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

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

2. 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 one’s “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

7. 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 God’s law • The Rabbi, the expert in God’s 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

9. 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

10. Assisted Suicide/Euthanasia • Absolutely prohibited • Deliberate hastening of death is considered an act of murder

11. 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.

12. 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.

13. 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 II:74 in Tendler MD: Responsa of Rav Moshe Feinstein, NJ, Ktav Publishing, 1996. Lamm M: Commentary in NIJH Jewish Living Will, California, NIJH, 1992.

14. 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

16. 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

17. 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

18. Nutrition and Hydration Rabbi Moshe Feinstein Iggros Moshe, Choshen Mishpat II:74 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, z”l. Journal of Halacha and Contemporary Society 13:5, Spring, 1987.

19. 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.

22. 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

23. 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

24. Holocaust Survivor Issues • Recurring Loss • “Dying” Again • “Beating it” Again • Change in body image • Anger and resentment • Survivor’s Guilt

25. 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.

26. Vidui: Confessional Prayer • Special prayer said when death may be near • Shulchan Aruch Yoreh Deah 338:1 • 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.

27. 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

28. 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

29. 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 orfamily member who remains with the body until burial Lamm M; The Jewish Way in Death and Mourning. NY, Jonathan David, 1969

30. 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 • Preparationshould not be performed by non-Jews Lamm M; The Jewish Way in Death and Mourning. NY, Jonathan David, 1969

31. 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

32. 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

33. 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

34. 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

35. 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

36. Mourning and Bereavement Funeral • Special Prayers • Psalms, including Psalm 23: “The Lord is My Shepherd” • K’ail 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

37. 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: Mourner’s 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

38. Mourning and Bereavement Kaddish • Central prayer in Jewish liturgy • Aramaic: Language of the people • Motif of prayer: Blessing and praising of God’s 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, Rabbi’s Kaddish, Burial Kaddish, Mourner’s Kaddish Lamm M; The Jewish Way in Death and Mourning. NY, Jonathan David, 1969

39. 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

40. 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

41. 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

42. 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

43. 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

44. 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 • K’ail 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

45. 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

46. 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

47. 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.