and Bereavement

• Funeral
• Usually takes place within 24 hours
• Plain Wooden Casket with no metal
• Burial Shroud
• Body is not viewed
• Keriyah Tearing of the Garment
• Men by heart, women left side near collar
• Use of black ribbon by Conservative and Reform
• Lamm M The Jewish Way in Death and Mourning. NY,
  Jonathan David, 1969

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Mourning and Bereavement

• Funeral
• Special Prayers
• Psalms, including Psalm 23 The Lord is My
  Shepherd
• Kail maleh rachamim God, full of compassion
• Asks God to treat the returning soul with mercy,
  kindness, and peace.
• Eulogy
• Praises of the deceased
• Delivered by officiating rabbi and/or family
• Lamm M The Jewish Way in Death and Mourning. NY,
  Jonathan David, 1969

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Mourning and Bereavement

• Funeral
• Complete Internment of the Body
• Earth from Israel
• Mourners and others participate in burial of
  casket
• Burial should be completed under observation
• Kaddish Mourners prayer praising God
• Recessional
• "May God console you among the other mourners of
  Zion and Jerusalem."
• Lamm M The Jewish Way in Death and Mourning. NY,
  Jonathan David, 1969

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Mourning and Bereavement

• Kaddish
• Central prayer in Jewish liturgy
• Aramaic Language of the people
• Motif of prayer Blessing and praising of Gods
  name
• Recited a minimum of 13 times during morning
  prayer services
• Marks separation of parts of and end of service
• Completion of study of a Jewish source or text
• Requires a prayer quorum (10 men/individuals) to
  recite
• Different versions Full Kaddish, Half-Kaddish,
  Rabbis Kaddish, Burial Kaddish, Mourners
  Kaddish
• Lamm M The Jewish Way in Death and Mourning. NY,
  Jonathan David, 1969

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Mourning and Bereavement

• Shiva 7 Day Period of Mourning
• Meal of Consolation
• First meal after returning from funeral
• Traditionally provided by others
• Days 1-3
• Intense mourning
• No greetings aloud
• Days 4-7
• Less intense mourning
• Greetings permitted
• Lamm M The Jewish Way in Death and Mourning. NY,
  Jonathan David, 1969

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Mourning and Bereavement

• Shiva Prohibited activities
• leaving the house
• shaving and grooming
• bathing for pleasure
• working or conducting normal business activities
• wearing new or freshly laundered clothes
• engaging in conjugal relations
• Lamm M The Jewish Way in Death and Mourning. NY,
  Jonathan David, 1969

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Mourning and Bereavement

• Shiva
• Mourners wear torn garment or ribbon
• Prayer services are held in house of mourning
• Prayer Quorum (Minyan) 10 men or persons
• Kaddish
• Mirrors in home remain covered
• Candle remains lit for entire 7 days
• Shiva suspended for Sabbath
• Lamm M The Jewish Way in Death and Mourning. NY,
  Jonathan David, 1969

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Mourning and Bereavement

• Shloshim 30 Days
• 30 Days from burial, includes Shiva period
• Following Shiva
• Mourners begin to reintegrate into society
• May leave house and work
• Avoid celebratory functions especially with music
• May not shave or groom
• Obligation to recite Kaddish with a prayer quorum
• Lamm M The Jewish Way in Death and Mourning. NY,
  Jonathan David, 1969

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Mourning and Bereavement

• 12 Month Period
• Observed for loss of parents only
• Count includes Shiva and Shloshim
• Following Shloshim
• Avoid celebratory functions especially with music
• Obligation to recite Kaddish with a prayer quorum
  in all daily prayers for 11 months
• Lamm M The Jewish Way in Death and Mourning. NY,
  Jonathan David, 1969

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Mourning and Bereavement

• Unveiling
• Origin late 19th century in America Western
  Europe
• Usually occurs after formal mourning has ended
• 11-12 months for parents
• After Shloshim for others
• Formal Unveiling ceremony
• Recitation of Psalms and a brief eulogy
• Removing the cloth covering the headstone
• Kail Maleh Rachamim prayer Mourner's Kaddish
  (if a minyan is present)
• In addition to dedicating the grave monument, the
  mourning an opportunity to commemorate the
  deceased.
• MyJewishLearning.com, About.com Judaism

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Mourning and Bereavement

• Ongoing Memorialization
• Yahrzeit
• On anniversary of death
• 24 hour candle
• Recitation of Kaddish in a prayer quorum
• Yizkor
• Special Memorial services
• Held on Yom Kippur and on the final holy day of
  the 3 festivals
• Lamm M The Jewish Way in Death and Mourning. NY,
  Jonathan David, 1969

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Mourning and Bereavement

• Bereavement Support
• Shiva visit
• Support in observing shloshim and 11 months of
  reciting Kaddish for parent
• Working with community rabbis
• Individual Counseling
• Groups
• Biblical narratives as a paradigm
• Lamm M The Jewish Way in Death and Mourning. NY,
  Jonathan David, 1969
• Cirlin Leaving Egypt, A Jewish Model for
  Facilitating Bereavement Groups. NHO Conference,
  1999

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Patients and Families Come First

• There is no set approach to delivering culturally
  competent care, however we can respect and learn
  from our patients and families.