Boca Raton Regional Hospital of Baptist Health South Florida hosted a symposium, "Caring for Jewish Patients and Families at End of Life," on December 4, 2024. The keynote speaker was Dr. Barry Kinzbrunner, with responses from Dr. Claudio Kogan, Dr. Jessica Eichler and Rabbi Ed Bernstein.
Boca Raton Regional Hospital of Baptist Health South Florida hosted a symposium, "Caring for Jewish Patients and Families at End of Life," on December 4, 2024. The keynote speaker was Dr. Barry Kinzbrunner, with responses from Dr. Claudio Kogan, Dr. Jessica Eichler and Rabbi Ed Bernstein.
Dr. Barry Kinzbrunner, MD, FACP, is Former Chief Medical Officer, VITAS Healthcare. He is board certified in Internal Medicine, Medical Oncology, and Hospice and Palliative Medicine and he was ordained as an orthodox rabbi in Jerusalem, Israel in 2002. Dr. Kinzbrunner’s publications include a textbook entitled “20 Common Problems in End of Life Care,” a second edition of which, under the title “End of Life Care: A Practical Guide” was published in January, 2011. As a pioneer in the development of the role of the Hospice Medical Director for Vitas, as well as for the hospice industry in general, Dr. Kinzbrunner had the opportunity to author and publish a monograph entitled “Medical Director Model” for the American Academy of Hospice and Palliative Medicine (AAHPM) in 2004. He also was an editor in a more recent AAHPM publication for Hospice Medical Directors entitled “The Hospice Medical Director Manual.” Dr. Kinzbrunner is a member of Neshama: Association of Jewish Chaplains.
Dr. Claudio Kogan, MD, MBE, M.Ed., is Director of Bioethics for Baptist Health South Florida. Dr. Kogan is a native of Buenos Aires, Argentina. He attended the University of Buenos Aires Medical School where he received his M.D. Dr. Kogan received his Masters of Hebrew Letters and his rabbinical ordination at the Hebrew Union College-Jewish Institute of Religion and his Master of Education from Xavier University, in Cincinnati, Ohio. He also received his Master of Medical Ethics from the University of Pennsylvania Medical School. Rabbi Kogan served on the Human Investigation Committee at Yale University.
Rabbi Kogan served 26 for years multiple Jewish congregations in Buenos Aires, Michigan, Ohio, South Dakota, Kentucky, Florida and Texas. He is also a Mohel (certified to perform circumcisions) and a firm believer that Medicine and Religion are two sides of the same coin. Dr. Kogan is a strong advocate to combine Science and Spirituality and an activist who has traveled around the world promoting interfaith dialogue.
Dr. Jessica Eichler, MD, is Chief Hospice and Palliative Care Specialist for Boca Raton Regional Hospital. She also serves as the Associate Medical Director for Trustbridge Health and as an Assistant Professor for Florida Atlantic University, teaching all internal medicine residents on palliative care service at Boca Raton Regional Hospital. Dr. Eichler earned her medical degree at Universidad Iberoamericana School of Medicine, Santo Domingo, Dominican Republic. She completed her hospice and palliative care medicine fellowship at the University of Miami Miller School of Medicine. She serves on the ethics committee of Boca Raton Regional Hospital.
Rabbi Edward Bernstein, BCC, serves as Chaplain at Boca Raton Regional Hospital of Baptist Health South Florida. He is a member of the Board of Neshama: Association of Jewish Chaplains.
Rabbi Ed Bernstein: Shalom and welcome to NeshamahCast, exploring Jewish spiritual care today. Brought to you by Neshama, Association of Jewish Chaplains. I'm your host, Rabbi Ed Bernstein. In my day job, I have the honor of serving as chaplain at Boca Raton Regional Hospital of Baptist Health, South Florida. On December 4th, 2024, we hosted a symposium titled Caring for Jewish Patients and Families at End of Life. The symposium featured a keynote lecture by Rabbi Dr. Barry Kinzbrunner, a member of NAJC. Dr. Kinzbrunner presented an overview of end-of-life care from his perspective as both a hospice physician and an Orthodox rabbi.
Dr. Kinzbrunner was followed by responses from Dr. Claudio Kogan, Director of Biomedical Ethics for Baptist Health South Florida, who also has rabbinic ordination in the reform movement.
Dr. Jessica Eichler, Chief Palliative Care and Hospice Specialist at Boca Raton Regional Hospital, and me, Rabbi Ed Bernstein. I was ordained within Conservative Judaism and spoke about my experiences as a chaplain in end-of-life care.
Our audience included people from a cross-section of disciplines from healthcare and social service fields, mostly based in Palm Beach County, Florida.
This symposium was made possible by a generous grant from Arthur Gutterman through the Boca Raton Regional Hospital Foundation. My supervisor at the hospital, Reverend Misty Johnson-Arce, the Director of Spiritual Care at Boca Raton Regional Hospital, introduced the program. I'll send it over to her now to do just that.
Reverend Misty Johnson-Arce: Hello, everyone. My name is Reverend Misty Johnson-Arce. I'm the Director of Spiritual Care here at Boca Raton Regional Hospital. And it is my honor to welcome all of you today and to thank you for taking time out of your schedules to come and be with us today and receive education in the midst of all that's going on.
Today's event was made possible by a generous grant from Mr. Arthur Gutterman, and the efforts of our Boca Raton Regional Foundation and our representative Roberta Cohen Perkins is here with us today. Thank you for your generosity and for your vision for having this event.
Now I want to introduce to you our keynote speaker and the panelists. Rabbi Dr. Barry Kinzbrunner is our keynote speaker. He served as the Executive Vice President and Chief Medical Officer for VITAS Healthcare Corporation of Miami, Florida until his retirement in February of 2018. This is an organization that specializes in hospice and end-of-life care. He was board certified in internal medicine, medical oncology, and hospice and palliative care medicine, and he was ordained as an Orthodox rabbi in Jerusalem, Israel, in 2002. During his 30-year career in hospice and palliative medicine, Dr. Kinzbrunner has spoken and published extensively on the care of patients at the end of life, including a textbook entitled End-of-Life Care, A Practical Guide, which was published in early 2011. Rabbi Dr. Kinzbrunner also has developed expertise in end-of-life care issues pertaining to patients of the Jewish faith, and has published and lectured extensively in this area. From 1998 to 2018, he was a voluntary consultant for JDC Eshel in Israel, which is the American Jewish Joint Distribution Committee, assisting in the development of hospice, palliative care, and spiritual care services in Israel.
Rabbi Dr. Kinzbrunner and his wife, Anita, who is here with us today, have three sons and 14 grandchildren. Since September 2020, he has been taking online classes toward a master's degree in biblical archaeology from the Trinity Southwest University in Albuquerque, New Mexico.
Now for our panelists. Rabbi Dr. Claudia Kogan is the Director of Bioethics for the Baptist Health System, which includes 12 hospitals and Miami Cancer Clinic. Also, Rabbi Dr. Kogan is the Vice Chair of the Baptist Health South Florida Internal Review Board. He is a member of the American Society for Bioethics and Humanities and the American Bioethics Program Directors. He was the founding director of the Institute of Bioethics and Social Justice and the associate professor of the Department of Internal Medicine and a module co-director of Medicine, Behavior, and Society at the University of Texas Rio Grande Valley School of Medicine in Edinburgh, Texas. He is also a chaplain to law enforcement agencies in Florida. Dr. Kogan is an RGV Food Bank and RGV United Way board member. Dr. Kogan is a native of Buenos Aires, Argentina. He attended the University of Buenos Aires Medical School where he received his MD. He received his master's of Hebrew letters and his rabbinical ordination at the Hebrew Union College Jewish Institute of Religion and his master of education from Javier University in Cincinnati, Ohio. He also received his Master of Medical Ethics from the University of Pennsylvania Medical School. Rabbi Kogan served on the Human Investigation Committee at Yale University. Rabbi Kogan served for 32 years in multiple Jewish congregations in Buenos Aires. Michigan, Ohio, South Dakota, Kentucky, Florida, and Texas.
He is also a mohel, certified to perform circumcisions and a firm believer that medicine and religion are two sides of the same coin. Dr. Kogan is a strong advocate to combine science and spirituality and an activist who has traveled around the world promoting interfaith dialogue.
Dr. Jessica Eichler is our Chief Hospice and Palliative Care Specialist for Boca Raton Regional. She also serves as the Associate Medical Director for Truss Bridge Health, overseeing the consultations put in by our medical team. She also serves as an Assistant Professor for Florida Atlantic University, teaching all internal medicine residents on the palliative care service at Boca Raton Regional Hospital. She routinely mentors and coaches medical residents as they serve clinical rotations with her. Dr. Eichler earned her medical degree from the University of Ibero Americana in the Dominican Republic. And she completed her hospice and palliative care medicine fellowship at the University of Miami Miller School of Medicine. Prior to this, she earned a master's of arts degree in psychology from the City College of New York. Her master's thesis was on examining family hardiness and social support as buffers in the stress illness relationship in homeless families. Her bachelor's degree in English was earned at Columbia University. She also served as a research assistant or coordinator several times. Dr. Eichler also serves on our ethics committee here at Boca Raton Regional Hospital. And she is a member at Temple Beth-El.
Rabbi Ed Bernstein is a board certified chaplain and serves as a chaplain on our staff here at Boca Raton Regional Hospital. He has been with us since July, 2021. He also serves on the board of Neshamah, the Association of Jewish Chaplains, and is the host of NeshamahCast, which is a podcast on Jewish spiritual care produced by the National Association of Jewish Chaplains. He previously served as a chaplain for VITAS Healthcare in Palm Beach County, Florida.
He edited a book called Love Finer Than Wine, the writings of Matthew Eisenfeld and Sarah Ducker. This work was a 2016 National Jewish Book Award finalist. Rabbi Bernstein was ordained at the Jewish Theological Seminary. He has served congregations as a full-time rabbi in New Rochelle, New York, Beachwood, Ohio, and Boynton Beach, Florida. Rabbi Bernstein has a bachelor's degree in American history from Columbia University. He earned three degrees from the Jewish Theological Seminary, a bachelor's in Bible studies, a master's in education, and rabbinical ordination. Rabbi Bernstein resides in Boynton Beach with his wife, Ariella, and their three children. Please welcome our speaker, Dr. Barry Kinzbrunner.
Dr. Barry Kinzbrunner: Good morning, everybody. It's nice to be here. I'll just make a comment. I don't wear a tie anymore since I'm retired. And I live in South Florida. And for both of those reasons, I don't even. The last time I had to wear a tie, it took me five times until I was able to tie it, because I'd forgotten how to do it. But anyway, what I'm going to give you is an overview of issues related to Jewish end of life care. And then I think the panelists are going to do is they're going to try to take this information and make it real by talking about cases that illustrate many of these issues that come up, you know, with patients and families that we've been taking care of.
OK, before I get into the medical part of this, I just want to say a few words about how Judaism is observed here in the United States. There are many different levels of observance. We start at the top of the Orthodox or the most traditional who really follow the Word of God and follow Jewish law and will usually look to a rabbi to guide them if they don't know the Jewish laws themselves in terms of what to do. And then when we move into the Conservative reform or constructionist, I would say it didn't develop consecutively, but Conservative and anybody who's in that movement will forgive me if I misrepresented a little bit. I spent some time in the Conservative movement before I became Orthodox. Conservative Jews really, it's a matter of following Jewish law, but the Jewish law has been sort of reinterpreted more to fit the modern times. So there are times when the law has been modified by Conservative rabbis to try to reach more modern people and make it a little more compatible with the modern world we live in, and perhaps in the traditional orthodox sense, reform even more so. And Reconstructionist is actually is something that came off of the Conservative movement. And I don't know much about how it works exactly, except I know that they use a lot of song and musical instruments and things of that nature, and part of their prayer services as well.
Now, with having said all that, the majority of Jews in the United States are secular or unaffiliated. They don't belong to any Jewish movement. They don't observe most Jewish laws or customs. Probably the two things that most American Jews do is they, to some level, observe Hanukkah, which is coming up at the end of the month. which is the Festival of Lights where people light candles, exchange gifts, and it's sort of in keeping with the holiday that occurs at the end of the month, at the end of this month every year. And then Passover, the holiday in the spring, where we celebrate the redemption of the Jewish people from Egypt 3,500 years ago, And in that, most people participate in the ritual festive meal called the Seder, where we not only eat, but we tell the story of the Passover from Egypt, which, of course, is derived out from the Bible and the Book of Exodus. And those are the two things that most Jewish people do.
So then the question is, I've always been asked is, why then is it so important to learn about Jewish issues at the end of life when most American Jews don't spend a lot of time with their Jewishness while they're alive or while they're alive and healthy? And what's interesting is in my years of doing this, what I learned was a lot of people who were not religious will say things like, well, I'm not religious, but I want a Jewish burial. I want it done right that's one thing I want done properly, I want done by Jewish law that a lot of people a lot of people I know, and a lot of people I've encountered during my career would tell me that. So that's why it's important, even if they're not observant their whole life, they people will often want to observe at the end of life. And whether it's I always say they're covering their bases just in case. But it really is something that I've seen a lot. And I think that's the main reason for why you need to learn this and know this about Jewish people.
I will also add that you can take this paradigm, this idea, and apply it to any subgroup you want. It can be for other religious groups, other faith-based groups. It can also be for other ethnic groups. You can take and learn about their culture, different cultures, and apply them to end of life as well. So what I'm going to share with you here not only is important to learn about from the perspective of understanding how to better care for Jewish patients at the end of life, but you take the same paradigms and then apply them to other types of patients by learning about their customs and their laws and the things that drive them in terms of who they are and how they identify themselves. and how that interacts with their end-of-life decision-making and the care that they want to receive. So I think there's a double-fold purpose for this as well.
So how does Judaism look at terminal illness? When I first got involved with this, I was basically told, well, hospice and palliative care is foreign to Judaism. We don't do this. And that actually was an article written in a palliative care journal back in the 1980s by the late Lord Emanuel Jakobowitz, who was the chief rabbi in London, England. And he said, palliative care and hospice are not Jewish and they don't belong in Judaism. Because he said, like we believe is an infinite value so much so that the Sabbath and holidays may be violated to preserve life. We have a lot of different rules regarding how we observe the Sabbath and holidays. I'm not going to go into them today. We don't have time. But you can violate them if somebody's life is in danger. Because the idea is better that you should violate one Sabbath so the person can observe many Sabbaths. That's the idea about it.
But the other thing is that in Judaism, the principle has always been that sanctity of life is more important than quality of life. And while in today's paradigm in the secular world, we look at quality of life as being more important to some degree, in Judaism, sanctity trumps quality. Now if you notice I have here in parentheses the word almost. Life is of almost infinite value. This actually is it comes from a slide that I have seen many times that was originally written by Professor Ivan Steinberg was probably one of the world's experts in many fields, including Jewish medical ethics. And up until about five 10 years ago, he almost wasn't there was life is of infinite value period. The almost is there now because even among orthodox circles in Israel, there's now a recognition that palliative care is an appropriate approach for many people as they're getting closer to the end of life. And therefore, at certain times, it might be a palliative approach that would be better for this particular individual than a purely aggressive medical approach, which is not really the right word, but that's about the best way to describe it. And I think that that's why we now say almost.
And the other thing is, is that even though we try, in some respects, the rabbis try to deny this idea that people die, if we go to the, you know, if we go to the Bible itself, we know that the Bible understands that people die. For example, this this quote from Kohelet or Ecclesiastes, which everybody's familiar with. Most people are from a song from the 60s, I believe it was. To everything there is a season and a time to every purpose under heaven, a time to be born and a time to die. King Solomon says it right there. So even Judaism recognizes that there's a time to die. So King Solomon and Ecclesiastes tell us there is a time to be born and a time to die. So how does Judaism look at terminal illness? And this was a, this particular story, and I always start with this story, I learned about many years ago when I first got acquainted with, when I first became Orthodox, and I tried to figure out how am I gonna take what I do for a living, which is hospice and palliative medicine, When I've learned that Lord Jacobovitz thinks it's not Jewish, but I'm Jewish and I'm trying to be more observant, but I'm working in this field that he's telling me isn't really Jewish, how do I figure this out?
And then as I was doing my reading, I found this very interesting story in both the Talmud and the Midrash. The Midrash are rabbinical tales, and some of them are repeated in the Talmud. The Talmud is a combination of Jewish legal text and also stories. The stories are very often taken from the Midrash. And so how do people die? The way people died in ancient times, if you look in the Bible, all the Bible tells us is, for example, Adam was 930 years old. He begot sons and daughters, and he died. And then it says, and it also said he had a son named Seth. And Seth was so old, and he gave birth to the, I forget, the next person, the genealogy. And then he had other sons and daughters, and then he died at someone's own age. It never tells you how he died. how any of them died, until we go way up to Noah. It still doesn't tell us anything. If you look at the story of Noah, at the end of the story of Noah, you get the same kind of genealogy, and again, doesn't tell us how people died. And the way they supposedly died, according to an ancient text called the Pirkei de Rabi Eliezer, was people would sneeze, and when they sneezed, their soul would leave them. I think that's where we get this idea when people sneeze, we say something like, God bless you, or some other phrase, because it represented dying in ancient times. And also, people didn't age. They didn't change appearances. They got older. It just happened one day that they passed away. So when Abraham and Sarah have Isaac, Abraham's 100 and Sarah's 90. And there was actually a question of who Isaac's father was. Because if you remember in the Bible, right before Isaac is born, there's a story where Abraham and Sarah have to go to the land of Gerar, where Abimelech is the king. And as was practiced in ancient times by many of the pagan cultures, the king would often take beautiful women for themselves. And Sarah was a beautiful woman. So Abraham said, tell them you're my sister. So that's what they said. Sarah was his sister. So Abimelech took her. And of course, he was prevented from doing anything by God. But nevertheless, everybody knew that Abimelech took her for a period of time, and now she's pregnant. And they knew Abraham, although he did have Ishmael, that Abraham and Sarah couldn't have kids. So who says that Sarah's pregnancy wasn't from Abimelech? So God made Isaac look just like Abraham. So there'd be no question that Isaac was Abraham's son. But what happened is people would confuse the two of them. They'd be talking to, they'd see Isaac in the street, and they talked to him like he was Abraham. They see Abraham, they talk to him like he was Isaac, because they both look alike. So Abraham said to God, you know, this is a problem. So maybe what you should do, since I'm older, is make me look old somehow. He didn't tell him exactly what to do. God figured out, obviously, what to do. Gave him wrinkles, gray hair, so forth. And God said, you know, that's a really good idea. I'll make you the first one who turns old. And so the Bible in the book of Genesis, chapter 24, verse one says, now Abraham was old well on in years. And the rabbis say that verse is telling you that God made Abraham look old. But again, how did he die? Doesn't tell us. It just says he was 175, he gathered his feet up, and he was gathered unto his ancestors. And that's what happens to Isaac as well, and Ishmael as well, and so forth. Now we get to Jacob. And this is where it gets very interesting. The last four chapters of the book of Genesis, Jacob is goes to Egypt for the famine after Joseph has already been there for 22 years. And Jacob and the family joined Joseph because of the famine that was occurring all across the land, including Egypt and including Canaan. But of course, Joseph had the keys to the food, so that was where they all went. And then Jacob was there for 17 years, and then it was time for him, his time to die. And what happened was you read in the Bible a whole account. First, Joseph brings his two sons, and Jacob blesses them. And then Joseph and all his brothers come back to Jacob when they're told that their father is dying. And Jacob has the opportunity to bless all his children. And then in the Bible says that he gathered his feet up onto his bed and he died. And I always say, if you read the description, it sounds like the first hospice death. He died with his family around his bed, no IVs, no feeding tubes, nobody called 911, nobody pounded on his chest, nobody put him on a ventilator or anything else. He died naturally when he was supposed to.
And what's interesting in this story is that what we learn from the Midrash is that Jacob actually asked God to create illness before death. Because they said people would just sneeze and die. They didn't know when that was going to happen. So Jacob was the first one. God said to Jacob, that's a good idea. Jacob said, I want to do this so I can bless my children. God said, yeah, that's an excellent idea. You're going to be the first one to get sick before he dies. So God, in essence, Jacob asked for the creation of terminal illness. And I like to describe Jacob's death as the first hospice death in recorded history. Because he died probably the way most people would want to if they could pick and choose how it happens. There's a corollary to this story, which I don't spend a lot of time with, but I want to mention it, about King Hezekiah. He gets this illness, and Isaiah comes to him and says, God said, send me to tell you you're going to die. And Hezekiah says, I don't accept that. I'm going to pray to God. I'm gonna, we call him in Judaism, Dutashuva, return to God. And he did enough praying and whatever penitence he needed to do, that God sent Isaiah back to Hezekiah and said to him, he said, tell Hezekiah you're gonna have 15 more years. So the point of that addition to the story is you never want to take away somebody's hope while you're treating them, even if it's in hospice. It happened to be I was somewhere yesterday and a woman came into where I was and was talking to the people there. And she says, this is my last time I'm going to be here because they're putting me on hospice. You know what hospice means? She went like this, bye bye. And she was awake and alert, and she understood. And you always say, well, how do you tell somebody that in the proper way? And I think she was very matter of fact about it and very accepting of it, but yet I could hear the pain in her voice. and see the pain that she was experiencing while she was there. And it's a very tricky thing to be able to tell people that they need end-of-life care, and at the same time, keep whatever hope you can, give them that spark of hope. I always say, the way you give hope is you change the goal. Instead of the goal being curing whatever the illness is, the goal is, to make the patient as comfortable and symptom-free as possible for whatever time they have left, so that that time can be spent the way they want to spend it. And that's, I think, the hope that you can give anybody in this kind of situation. OK, so now let's get into the meat of this a little bit more. These are the medical ethical values. I'm not going to spend a lot of time on this. Dr. Hogan is going to take care of that. But I wanted to mention it because, What's happened is the way Judaism looks at the issue of of end of life decision making or any medical issue. Is we apply this these ethical values, but give them a Jewish spin, so to speak, we look at how Judaism would look at them. and then apply them.
Now, three of the four, beneficence, non-maleficence, and justice, are pretty much the same in the secular world and in the Jewish world. Autonomy is the one that really has a difference to it. And that's why I just wanted to emphasize that a little bit. Because what happens is one limits one's autonomy in the sense that instead of making decisions that I want to make, I make decisions that are consistent with what God wants me to decide to do, based on God's law. Now, if I talk to somebody who's been what we call, what Jewish people call, from birth, somebody who's been religious their entire life, who wasn't given a choice because their parents were religious, and that's the home they grew up in, they'll tell you, I had no autonomy. I have to do what I was told. Now, I wasn't religious my entire life. I chose to become religious. So for me, I look at it as I autonomously chose to follow God's law. But I think that in Judaism, even though people feel that they're compelled, nobody's compelled to do anything.
As I showed you, most people, most American Jews are secular. They don't follow God's law in most things. But nevertheless, this is how one looks at it from a Jewish perspective is we limit our autonomy to follow what God wants us to do. But of course, not everybody's an expert in what God wants us to do, especially in something like health care. So you need a rabbi who is an expert in God's law to provide advice and counsel. And actually, you do that with anybody, but with any issue, rather. But the rabbi that you're going to use for health care should be schooled and expert in health care decision making. And that's really the important thing. In other words, what happens if somebody goes to a community rabbi, and the community rabbi doesn't really know anything about health care? What does that community rabbi do? And fortunately, in all of the denominations, there are people, there are rabbis within each group that are expert have chosen to become experts in healthcare decision making. And I know from the Orthodox perspective, there are many people one can call to get advice if one doesn't know what to do. And I suspect the same is true, the Conservative, the Reform movement, the Reconstructionist movement as well. There are experts in all of those areas to provide guidance to local to community rabbis who don't have that level of expertise.
Now, when we talk about end of life decision making, and we're going to get into the nitty gritty of it now, it only applies to patients who are terminally ill. And I'll explain how Judaism looks at that in a second. And what I'm going to tell you are guidelines. And I say they're guidelines because just like in hospice in general, decisions in Judaism are made on a case-by-case basis. Most non-Orthodox people don't know, but the Orthodox literature is filled with case law. And what happens is, is that if you look at the Talmud, there are always cases, they talk about cases of various kinds all the time. And then the rabbis make decisions based upon those cases. And there's a lot of disagreement. And that's because depending on the case, a rabbi may make a different decision in that specific situation. And that's true in the Orthodox world, and it's true in the non-Orthodox world as well. I just really, I went through, I forgot I had to, I went through this slide already basically, but I just want to make another point here that one of the things a rabbi must do if they're going to guide people in healthcare is they must talk to the patient's physicians and other healthcare providers before making any rulings or recommendations to the patients and families.
And the reason for that is, and I've seen this, patient families will often filter information. Very often they know what they want. They have an outcome in mind that they want to hear from the rabbi. And so they'll tell the rabbi what they think the rabbi wants to hear to meet their expectation of what they want the rabbi to tell them, which may or may not be accurate information about the patient's medical condition. So I think a responsible rabbi will talk to the patient's physician or physicians as part of their fact finding before they make a recommendation to a patient or family about the specific situation that they're in. And I always stress this when I talk to groups of rabbis, because a lot of rabbis don't do that. They make decision based on what they understand are the general rules without being specific. And I'm sure you'll hear cases like that as we go through this. And of course, the other thing that the community rabbi can do and should be trained in is spiritual support to the patient. And very often the community rabbi can work with a hospice chaplain or the palliative care chaplain to make that happen. So very often there's a team approach with palliative care and hospice chaplains and the community clergy to get the patients and families where they need to be. Okay.
So now I'm going to select the definitions. How does Judaism define terminal illness? The basic definition is a prognosis of one year or less. And I'm not going to get into the details of how that's derived. It's based on the animal model called treif, which is an animal that is kosher, slaughtered properly, but is then found to have a defect in which it would have died within 12 months. And that animal is now considered not, that particular meat cannot be eaten by Jews, it's not kosher, even though it was slaughtered properly and is a kosher animal. And then there's a whole discussion of how you then derive the human model, because there are a lot of differences. But that's the basic ideas, one year or less.
And I always like to point out that it's more generous than the hospice benefit, which is only six months or less. There's a second definition in Judaism called the gosses. We find this in Jewish literature in the Talmud primarily. It's probably what we would call in the field of palliative care and hospice, someone who was a patient who was actively dying. And the classic sign that's given in the Talmud is what we call in the vernacular death rattle, the upper airway noises. that very often you hear that people make with the upper airway secretions. And what we usually can get rid of those with a drying agent. But nevertheless, that's how the Talmud describes it. So that's the definition that's used. It's often also described as the last three days of life. And what's important there is only basic needs may be provided and other interventions are prohibited. But when I say only basic needs, that includes bathing and keeping the patient comfortable and doing whatever you have to do to do that, turning the patient if it's appropriate and necessary and so forth.
Now, I just wanted to mention the definition of death in Judaism. I often don't get into that much, because we're really talking about care before the patient dies, not once they die. But I just wanted to mention that there are two, within the orthodox world, there are two definitions. One definition is really respiratory, that the respirations cease. And that can also be caused by the loss of brain function, including the brain stem. And I mention this because if higher brain functions are lost, say somebody who's in a vegetative state or has a cerebral infarction but no damage to the cerebellum, that's considered, in Judaism, a person would not be considered to have passed away.
Whereas in the secular world, they might consider a patient brain dead and that they've died. And that's where we sometimes get into controversy. The other definition is when the heart stops. It's purely cardiac. So as long as the patient is being given on life support and their heart is beating, they would not be considered dead according to Jewish law. These things come in most commonly either in removing ventilators at the end of life and or when the question of organ donation comes up. And those are things that I want to have more time I talk about, but in this forum, You can want to ask about and talk about it later. That's fine. But I don't spend that much time on it because it's just too many other things to cover.
OK. Physician-assisted suicide and euthanasia are absolutely forbidden by Jewish law. And there are several reasons man's body and life are not his to give away because the proprietor of all human life is God. And so it's up to God to decide when we die, not up to us. It's about it's not related, though, to the commandment, I shall not kill. And the fact that people who commit suicide are considered it's considered improper is the fact that people who do commit suicide are not buried in normal fashion. Now, there's a loophole here that the rabbis often use, which is if you commit suicide, you're probably not in your right mind. If you're not your right mind. And you're ill, therefore, they can't hold it against you. And therefore, the person, even though it's a tragic thing, can be buried normally in most cases. So there's a lot of compassion addressed here as well. But in the terminal patient, euthanasia and assisted suicide with intent are absolutely forbidden. And I mention it also because eventually, it's going to come up to a vote here, like it has in a lot of other states. And some states have passed laws that allow it. Other states have not.
Can Jewish patients refuse medical therapy? And if they're terminally ill, yes, they can. They can if the therapy is not proven to be effective, if it's clearly futile, or it entails great suffering or significant complication. This is important. I used to deal with my oncology colleagues, and they were orthodox. They would often tell me, well, by Jewish law, you have to treat the patient with everything you can think of. And I say, no, you don't. You don't. You absolutely don't. But that's what they would tell people. So it's important to be able to come back to them. Patients can say, I don't want this. They can all say, I want it. They can accept it and that's fine. But they have the right to say, I don't want it if it's not going to help. What about withdrawing, withholding? The patient can't make a decision for him or herself. And other people are going to make it.
Can you withhold? Can you withdraw? Now, secular medical ethics today says withdrawal and withholding are the same. Some ethicists, I remember this years ago, promoted the idea that withdrawing was actually superior ethically to withholding because if you withdraw something, the presumption is you tried and it didn't work. And that's why you're withdrawing it now. Whereas if you withhold it, you don't know whether it was going to work or not. But in Jewish medical ethics, withdrawal and withholding are different, and they go back to probably what we used to have as the secular ethical values about 40 years ago, meaning withholding was permissible when the 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, however, is not generally permissible unless the intervention is clearly viewed as an impediment to dying. And that's a very difficult definition, at least in the traditional world, to meet. It may be in Conservative reform, it's a little easier to get there than it would be in the orthodox world. But that's the test. Now, I'm going to go through some treatments just to give you a flavor for this. And I'll be quick, because I know I'm already running out of time.
CPR and DNR. First, remember, CPR is a procedure. It was originally described to treat acute post-anesthesia cardiac and respiratory arrest, and then was expanded to be a default procedure to treat anybody whose heart stops when they stop breathing, or both. and that everybody wants CPR unless they tell you specifically they don't want it. Do not resuscitate is a physician's order, and that's an order not to treat the patient with CPR if the patient experiences a cardiac or respiratory arrest. And when I put it at this bottom, and I'm going to repeat it again, it doesn't mean do not treat. And the reason I emphasize that is because what I've heard from a lot of rabbis in my travels over the years is that in their hospital system, they're told if they put a DNR on the trot, the patient's not going to be treated for anything. So he's stuck in a corner and left the dot. And now rabbis don't want that, and the patients don't want that. But that's not what a DNR means. But that's how people sometimes interpret it. So you've got to be very careful. You're very specific about what you're telling people. Can CPR be withheld? We already talked about withholding treatment. But CPR generally, especially, nobody ever studied CPR in terminally ill patients. But in chronically elderly patients, I think their success rate is somewhere between 1% and 2% in the literature. To get the patient's heart going again doesn't mean they're going to survive and walk out of the hospital. So most people would see CPR as an ineffective therapy for terminally ill patients. It also may cause harm, because you can crunch it. You can break ribs. It can cause other problems. They may become ventilator-dependent, which then creates another set of issues. And even if you don't do CPR, you put a DNR on the chart, as I said, the patients may continue to receive treatments that are necessary to treat their other conditions. And as I said, DNR does not mean do not treat. I just want to emphasize that, because that's really where the barrier comes from. And it's something you have to explain to patients, families, rabbis, others. Patients and families watch doctor shows on television, hospital shows. Almost everybody comes from CPR. But that's not real life. Pain and suffering. Judaism does not espouse pain and suffering as a virtue. However, one may not hasten death, and one may withhold treatment or remove impediments to death that prolong life in the face of suffering. So what does that all boil down to?
Treatment of physical pain with opioids and other medications under Jewish law is mandatory. Opioids should not be withheld, even if there is concern that death may be hastened. Although again, it's all about intent. There's a principle in Jewish law called, something not intended. This is actually taken from the laws of the Sabbath. If I do something that's not allowed on the Sabbath, but the reason I'm doing it has nothing to do with why it's not allowed, I'm sometimes able to do it even if the effect the effect might occur. The example used in the Talmud is if I take a chair and I drag it over the ground, and it's a heavy chair, I'll do that on the Sabbath, the chair leg will create a furrow in the ground. You're not allowed to create a furrow on the Sabbath. You don't have to dig and move dirt on the Sabbath. But since that's not my intent, my intent is to move the chair from here to there. The furrow is an unintended consequence. And if I lift the chair a little bit, I might not create the furrow. So it's not guaranteed to occur anyway. And under those circumstances, one is allowed to move the chair, even if they might create the furrow. And so we look at opioids the same way. Although those of you who've been working in this field for a long time will know that patients get tolerant to the respiratory depressive effects of opioids over time. And therefore, if you're continuing the same dose or slightly more elevated dose, you're not gonna suppress respirations. That usually only occurs when you up the dose by 50 to 100% or more.
And finally, Judaism also recognized the importance of treating mental anguish and suffering. What about antibiotics? Antibiotics, this is an area I always struggled with because when people are chronically ill and terminally ill, with the kinds of illnesses that you deal with, especially in the cancer field, which is where all of this hospice really started, primarily for cancer patients, those expanded way beyond. But even in patients with advanced neurological conditions, cardiac conditions, pulmonary conditions that are terminal, infection is often the proximate cause of death. Many of these people die from infection. So we said, well, why would I give them antibiotics then if that's what's going to cause their death? But certainly the antibiotics we have today, especially the oral ones, are powerful enough. You certainly can give the patient a trial before saying, well, this is just too advanced an illness to be able to treat in this person who is terminally ill. So, and not only that, but in the Orthodox world, many of the rabbis, when they would talk to about this, interpreted that the infection is a separate illness and therefore felt that it should be treated. But again, if the patient has pain and suffering and the antibiotic isn't going to help that, you don't have to give the antibiotic, you should treat the pain first. Now, I've also learned over the years that in certain circumstances, one of the things that infections can do is cause pain because of swelling and duration. So sometimes treating with antibiotics not only will affect the infection as the infection, but also help the patient's discomfort and pain. So that's the second reason you might want to use antibiotics, at least a trial of antibiotics, in certain patients who are nearing the end of life.
Now, removal of ventilator, that's a tricky one in the Jewish law. It's forbidden under most circumstances. And as I said, even if the patient might be considered brain dead by secular ethics, if it doesn't include the brainstem and they don't have, and they can still breathe, they're still breathing on their own, because the brainstem is still functioning, Judy would not consider that person terminally ill, and therefore you couldn't just remove the ventilator. But what one can do is keep them on the ventilator, have them receive basic care, and allow them to expire on the ventilator. That'll take longer. It may be more difficult for the family to deal with. But sometimes the family insists by Jewish law, that's what they want. Sometimes that's the only alternative. There have been other ways that have been discussed, but they're mostly theoretical. One was using, in the old days, we used to use oxygen tanks to get higher levels of oxygen. So while you'd keep the patient on the ventilator, When the oxygen runs out in the tank, putting in another tank is considered a new treatment. Therefore, you can decide, I'm not going to give the new treatment. And let the ventilator work on room air. And many patients need more oxygen than that. So again, keeping them comfortable, that will be a way around it.
Another way to deal with it, which has been tried, not yet successfully, but is being worked on in Israel, is timed ventilation. The idea that when a person comes in and they need ventilatory support, let's say with advanced, they had a massive stroke. And you know that they need three or four days to see if they're going to wake up or not. So you want to put them on the ventilator, but you know if they don't wake up in three or four days, they're probably not going to wake up. And the family may then want them taken off. And under Jewish law, you couldn't do that if they need to stay on the ventilator. So what they thought of was, when the patient comes in, we're going to put them on a ventilator for two weeks. Place the patient on the ventilator for two weeks, write the appropriate orders for whatever rates and tidal volumes you want for the ventilator. And then as the two weeks are approaching, you'll know whether this patient is going to get better or not. And if they're not going to get better, and the family doesn't want to prolong this, They may decide, don't put the ventilator back on when it shuts off, because if you're not shutting it off, it's shutting itself off when the two weeks are up. There's a concept that is used by Jews who observe the Sabbath when they want to turn lights on and off, among other things. You hook the lamp up to a timer. So you have it set to go off, it turns the light up at 11 o'clock at night, turns it back on at three in the afternoon when it starts to get a little dusky, close to dark, especially this time of year. And then you have light you can read by on the Sabbath, both at night, Friday night, and during the day. It has to be done at the time you first put the patient in a ventilator. You can't wait a month and then say, well, now we'll put them on a timer. Actually, I gave a talk to a group a couple of weeks ago, and somebody said, we can put them on a timer. And he said, only if you do it initially. And Israel, they're trying to develop this technology, but they've run into some snags. So they haven't really gotten there yet, or they were hoping to have it by now. So we really, here we don't have it available yet, but eventually that might be another way to deal with it.
And unfortunately, in most situations, rabbis will not accept that the ventilator is an impediment to death. They'll phrase it as it's life supportive. And I've never been able to talk a rabbi out of that. So there are certain things you just can't win and you don't try, you just work with them where they are.
Artificial nutrition hydration, this is the biggest, I don't want to say barrier anymore, but this is the biggest hurdle in end-of-life care regarding Jewish patients and other patients as well. Because especially in the Orthodox world, food and fluid are considered basic care, even if you deliver it with a feeding tube. And therefore, from the orthodox position, most rabbis will not consider, even if put in a PEG tube or an NG tube, will consider that a medical intervention. They will not. And they will say, you have to do it because you don't want the patient to starve to death. Now, we've, you know, over the years, we've learned how to play with this a little bit. Sometimes, for example, they're too sick to have another PEG tube placed, so the PEG tube comes out. And if you ever put an NG, had an NG tube put in, it's very uncomfortable. I've had it done a couple of times. It's not pleasant. And I've even had patients who are semi-responsive, and I've had this where a family wants an NG tube, and I take them in the room with me, and I start doing it, and they see their loved one pull back, they don't want me to do it anymore. Sometimes that's what you have to do.
Another way to deal with this is I sometimes will use hydration with hypodermoclysis, using a very small celastic needle in the chest wall. It's not very painful. You give a half a liter a day. The family's happy that you're giving them fluid and you're not overloading the patient, which you would do if you gave them, let's say, two liters of IV fluid a day, which when I was in medical school in residency, That's what I always thought you had to do on people like this. And then when they start drowning, you give them Lasix to flush them out. And that's what we do. We give the fluid in and then give the Lasix to take the fluid out. Makes no sense, but that's what we did. That's what we would do.
Now, outside of the orthodox world, there's less of an issue here because I think in most Conservative and probably all Reconstructionist rabbis consider artificial and spiritual hydration to be medical interventions. And therefore, they don't try to push the issue on families or on patients. Their feeling is, I give them a tray. If they can't eat the tray because their physical condition doesn't allow it, I've done what I had to do. And again, that's more of a family with their rabbi decision than anything else. But it's another way to deal with it. But this is probably the biggest barrier, especially, I think, in the Orthodox community. And the reason this is a barrier in the Orthodox community is because these are translations from Rabbi Moses Feinstein, who probably in the late 20th century was the expert here in the United States on medical decision making of all sorts, including end of life. And in a response that he wrote when asked the question about the idea of feeding somebody at the end of life, he said, there are two translations. He wrote this, I think this was in Yiddish. Quite clearly, providing food to the patient is beneficial. And the second translation is, clearly, we must feed him food that will cause him no harm. What I like about putting these two definitions next to each other is it sets up that beneficence, non-maleficence very clearly. So the intent is you give somebody food that's beneficial and won't harm them. So people are, for example, aspirating from the feeding. You don't have to keep that going in. I used to run into this in nursing homes all the time where the patients with dementia would be fed you know, 3000 cc’s a day, they would start aspirating, they cut it back. The aspiration would be treated. And then as soon as the patient got better, they'd up it back to 3,000 cc's a day, and it would happen again. And I remember once saying to a doctor in his office, why don't you just give them 1,500 cc's a day? See if that works. Because they're telling you 3,000 cc's a day is too much. And he says, well, can I do that? The nursing home nutritionist is telling me I have to give them 3,000 cc's a day. I said, well, you're the doctor. You write the orders. If you write, I only want the patient to get 1,500 cc's a day, because if they get more, they aspirate, and it's dangerous to give them more. Who's going to argue with that? What about the inspectors in the nursing home? I said, they're not going to argue with that either. You're the doctor, and that's what you're doing it for a sound medical reason. It should not be a problem. So there are ways, again, to work around these things.
So finally, I think this is where we end off, is with advanced directives. I think people are familiar with the two major types, the healthcare proxy, where you designate someone if you are incapacitated to make healthcare decisions for you, and you need to have conversations with that proxy to make sure he or she knows exactly what you want or don't want if you're in that situation. And then the living will, which are instructions given by the patient for interventions that the patients want or don't want when they're in a terminal condition or suffer from, and this I think is from the Florida one, certain irreversible neurological conditions. But that phrasingology varies by state. But some kind of advanced neurological condition and cannot express their wishes.
And from a Jewish perspective, health care proxies are permitted by everybody, just about. But in the Orthodox world, it includes the designation of a rabbi to advise the proxy agent on the Jewish perspective of any decision that needs to be made. So whereas the proxy, the patient names two proxies. They name whoever they want in terms of their loved one or person they trust, and they name a rabbi that that person should consult with. That's the only way in the orthodox world that a proxy would be accepted. The living will is more controversial because It doesn't really call for rabbinical consultation. It simply says, I'm the patient. I want this. I don't want that. So you also will see combined documents where you will see a living will type of approach. But then, for instance, the National Institutes of the Jewish Hospice has one where you see, this is what I want. This is what I don't want. And in consult, also, provided it's appropriate in consultation with rabbi so and so. So it covers both them. And you can also do that secularly as well. Say, this is what I want, this is what I don't want, and I want this person to be my proxy to make sure that my wishes are carried out. And again, most people you can use, most of the Jewish movements have their own living wills and health care proxies. And you can also, many people will use the five wishes or other similar documents. to do that. And I apologize for going over a little bit, but that's my last slide. I think we're going to do questions later on. Okay.
Rabbi Kogan: So good afternoon, everybody. And sometimes it's hard to follow lunch and Dr. Kinzbrunner presentation. So it's an honor to be with you today. I am a rabbi, a medical doctor, and an ethicist, as well as a mohel. I will not use that part here, but I'm bringing those three fields because sometimes it's hard for me to speak for just 15, 20 minutes. But I will do my best to at least to give you some of the ideas, some of the values. I'm serving here in Baptist as the Director of Medical Ethics, Bioethics. So I try to concentrate, but I need to bring some of the Jewish sources that in some ways inspire my career as an ethicist as well. But of course, understanding that when I am practicing my job, my role as Director of Bioethics, especially here in Baptist, in the whole system, I see patients from all over the spectrum, all over the faith, you know, from inside Judaism as probably Dr. Kinzbrunner spoke, there are five different at least branches, but we know that Jewish people, three ideas. So this makes as well a little bit much more complicated, but then trying to accomplish that.
So especially when I'm talking about bioethics reminds me about the story that a big rabbi is coming to town And the whole congregation is preparing him for to come and the whole room is packed. And he comes and he said to everybody, do you know what I'm going to be talking about? And people look very surprised and say, no, we don't know what you're going to be talking about. So the room was packed. Everybody was expecting his speech. And he said, well, I'm sorry, but if you don't know what I'm going to talk about, I leave. And he left. So everybody was saying, what's going on? So he went to his hotel. The president said to the congregation, well, we have to bring him back. But if he asked that question, what are we going to say? Yes, we know what you mean. So he comes back after, you know, pushing him to come back and comes back. And people said, and he said, ask, well, now you know what I'm going to talk about. And everybody said, so he said, well, if you know what I'm talking about, I leave because I have to speak up. And he left. So everybody was so shocked. We have to try for the next time. So the president said, how about if he said, you know, half of the room would say yes, and half the room would say no. So they went, and he finally agreed. He came back, and he comes back, and he said, well, now guys, do you know what I'm going to talk about? And people said, and people said, and he said, how about if those who knows what I'm talking about, they tell those who knows, and he left.
So I'm talking about, because especially when I'm talking about this bioethics, people said, what is bioethics? And we don't know what is bioethics, and it's biometrics, biothetics, ethics, whatever. So to make a long story short, it's the combination that we have between the medicine and the ethics, especially in a world that every day is moving fast. I just came back. One of my roles as a Baptist is to be the vice chairs of the IRB. I came back from PRIMAR, which is the National Conference in Research that was in Seattle just days ago. AI, Artificial Intelligence, is taking over almost every single field, every single field. At some point that people are scared so far. And they're already talking about changing, instead of calling AI, Artificial Intelligence, they're calling software solutions. because we are going to a war. And in any way, and I give an example from my field, because I'm trying to concentrate in ethics. We always try to respect patient wishes. And this is what we're talking about. Advanced directive, what the patient wanted. So if he or she didn't express, didn't say what they really want, we don't know and we have to go to the family. And what happened in the family disagreement, and this is a great question post after for the q amp a, if there are three kids, one, say a, and the to be safe seed from Jewish perspective, what will happen. So, one of the things the solution that they're talking about and a very advanced stage is to have. to understand the wishes of the patient, but what he or she wanted before. So that's one of the things that I just shared with you.
Advanced directive, as again, Dr. Kinzbrunner shared, and I will not have so much time, but I'd like to concentrate in a couple of things. This is what we do, especially in ethics. We talk here about the ethics consultations, and this is conflict resolution. We have always wrote about communication. Closer to the camera I didn't put my mic up to it and the camera is out here. Okay, everybody see me now okay no that's good. Anyway, so we are concentrating in communication. This is one of the big issues. That's why, if there is something to take from this talk, is ask everybody that you know to speak about, to talk about what he or she wanted, God forbid. And let's hope that every single person lives until 120, transiting in that US. People may know 120 years. Why is that? Because Moses lived at that time, and this is what in Jewish life what we want and express and share that every single human being live but hopefully if there's going to be a time what he or she wanted this has to be talk and this has to be speak because we often encounter communication issues. We talk about policies in my world and education what we do and this is the four principles that we use beneficence, non-maleficence, autonomy and justice. What does that mean? Beneficence to do the best for the patient, no maleficence, no harm, autonomy, which is what is the patient's wanted, what he, you know, wanted, you know, and I come from Argentina. And I always laugh because in Argentina is much more doctor oriented medicine still today. And America is still autonomy, which is patients oriented. I wish, I wish that's going to be like a pendulum to go to the middle. neither the patient, neither doctors, to establish a way how we can provide the best cure, the best healing for every single human being. And justice, which means to do what is right.
So I'm going to go to two cases. This is a famous case that appeared in 1988 in the New Natural Medicine that was, it's called, It's Over Debbie. If you just take a second to read it by yourself, Basically, this was a case that was a kind of a bone, you know, that people were not, they knew about that. But until this was not published, this was kind of the beginning, you know, not the beginning, but medical ethics by the study in the 70s, I do believe this started as a kind of a consequence of what we know about the Shoah, the Holocaust, which, by the way, I just come back as well from a meeting that was promoted by the Lancet magazine, the medical world. And basically, the meeting was about when healers became killers. You know, of course, we know that we're talking about doctors, Germans, doctors, during the Holocaust and what they have done. And I believe that in some ways medical ethics started around that time as well. So this was a big case at the time. So, and to make the story short, the resident, you know, did it, you know, about three in the morning, you know, established and gave the patient 20 milligrams of morphine and the patient passed away. So this was a kind of a case of, you know, how can we do that? And if that is something that was happening and was happening, and, you know, the author wrote it in an anonymous way. So, you know, just to make sure that everybody was kind of understand that we have to take care of that. So this is the first thing.
The second thing, I like to go to a Jewish patient, you know, and you know, this is something that I personally encountered. And this is an 18 year old lady, you know, that you are reading with me, lies in hospital bed hooked to a respirator. She has been there for nine months. She went into a coma and lost consciousness following an evening of alcohol and drugs, and her doctors believe that swelling has suffered irreversible brain damage and that she will never regain consciousness. Sue Ellen is not technically dead. The hospital machines indicate that despite her coma, there is still some brain activity. According, she's kept alive by intravenous feeding and mechanical respirator, which supplies oxygen to her weakened body. And the cost of maintaining these services is very high. And her parents visit her daily and speak to her, but she's unable to respond. No one knows what Sue Ellen will say or think. And she was aware of her situation, her future is because of those around her. And this is unfortunately a case that we are encountering, you know, because of technology, because of advanced medicine, you know, in a frequent, basically, much more than years ago. So, so when in the Jewish life, and now I put my other hat, you know, when counter cases like that, we always consult our sources, as the case was said before. And here is, you know, one of the sources that I like to bring, you know, a dying person is considered as a living being, you know, matters and is forbidden to touch him. you know, less that disgusting, whoever touches him is considered like one who shed blood, and this is compared to a prickling candle, which becomes extinguished as soon as touched. From a Jewish perspective, We talk about there's differences between the three, so to speak, main branches, which is orthodox, Conservative, and reform. And the basic is about the halacha, which is the Jewish law. The orthodox will go orthodoxly going through that. The Conservative will be calling what they call a dynamic halacha, which means a law that has to be dynamic. And I am a Reform rabbi, which means that in Reform Judaism, we consider Halacha, but we are not bound by Halacha. But my personal case, I studied with Rabbi Steinberg, Abraham Steinberg, which was a year ago after what happened in Gaza. It was in Israel, close to Gaza. I visit his hospital, which is in Jerusalem. I'm not miscounted that. I was with him in his hospital. His name, hospital will come, Shaare Zedek. And I studied in the Conservative world with Elliot Dorff. And in Reform, my mentor was Dr. Mark Warshawski.
So I've been exposed to the feeling of the Jewish law and how to consider Jewish law in different situations. But I must say, and as discussed before, sometimes the practical life is different to the theoretical life and we have to be careful how we follow all the cases because we may, you know, do something wrong if you're not studying and be quite what we have, but we have to always understand. from my perspective now as a geneticist, that in America will give, you know, precedence to what the patient wants. And if the patient is an orthodox Jew, we had already cases here in Boca, we will call the rabbis and talk about the rabbis and what the patient wanted and respecting his or her wishes.
This is, for me, the case. This is the case that I always cite. So take a minute to read, basically. And if there's another point to take from my presentation, it's that. Rabbi Judah, the prince, was very ill. Seeking this, his servant went up to the roof and prayed for his death. Since the prayers from the rabbis below in the synagogue were keeping him alive, as the rabbis continued their prayers, For heavenly mercy, their maidservant took up a jar and threw it low from the truth to the ground. In doing so, she caused such a noise that the rabbis below were distracted and ceased their prayers in that moment of silence."
For me, this is one of the big cases that we have in our literature in the Jewish literature that in some ways inspire me. And always I will prefer, you know, as an ethicist as well, what I call with with hold down withdraw. We can not move forward because families sometimes say do everything, do everything, do everything. But I always say the same, you know, it's like I'm going to a Chinese restaurant. I know Cantonese, but not so much. but I want to eat. And the menu is in Chinese. So, you know, you want to eat, so you don't want to eat, you know, say, give me food, but you don't have no idea what you're talking about, what is kind of food. So we have to be careful how we said from medical perspective. And doctors sometimes I said, be careful how you sell, quote, the whole to the family. Because in situations like that, family gets desperate, and we have to be careful and our hope cannot be the real hope.
So primo noce, which means Even though we have it, doesn't mean that we need to do it. It's kind of the story that I said, I'm going to a doctor, please cut my arm. He said, but what do you mean? Yes, I ask you, please cut my arm. But you don't have an indication. But I ask you, please cut my arm. Hopefully, the doctor will say, I'm sorry, I cannot do that. So I hope to encounter my colleagues, doctors, who when we have a case, if we know that the patient will not benefit, will not move forward. So I think Rabbi Kenneth will talk about that. The Torah permits a physician to heal the sick. The duty of competent physician to heal the sick is included in the general rule of pikuach nefesh. Pikuach nefesh means to do our best to save a life. And this is, I think, one of the best principles. And as well, briefly, there are some cases interesting, you know, Rabbi, can I first talk about Abraham and Jacob? There are some other cases that we have with Saul that talks about euthanasia, you know, and finally, you know, I always like to share a little bit of my hometown, Buenos Aires, you know, just to have a little bit of nice things that happen.
And the active euthanasia is causing an intention for the patient to pass away. Assisted suicide is when a doctor will prescribe a medicine, something that will cause the patient to die. And there's something called passive intonation as well, which is a refusal to intervene. And this is kind of, I will say that in my studies, I found that, of course, active euthanasia and acidic suicide is forbidden, but there are some, you know, some sources that will bring passive euthanasia in different categories. And finally, let us assume that you are dying and in pain and anguish will rather prolong your suffering or curtail it. If that question squarely frame the issue, there could be little disagreement. What we should be asking ourselves is when is death, and the best response is suffering. In this debate, we are hearing only voices of compassion. And this is kind of my last word. And I think trying to come from these three areas being a rabbi, an ethicist, a doctor, I always think about what is the best for the patient. Or I always said, if I will be the patient, and this is the exercise that I'm putting my students, I said, look at the world from the bed. And how do you imagine, hopefully, at the end of your life that day is going to be? We have to be very careful what we are saying, how we are advising, what kind of hope we are bringing to patients, because sometimes we can hurt them as well. Thank you very much.
Dr. Jessica Eichler: So I'm Dr. Eichler. I'm a hospice and palliative medicine physician. So I'm going to be talking a little bit about the importance of culturally sensitive care in the setting that I work in and trying to focus on Jewish beliefs and practices regarding end of life care. I really want to focus on identifying some barriers that we may face When trying to provide Jewish individuals with comfort care, and to also elucidate some strategies for overcoming the barriers. I am also including, but some of the things that everybody else spoke about just for completion sake that might be breezing through those parts, trying to keep us in the right amount of time.
So just to talk about a little bit the some key beliefs. It's fundamental Jewish perspectives on life and death. Life is considered sacred and the preservation of life is paramount. But death is also seen as a natural part of life, often approached with a sense of peace. And there are also some varying beliefs, even on the afterlife, even resurrection. So it can shape how patients and families view end of life care and influencing their decisions, of course, openness to even embracing the idea of hospice and palliative care, or even just open to the conversation. And this, I guess, Dr. Kogan spoke about the obligation to save a life, dignity of the individual, and families also feel this strong sense and can make them a little reluctant. Community plays a vital role, so it's really important to support that. They often look to their religious and cultural community for guidance during difficult times. In hospice and palliative care, we always try to, as much as possible, look at someone holistically. You know, there are many different sides to a patient, which is also, and family as well, because we're also supporting the families. And this is why really a palliative care team is a multidisciplinary team. It's usually not just one person because everybody has a different part of their expertise that they can provide and help the patient and family. So sometimes instead of involving a chaplain, when it's a more religious Jewish family, we might try to involve the rabbi.
So my role as a hospice and palliative physician is, like I said, to adopt a holistic approach and try to address the physical, emotional, and spiritual needs of the patients, collaborating with the interdisciplinary team, and as well as trying to involve other members of the medical team, if possible. The communication is really important. Engaging in open discussions about prognosis and treatment options allows us to meet patients where they are and their understanding and beliefs. So when communicating with Jewish patients and families, cultural sensitivity is very important. And, you know, of course, with every culture, it is important. but using appropriate language and being mindful of the cultural norms regarding death and dying. I can also help establish trust in a bond with the family, get them to open up more. It's crucial to encourage family participation and decision-making as this is a cultural norm and recognizing their integral role in the care process. Again, as I said before, very important to try to involve the rabbi whenever possible.
So just to kind of reiterate what Dr. Kogan spoke about, some ethical considerations. We have to balance medical interventions with respect for the natural dying process. It involves understanding Jewish legal perspectives on medical interventions. Of course, discussing advanced directives is vital to ensure that their care aligns with their values and respects their autonomy.
So now I want to really talk more about some of the key barriers, as you can see by looking at the next couple of slides, there are a lot of barriers that we face. So as I spoke about before, the idea that always trying to choose life, it really creates a reluctance to embrace comfort care. There may be a misunderstanding that choosing comfort care or even not escalating care is incompatible with Jewish law. So trying to, again, involve rabbis as much as possible involving the chaplain to try to address this in particular because you know as we've seen today, they're really not mutually exclusive. There's often assumption. In general, not just with Jewish families but in general that the patients that you can't introduce the idea of palliative care they're not ready they're not ready.
Sometimes the top of goals of care, it's not even broach because of this assumption. In practice, we see a lot of times that you do talk to families, they may be actually much more eager to talk about these things than you assume. And having a clear goals of care conversation, understanding what lies ahead can really give people a lot of peace. So it's important at least to try. Also, you know, very common misconceptions about palliative care can lead people to equate it solely with end-of-life care. In terms of palliative care, it doesn't have to mean that the patient just has six months to live. We can actually get palliative care involved much earlier because we know that involving palliative care really has been shown to improve quality of life. The other issue is in terms of misconceptions, You know, like Dr. Kinzbrunner was saying, you know, a lot of rabbis are actually not informed about health care, about end of life decisions. They, you know, people's rabbis in particular, they might really not have experience in this and also jump to conclusions without kind of understanding the medical perspective. There've been very few times that patients that I've dealt with have actually been willing to involve their rabbi in goals of care discussions. Not that it hasn't happened, but much less often. And so, you know, I also worry when that happens that this is really not even the rabbi's opinion, that this might just be sort of a way of blocking off further conversations by just putting that out there. You know, the idea that, well, this is my culture, this is my belief, So therefore, you know, you're not going to change it, you know, kind of thing.
And then there's also a worry, Dr. Kinzbrunner brought this up before, that prognosis may impact the patient's will to live. A lot of times families don't want you to talk to the patient at all. Even if someone is alert, oriented, able to make their own decisions, there's a huge resistance to talking to them at all about what lies ahead, and especially about prognosis because of the fear of taking away their hope that it might shorten their actual might shorten their lives and their will to live. And then, you know, just even broaching the discussion can be difficult, the subject of death. People don't want to hear that word, people don't want to hear the hospice word.
You know, and then also from the healthcare point of view, you know, we have also religious Jewish physicians, nurses, that also are just, you know, either not willing to consider hospice, not willing to talk about a DNR, don't want you to talk about a DNR because of their religious beliefs. They feel that, you know, maybe hospice is not compatible with their religious beliefs. You know, things like that. Then the other thing is trauma history. Trauma history, you know, of course can affect your overall health and, your involvement in health care. You know, maybe in the coming years, it won't be so much of an issue because people are kind of aging out.
But the Jewish people have, of course, a huge history with trauma, and it can influence sort of their perception of health care, their perception of care in general. So it really has to be taken into consideration. And, you know, they're And there can be sort of perceived conflicts between appropriate medical interventions and religious beliefs. The idea of medical futility is just kind of often thrown out. It's not even considered. People feel like they need to hold out for a miracle. They disregard the idea of not just a futility, but of doing harm. or there's no worry about non-beneficial care because that's their understanding of Jewish law is that we have to do everything, including things that are non-beneficial. So then there's the idea of also code status, that some people's understanding of Jewish law is that maybe hospice is appropriate But not do not resuscitate like that that's out of the question. That is a big hindrance because it can stop people who really have a lot of symptoms, or who are eminently dying from getting inpatient hospice care, or even getting crisis care and the life at home. Because normally, while you know you can be on hospice while being a full code that's totally acceptable to be in an inpatient setting, it's really not fair to the nurses and the doctors in hospice to have somebody come, and that we know we want to make comfortable we know is necessarily dying. but that we also have to do this futile maneuver on them. So the code status alone can kind of weed out a lot of people from being able to get appropriate end of life care.
So I just wanted to talk about, you know, some kind of tips to overcoming the barriers. We can, you know, implement several strategies. You know, the first thing is don't assume everything. Every patient's beliefs and values are unique. Even as we were talking about before even rabbis interpretation of the law can be very varied so you can't walk into a room of, you know, religious shoe and then assume that they're going to have sort of certain beliefs certain wishes, or like a cookie cutter plan for their care.
Um, obviously ask a lot of questions, ask open-ended questions. This is true for anybody. I mean, you know, you don't know them, so you have to ask questions to get to know them. Um, the more that you find out about them, um, the more that you inquire about their values, um, the more that they will actually think that you actually care about them. and maybe open up more to you and be more open to hearing about prognosis as well. If you talk about the prognosis before you get to know the patient, before you understand their values and their history, it can really create an adversarial relationship rather than a therapeutic relationship, whereas if you go the opposite way, people can tend to trust you and want to talk to you about these things.
You know, and then also, you know, before you go into these goals of care discussion, gather as much background information as you can. You know, don't review a chart and then go see the patient, review the chart, talk to the doctor, talk to the case manager, talk to the nurse, you know, so that you can have as much information as possible. Because without all that kind of corroborating information, it can also lead to a lot of assumptions. I mean, I can't tell you how many times I've had somebody tell me, oh, you're going to go see this patient. It's, you know, don't waste your time. And then I go in and it's a totally different, a totally different situation. People are totally open, happy to see you, you know. Of course, the other, you know, the opposite can be true as well. Um, also listen actively to, um, people's beliefs and wishes. Um, even if it sounds outlandish, even if they sound, you know, their, um, wishes are kind of impossible things. Listen and, and try, um, not to be judgmental and, um, and ask them why, you know, why they have that wish, why they have that belief, where that comes from, what they're hoping for. rather than just in saying, well, that's not, you know, that's not possible. Try to speak compassionately and then address whether these wishes are feasible.
You know, when you're talking to someone and you hear about their wishes, you know, using these kind of phrases like, I wish that this were, that this were the case as well. You know, I hope that you do have that, you know, more time but I'm worried, you know, and that can make people feel like, oh, they feel how I feel, you know, they understand. And then of course, you know, providing as much education to medical providers as possible about Jewish customs and beliefs, having, you know, any kind of in-service, of course, like, thank you guys all for coming for the symposium, but as much education as possible, anybody, was able to give the education, anyone who wants to get the education, you know, just more obviously knowledge is power. And I was also going to talk about, you know, first of all, early palliative care interventions, you know, not waiting to refer people to palliative care until they really are imminently dying, or not even waiting until they have, you know, just six months because palliative care is not just end of life care, you know, it's supportive care for a family, spiritual symptom care for people who have chronic illnesses.
And, you know, we've seen in people, you know, even with cancer patients that not only does it improve quality of life, but it can even improve length of life. So, and also if, when the idea is broached really towards end of life, it's more shocking, whereas people who have had palliative care interventions for many times, every hospitalization or on an outpatient basis, it's not threatening, it's more welcomed. So that can make it easier. So if someone has a chronic progressive illness, it might be a good idea to think about it. And then the other thing is in terms of, When someone is on hospice care, even palliative care, we've been using this type of therapy called legacy therapy or dignity therapy. It can be especially effective in patients that have had trauma like Holocaust survivors. So what you do is, it can be like a psychologist, a social worker, a chaplain that has sessions with a patient where they talk about their life, they talk about the difficult topics, you know, traumatic experiences or, you know, issues with distant family members, draws out the parts of their story that have to do with their meaning and purpose and helps them kind of try to leave a legacy that they want. It's really good when people are at end of life and have depression because of it as well. they can return sort of a sense of purpose that they may have lost. And then, you know, if the patient is interested, you can also record these sessions for posterity, kind of to give to their family. Obviously, very important as everybody's been talking about, talking about advanced directives proactively, super important.
Um, this, you know, uh, I think a lot of people have a misconception that you need a lawyer to make an advanced directive, you know, end of life wishes that you have to get an estate planner or something. It's not really the case. Um, Palmbeachcounty.gov. Um, if you just, if you just type that in and advanced directives, a packet on advanced directives will come up. print it out, you can give it to, and it has instructions. If you can't give them yourself, there are instructions on how to fill these things out. You just need two witnesses and it becomes their living will.
And it needs to be spoken about more often and it has to be seen as routine. When I talk to people about their advanced directives, they get so scared, like, this means I'm dying if you're talking about it. No, this means you're alive, that you have to have a living will. And the more that it becomes routine, the more people that talk about these things, I think the less scary it can be. And then, so also talking to people before they need hospice about what hospice is, so that if they ever need it, It's not such a scary thing. It's not like, you know, knowing it doesn't mean I'm dying tomorrow. The more you kind of have more early education, the more people will kind of not have such an aversion to the H word.
So I wanted to talk about a couple of cases. Mrs. M is a 98-year-old female Holocaust survivor. She's dying of metastatic ovarian cancer, and she told her family in the past that she would do anything to live as long as possible. She does not have a living will. She's had surgery, chemotherapy, radiation. Now she's in the hospital with a malignant bowel obstruction and is not a candidate for any kind of surgery. She's in terrible pain. She's delirious. She's full code and her blood pressure is a little bit low. So her children are not letting people give her opiate pain medication because of the fear that she will die sooner. So, you know, this is pretty common. You know, actually I think, for some reason, you know, we've been kind of doing a little bit more comfort measures more frequently at the hospital. And the hospital staff thinks that there's a policy that if you're not on comfort measures, if you're not on hospice, sorry, not on hospice, that you cannot give somebody pain medicine if their blood pressure is low. And so we've seen a lot, I've been seeing a lot of people kind of suffering like this woman. For no reason. Dr. Kinzbrunner talked a little bit about the principle of double effect, but he called it something else when there's a secondary effect. And it's actually a myth. People think that if you give somebody a normal amount of pain medication of opiates, that they will die sooner. But there are numerous studies, innumerable, to show that this isn't really the case, that people are not dying sooner. Even people in respiratory failure, their oxygen saturation goes up when you give them a little bit of morphine. So it is a myth and it causes people to have a much worse death than they really needed to have. When you give people pain medicine in an appropriate amount, obviously like the case that we saw earlier, there is an egregious amount and that is going to make somebody die. So that's going to put them in respiratory depression, et cetera. But in appropriate amounts, it will not. So, you know, in this case, really, you know, honoring this patient's wishes and explaining to the family that there really is no glory in suffering. It's not going to give her an extra minute to live. But that's not part of the Jewish beliefs is not that, you know, suffering in and of itself is not a it's not a blessing is not a virtue. and that the appropriate amount of pain medicine is not going to shorten her life. So she could have really the kind of death that she wanted, the kind of life that she wanted, the kind of care that she wanted, but also not have to suffer.
Okay, so this is Mrs. Z. She's 90 years old with a past medical history of congestive heart failure. Sorry, I also wanted to say, you know, that in terms of, you know, Holocaust survivors, there really are, it ranges the gamut in terms of what their wishes are. And I've had, you know, just as I had this person who was all the way, you know, wanting aggressive everything possible to live as long as possible. I actually had a patient who was a victim of Mengele, who was diagnosed with cancer who probably had treatable cancer, and she did not want anything she did not want one more test. She did not want one treatment, not one more hospitalization and she was that was that was it. She had had enough, you know, experimentation on her body in the past so it can run, you know, just like I say don't assume things because, you know, you have to just ask questions everybody really is different as a case by case basis. Okay, so this is Mrs Z 90 year old female past medical history of congestive heart failure hypertension, but a kidney disease multiple strokes, the last of which left her with left sided hemiparesis dysphagia dysarthria, she's able to say, sometimes one or two words. She requires total care as a feeding to severe infected pressure wounds hospitalized for UTI altered mental status. It, the son and daughter both agree like this is no quality of life, you do not want her to suffer anymore. They actually have come to a point where they want home hospice. But the son just can't agree to a DNR. He states that his rabbi has expressed that DNR is not compatible with his religious beliefs, with Jewish law, and he has recommended against it.
So this was another, you know, family where I kind of thought I was going into, you know, but everyone kind of prepared me with their, you know, you're not going to get anywhere, like why even bother with them? And in fact, after I talked to them for maybe 20 minutes, They said, we want hospice for my mother, we want her to be comfortable. She's really been suffering. She's been in and out of the hospital. So this wasn't even her first hospitalization. She's had aspiration pneumonia. Um, and, um, and they were actually the, the children were really in pain and they were really suffering because they wanted her to have comfort care, but they couldn't get it because she was, they couldn't make her a DNR. So, um, you know, we just kind of explored where this was coming from. Um, she had, I mean, she had such like really high nursing needs that she really would not be able to be on routine home care. It was really no way that she could be cared for at home on hospice without a nurse at the bedside, which she would not be able to get without a DNR.
So just, you know, what I did was I just explored, you know, I kind of posed the question, you know, if your mom from five years ago were to walk into her hospital room and see herself, how she is, What would she want? Would she want a DNR? And, you know, through talking to them a lot more, what kind of surface was that actually the orthodox, you know, the very, the orthodox beliefs were actually the sons and not the patients. The patient and her daughter were Conservative. And he was actually in a lot of pain, you know, thinking like, You know, I don't want her to have chest compressions either, but I can't, you know. But when we talked about the idea of autonomy and about surrogate, the responsibilities of a surrogate decision maker, he actually was able to relinquish his decision making to the daughter only so that she could make the appropriate decision for her mother. And she was able to go home with crisis care and appropriate care.
So just in conclusion, I just want to kind of emphasize the importance of understanding Jewish beliefs and practices. And I hope I was able to explain that our role is to offer compassionate, culturally sensitive care that meets patients where they are. That's for all people, not just obviously Jewish people. But I think I've made it pretty clear that I want everyone to avoid making assumptions and just actively listen to the patients. If we can address the barriers that Jewish families and patients face, and implement some of maybe some of the strategies or come up with your own, we can help them to receive the comfort care they deserve at the end of life.
Rabbi Ed Bernstein: Please indulge me for a moment while I do what rabbis often do and connect our discussion today with this week's Torah portion. In Jewish tradition, we read through the Torah, the five books of Moses, every year. And at this time of year, every year, we're right in the middle of the Book of Genesis. This week in synagogues around the world, Jewish congregations study a chunk of scripture from Genesis chapter 28 through chapter 32. This section is titled Vayetze, literally, he went out, Jacob went out from his home. The section begins with Jacob not just leaving his hometown of Beersheba, but fleeing for his life from the wrath of his brother Esau, whom Jacob deceived out of his birthright and Abrahamic blessing. Jacob flees to the home of his uncle Laban and ultimately marries Laban's daughters, Rachel and Leah. But at the outset, we're told that Jacob stops for the night and dreams of a ladder rooted in the ground, reaching heavenward with angels ascending up and down the ladder. It's a brief aside. I have a personal rabbi chaplain practice. I guess you could say it's my shtick and I coordinate themed neckties with the Torah portion of the week. The Zoom people will be able to see this easier, but this is my sort of a representation of the stairway to heaven, the ladder to heaven that Jacob saw in his dream. So there's this dream with the ladder and angels going up and down. And then in the dream, God appears and reassures Jacob that he will receive the blessings of a nation as promised to Abraham. And then Jacob wakes up from the dream and says, surely God is present in this place and I did not know it. Imagine Jacob, he is at a very vulnerable moment in which his life is hanging in the balance. The last thing on his mind was to have an encounter with the divine. When that happens, he is surprised. And at the same time, he acknowledges this extraordinary event and is able to name it.
In my career as a rabbi and chaplain, I meet people at their highly vulnerable moments. When I meet someone at end of life, I strive to be present with them and their families and help name what they are going through so that they can manage it and acknowledge their feelings of vulnerability and fragility. These vulnerable moments occur in seemingly profane places, such as in a hospital room or an ICU. Oftentimes what appears in my field of vision, ventilators, oxygen tanks, urine bags, colostomy bags, feeding tubes, to name a few, are not the things that you would expect to find in a place we might associate with the word holy or the word sacred.
And yet, it is often at these vulnerable, fragile moments in seemingly profane places with a person sitting literally on the border of life and death when we can sense the mystery of the universe flashing before our eyes. It's something transcendent, what I might consider for me an encounter with the divine presence. And it happens at times we least expect. Here's a story in which I unexpectedly felt presence of the divine.
It's from nearly a decade ago, at the end of my tenure as a pulpit rabbi, when I was serving a Conservative congregation in Boynton Beach. Now, brief aside, I am a Conservative ordained rabbi within the Conservative movement, and it's been touched on before, but just a thumbnail sketch. Conservative Judaism accepts the authority of Jewish law, Jewish tradition, and acknowledges that throughout the ages, Jewish law has always evolved and continues to evolve as Judaism is in conversation with the communities around us. So that's a thumbnail sketch of where I come from theologically. So I was called to the home of a woman from my congregation. We would say then in her 80s, she was dying after a long battle with leukemia. She had a beautiful marriage of some 60 years with her husband who was right by her side, several children, multiple grandchildren. But after many years of fighting leukemia, after many years of treatment, she was clearly declining. She had regularly received blood transfusions, but they were becoming less effective and more risky. My congregant had a razor sharp mind, and she and her family were faced with a difficult decision on next steps. She asked, I was her congregational rabbi, she asked me as a rabbi, what Jewish tradition would allow her to do in this circumstance. Now, for me, the facts as presented to me at the time certainly supported her entering hospice care. But what was, even though this seemed obvious to me that it would probably be best for her not to continue any more invasive treatment, and that at this point it was causing, not alleviating suffering, seemed obvious to me, but I refrained from sharing my opinion immediately.
It just so happens that at that time, nearly a decade ago, I had just read a short time before Dr. Atul Gawande's masterful book, Being Mortal. I opened the book in my mind, as it were, and I asked her questions that Dr. Gawande asks his terminally ill patients. What are your goals? What are your end-of-life goals? And in pursuing these goals, what trade-offs are you willing to accept? This woman articulated that her goal was to die peacefully at home, not in the hospital. Now, I was in the home and the house was decorated practically every inch of wall space was decorated with paintings that she herself had painted. Gorgeous, gorgeous paintings. And near her bed, there was an unfinished painting of a small country house in the midst of a beautiful flowing green meadow. This painting was sitting on an easel right near the bed. And the woman said that in the hospital, she is not able to paint, but it was very important to her to be able to paint. And once we articulated that, she was able to name her goal. And once that happened, the conversation after that was much easier, and she ultimately chose hospice care. She chose to discontinue her blood transfusions, and hospice care came into her home. And she spent her final week in the comfort of her home, surrounded by her husband, her children, and her grandchildren. And she painted, and she was surrounded by her paintings.
She died and I had the honor of conducting the funeral and facilitated the Shiva prayer gatherings in the home during the week following the funeral. And during the Shiva, right in the living room where we gathered for prayer, the family proudly displayed on that same easel, the finished painting of the house in the meadow. I'm getting a little, to use a Jewish term, verklempt now, just thinking about this 10 years ago, because I felt the presence of the divine during those moments.
Not long after that, had occasion to leave the pulpit rabbinate, and I gravitated to chaplaincy to a large extent because I wanted to experience and help facilitate more moments like I just described. And I, I initially became a hospice chaplain, and I immediately enrolled in my first unit of clinical pastoral education taught by Chaplain Misty when we were both in VITAS Healthcare. And I worked in hospice for three years. Then to my good fortune, I rejoined Chaplain Misty here at Boca Raton Regional Hospital to continue my chaplaincy training and to serve this hospital as chaplain.
As a professional chaplain, I, like all of my colleagues, am trained to work with people of all faiths and of no faith. As my chaplain colleagues know, everyone, everyone has spiritual needs, even people who do not practice a formal religious tradition, and even people who do not believe in God, still have profound spiritual needs. People of all stripes may raise questions, particularly at end of life, on topics such as their purpose in life, their hopes for their children and grandchildren after they die, or their struggles with why good people suffer. These are spiritual issues that chaplains work with on a day-to-day basis.
At the same time, chaplains are attuned to helping people be in touch with their specific faith traditions if they find religious guidance meaningful from within their own tradition. So again, as a chaplain, I'm trained to work with everybody. And as an ordained rabbi, serving as a chaplain, I'm able to tap into expertise of Jewish tradition to meet spiritual needs of the diverse Jewish community that we serve in this hospital community. As Dr. Kinzbrunner noted, there are different interpretations of traditional Jewish law regarding specific medical interventions, such as DNR and artificial nutrition and hydration.
And I recall a case I was involved in, a complex case here at this hospital, in which the hospital staff and The patient's family, who identified as orthodox, were not in agreement as to the best course of care for the patient. The patient was an 89-year-old woman with advanced dementia and multiple other physical and psychiatric issues. When she stopped eating, her daughter, who was the primary caregiver, sought a PEG tube. to be inserted, and a PEG tube was inserted. A few days after surgery, the patient pulled it out. The daughter lobbied to have it reinserted, though the medical team was advising against it. The daughter was coming from religious perspective that nutrition is essential and not a medical intervention. That's the perspective that she was coming from. So the ethics committee was involved. And there were lots of discussions with the family in which the ethical pillars of beneficence and non-maleficence were in apparent tension with the ethical pillar of the decision makers autonomy, which in this case, the daughter was making decisions in tandem with her rabbinic authority and her religious tradition as she understood it. There are many aspects of this case that could be parsed by ethics experts, but I'll highlight one piece that I was a part of I was in the room with the patient and her daughter when a representative from an outside hospice organization not affiliated with the hospital came into the room. The representative, who was not Jewish, had done, I think, admirable research on Jewish medical ethics, particularly on the matter of artificial nutrition which was the matter under greatest discussion between the medical team and the family. The consultant came in with a stack of paper. They were Xerox copies from relevant chapters of a rabbi who was mentioned earlier, Rabbi Elliot Dorff, a distinguished expert of Jewish bioethics. And he is also a Conservative rabbi. He's not Orthodox. He's a recognized authority within Conservative Judaism on bioethics and wrote an excellent book that I recommend called Matters of Life and Death. But Rabbi Dorff is known for his argumentation from within the Jewish legal tradition on behalf of permitting withdrawal of artificial nutrition and hydration in cases like the one I described. He also writes about the permissibility of removing a ventilator because a ventilator can be seen in his interpretation of Jewish law as an impediment to death. And so we've seen that impediments to death can be removed, but things that cause the hastening of death are not permitted in Jewish law. And so there's so different Halachic authorities of Jewish law within different Jewish communities have debates over where to draw that line. So I'm a Conservative rabbi, as I noted. I consider Rabbi Dorff one of my teachers, someone I turn to for my personal guidance. And when I was in a Conservative congregation, his works were works I regularly consulted. But here, someone walked in, a total stranger to the person before me, who was the person I cared about at that moment. And she's coming in with a stack of papers attributed to Rabbi Dorff whom I respect, but I know Rabbi Dorff is not considered authoritative within Orthodox communities.
And so here, this woman comes in, the hospice consultant has a stack of papers and say, here, read this stuff from Rabbi Dorff on artificial nutrition. And the daughter, the caregiver, looked at me without taking the stack of papers, and she just asked me straight out, what kind of rabbi is Rabbi Dorff? And I answered, honestly, he's a Conservative rabbi. And the daughter said she wasn't interested in reading his material. No discussion. She put her trust in traditional Orthodox interpretation and interpretation of her Orthodox rabbi. I'm not insulted, I accepted that and I accepted my role. And I accept the fact that the Jewish population is not monolithic. And it's in our interest as those who are caring practitioners of different types to be aware of religious and cultural nuances among different subgroups. And Rabbi Dorff's approach to Jewish law was not the right approach for this woman who was caring for her mother at that time. I try to imagine myself in the daughter's shoes. Her mother was dying. The daughter's world was collapsing. I believe the daughter was single, never married, and her mother was her life. So the daughter's world was collapsing on her. Religious tradition was her life force that provided meaningful structure amidst the chaos of the declining health of her mother. It's possible that if I were in the same situation with a dying parent in front of me that I might have acted differently based on my values and my interpretation of tradition, but I needed to respect where she was and where she was coming from. Looking back, I think about the daughters clinging to her mother, trying to literally nourish her back to life because that's what she felt our Jewish tradition required and because, well, she just loved her mother. To conclude, when my congregant a decade ago elected to go into hospice, she surrounded herself with people and things that she loved, and she died on her terms. And I felt something special at that moment. And years later, in that hospital room where a daughter was fiercely clinging to her mother and to her religious tradition, there was something special going on in that room as well. There was a lot of love. And it's very possible that God was in both of these places, and I didn't even know it.
Thank you very much. NeshamahCast is a production of Neshamah Association of Jewish Chaplains. Thank you to Boca Raton Regional Hospital and Baptist Health South Florida for sharing this program with NeshamahCast. Please check the show notes for information about the speakers at the symposium.
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