End of Life Archives | My Jewish Learning

Jewish Perspectives on End-of-Life Care

Jennifer Modlinger — Tue, 13 Feb 2018 20:04:25 +0000

Decisions concerning medical care in the final stages of life present a range of Jewish ethical and legal conundrums. They are often messy and complicated, and they have vexed ethicists, medical professionals and religious leaders alike.

While Jewish tradition maintains that human life is of infinite value and that its preservation and extension overrides virtually every other religious imperative, relieving pain and allowing for the soul’s peaceful departure are also values well-established in Jewish tradition. Of course there is a moral distinction between hastening death and removing obstacles to its natural progression, but in practice the difference isn’t always easy to discern.

Below is a general overview of a number of issues that commonly arise at life’s end — and how Jewish authorities have weighed in on them. Jewish thinkers often emphasize that specific cases vary substantially and must be considered individually. And while weight is always given to a patient’s wishes, those who are concerned about complying with Jewish law are always urged to consult with trusted advisers.

Artificial Nutrition/Hydration

For patients unable to eat or drink, doctors can provide food and water intravenously or through a feeding tube. This is a common situation faced by those with advanced-stage dementia. Most Orthodox authorities generally consider nutrition, hydration and oxygen — even if artificially provided by a feeding tube or ventilator — to constitute essential human needs that should never be discontinued as long as they are effective. This position is was also reflected in the 1990 paper on end-of-life care authored by Conservative Rabbi Avram Reisner. However, the Conservative movement’s religious law authorities also endorsed a paper by Rabbi Elliot Dorff, who advanced several possible justifications for removing artificial nutrition and hydration for the terminally ill, among them the contention that a medically administered treatment that conveys food and water to the patient by tube is more properly regarded as medicine than as simple food and water.

Hospice

Hospice is a form of medical care for people suffering from terminal illnesses with a life expectancy of six months or less. Patients are typically referred to hospice care when further medical treatment is not expected to reverse the course of their disease and they elect instead to focus on therapies geared toward reducing pain and sustaining the highest quality of life for as long as possible. Jewish hospice programs are typically equipped to provide hospice services while abiding by Jewish traditions. Because hospice focuses on a patient’s quality of life rather than aggressive medical treatment, some Orthodox rabbis do not believe hospice conforms with Jewish tradition. However, not all Jewish authorities agree. Many contemporary Jewish authorities argue that Jewish tradition allows a focus on comfort and pain reduction and the eschewing of aggressive medical interventions in certain circumstances.

Do Not Resuscitate Orders

Known as DNRs, these are legally binding directives signed by doctors ordering medical professionals to withhold CPR or advanced life support in the event a patient’s heart stops functioning. DNRs are typically requested by patients who are elderly or are suffering from an advanced terminal illness that makes it unlikely they would survive CPR without a severely diminished condition. Some Jewish authorities consider these orders extremely problematic, as a patient needing CPR is in acute distress and could be saved, even for a brief period, with proper treatment. But given the often low success rate of resuscitation and the high likelihood of adverse effects for the elderly or those weakened by terminal illness, some authorities permit DNRs under certain conditions. Reisner, in his 1990 paper on treatment for the terminally ill, writes that it is proper to respect a patient’s DNR request in cases where it is not possible to restore “a full measure of life.”

Advance Directives

These are documents specifying a person’s wishes concerning medical care in the event they are unable to make such decisions for themselves and/or appointing a health care proxy to make decisions on their behalf. The laws concerning advance directives vary considerably from state to state. A number of state-specific forms are available here. In addition, both Conservative and Orthodox Jewish versions of advanced directives are available, some of which explicitly state a person’s desire to have Jewish law and custom respected in their health care choices. There is typically also space to name a specific rabbi to be consulted when making such choices.

Experimental Therapies

While most Jewish authorities would require a patient to submit to a therapy if it is known to be effective at curing their condition, this is not the case with respect to experimental treatments whose success rate and potentially adverse side effects are not known. These can include treatments whose effectiveness has yet to be demonstrated in clinical trials, or new drugs whose safety and effectiveness have not yet been established. Jewish authorities from across the denominational spectrum support the right of a patient to refuse treatment that is risky or of unproven value. Equally, a patient who desires to undertake an experimental therapy in the hope of being cured is permitted to do so even if there are risks involved. According to some authorities, this is even the case with a hazardous treatment that may itself result in death. Dorff writes that it is permissible to undertake a hazardous therapy if it presents a “reasonable chance” of cure, even if it simultaneously poses a risk of hastening death if it fails.

Refusing Treatment

Jewish tradition generally requires that every effort be made to sustain and extend life, but that position is not absolute. In cases where diseases are incurable, and medical interventions would be risky, painful, of uncertain efficacy or serve merely to prolong a life of unbearable physical or psychic pain, there is support in Jewish tradition for an individual’s right to reject such treatment. This was the reasoning behind the Reform Rabbinate 2008 ruling that a lung cancer patient did not have to submit to chemotherapy that could extend her life by three months, but only at a cost of significant pain and suffering. Within the liberal denominations, there is broad respect for individual autonomy in making decisions concerning health care, including the right to refuse care if the patient feels it would not be effective or would be too painful. Among Orthodox authorities, there is also support for refusing treatment in situations where it would not cure the patient but would only prolong individual suffering.

Praying to Die

Taking active steps to hasten death are prohibited in Jewish law, but praying for death is another matter. The 14th-century Catalonian Talmud scholar Rabbenu Nissim, commenting on the talmudic story in which the maidservant of Rabbi Yehuda Hanasi prays for his death, observes: “There are times when one should pray for the sick to die, such as when the sick one is suffering greatly from his malady and his condition is terminal.” (Nedarim 40a:2) The Jewish bioethicist J. David Bleich has formulated it this way: “Although man must persist in his efforts to prolong life, he may, nevertheless, express human needs and concerns through the medium of prayer. There is no contradiction whatsoever between acting upon an existing obligation and pleading to be relieved of further responsibility.”

Withdrawing life support

Many Jewish legal experts believe it is permissible to withhold advanced life-support measures from terminally ill patients. However, once such measures have been provided, withdrawing them to let natural death occur becomes more problematic. While there are grounds in Jewish law for withholding advanced life-support measures from terminally ill patients, once such measures have been provided, withdrawing them to let natural death occur becomes more problematic. As a general rule, withdrawing life support is not permitted in traditional readings of Jewish law. However, there are many contemporary Jewish authorities who consider a person to be dead if activity in their brain stem stops. If such a patient were kept “alive” only by means of medical machinery, these authorities would permit those machines to be disconnected. For those seeking to adhere to more traditional interpretations of Jewish law, there have been some interpretations used by rabbinical medical experts, that have been applied to withdraw treatment in cases where a patient is entirely dependent on machines for breathing and blood circulation and has little hope for recovery. However, it must be considered on a case by case basis, informed by accurate information between the physician, rabbi and family.

Organ Donation

Jewish authorities from across the spectrum of religious observance, from Reform to ultra-Orthodox, support the lifesaving potential of organ donation, with some authorities going so far as to suggest that Jewish tradition mandates organ donation. Traditional requirements — such as burying the dead quickly, avoiding defilement or benefit from a dead body — that would seem to preclude organ donation are superseded by its lifesaving potential. The Halachic Organ Donor Society (an organization for Jews who want to strictly comply with Jewish law) offers an organ donor card that specifically states that any transplant procedures be conducted in consultation with the deceased’s rabbi. The Conservative movement has a similar card.

Euthanasia/Assisted Suicide

Most Jewish authorities adamantly reject euthanasia or assisted suicide of any kind. Taking active steps to hasten one’s death is considered tantamount to suicide, while assisting another to do so may be considered murder. A number of Reform rabbis have challenged this view, questioning the validity of the commonly drawn distinction between active measures to hasten death and merely withholding treatment or removing impediments to death. Peter Knobel, a prominent Reform rabbi and past president of the movement’s rabbinical association, has argued that in certain cases, active euthanasia may even be a praiseworthy act, however this remains a decidedly minority view. Over the years, the Reform rabbinate has repeatedly reiterated its opposition to euthanasia and assisted suicide.

Truth-Telling

While honesty is a well-established imperative in Jewish tradition, there is ample precedent for the idea that full disclosure of a terminal diagnosis ought to be withheld from a patient since it may sap their will to live. Various biblical sources are cited in support of this idea, including the prophet Elisha’s response to the query of Ben Haddad, in which the prophet told the king he would recover from his illness though he knew the opposite was true. The Shulchan Aruch rules that, while a person near death is instructed to confess their sins, they must also be reassured that many have confessed their sins and not died. (Yoreh Deah: 338) Bleich has gone so far as to suggest that a doctor not only refrain from conveying information that might cause a patient to despair and thereby hasten their death, but he must continue to “feign medical aid even though there is no medical purpose in his ministrations.”

End-of-life decisions can be challenging, particularly for those who wish to ensure that the decisions comply with traditional Jewish law. And, while there are areas of consensus, there are also differences in how Jewish leaders interpret relevant Jewish teachings and texts. While the article provides an overview, we encourage families concerned with abiding by Jewish practices and beliefs when facing these difficult decisions to consult with trusted spiritual leaders for advice.

Resources

Looking for a way to say Mourner’s Kaddish in a minyan? My Jewish Learning’s daily online minyan gives mourners and others an opportunity to say Kaddish in community and learn from leading rabbis.

The post Jewish Perspectives on End-of-Life Care appeared first on My Jewish Learning.

Must-Know Words and Phrases Related to End-of-Life Care

Jennifer Modlinger — Wed, 06 Dec 2017 14:13:10 +0000

Navigating any stressful and significant situation requires effective communication and clear understanding. All the more so when that scenario involves life-and-death decisions and the stress, guilt, grief and unfamiliar surroundings that often entails.

To help you better understand the various issues that may arise, both in a general and Jewish context, the list below explains terms you are likely to encounter. Click here to skip directly to the Jewish terms. You also may want to review our Must-Know Jewish Death and Mourning Terms.

General Terms

Advance Directive: A document that is legally binding (if signed by witnesses or notarized), in which one makes one’s healthcare goals, values and preferences known. There are different types of written advance directives used in healthcare: the “living will,” “ health care proxy” or “MOLST/POLST.” Each fulfills a different role, and hence a different need.

Living Will: This type of advance directive document includes specific instructions regarding one’s goals, values and preferences as they relate to various treatment options and circumstances. This was the very first kind of advance directive, developed in the 1960s, and it is what many people think of when they hear the phrase “advance directive.” There are various versions of “living wills,” including Jewish living wills issued by different denominations.
Healthcare Proxy: This is a document in which an individual assigns another person or persons the authority to serve as his or her surrogate — that is, to speak on one’s behalf when one lacks the capacity to do so — and hence to represent the patient when medical decisions need to be made and values-based input from and about the patient is crucial.
Combined “living will” and “healthcare proxy” documents: Often referred to as “advance healthcare directives,” these documents combine the two above types into a single document. Most documents used nowadays in the United States are of this type, including those encouraged by various state laws. The current Orthodox forms are this type of document; their primary goal is simply to appoint a proxy, but they also include some mention of the patient’s values.
MOLST/POLST (Medical/Physician’s Order for Life-Sustaining Treatment: A physician-initiated medical order form that begins with a conversation between the patient and doctor, based on the patient’s current condition. It assures the patient’s wishes regarding life-sustaining treatment will be carried out and is generally used for patients who are seriously ill. The MOLST is a durable form that travels with the patient and is honored across different care settings.

Chaplaincy/Pastoral Care: Most hospitals and hospices in the United States have chaplains available to provide spiritual care. Chaplains are clergy members who are ordained in their own faith tradition but have also undergone rigorous training to become interfaith practitioners. They function as an integral part of the interdisciplinary healthcare team. A professional chaplain can become board certified through various professional chaplaincy organizations including the Jewish chaplaincy organization, Neshama: Association of Jewish Chaplains.” Chaplaincy is based on the understanding that healing involves the whole person — body, mind and soul — and it attempts to support patients, their loved ones, and staff. This is done by spending time with patients and families and providing a compassionate, non-anxious, non-judgmental presence. Chaplains are trained to listen deeply and help patients and families sort through their spiritual and emotional distress and questions. At times, chaplains may provide a spiritual perspective, prayer or blessing if the patient or family so desires. At other times the chaplain participates in lifecycle events, holiday observances, healing rituals and celebrations. Chaplains who share a patient’s religion can often offer more specific rituals and interventions, but even chaplains of another faith tradition can often provide general support.

Code Status: Code status refers to the level of medical interventions a patient wants to have started if their heart or breathing stops. A code is called when a patient goes into cardiac or respiratory arrest. If a person chooses “DNR” (see below), that is also known as “no code.” There are also numerous other codes which vary based on the situation and healthcare setting often with a name, and sometimes a corresponding color code.

Curative Care: As opposed to hospice, which focuses on symptom and pain management, “curative care” is any medical intervention seeking to treat patients with the intent of curing them, not just reducing their pain or stress. An example of curative care would be chemotherapy, which is often used to cure cancer patients.

DNR: A DNR (Do Not Resuscitate), or sometimes referred to as “DNAR” (Do Not Attempt Resuscitation), is a medical order indicating that if the patient’s heart stops beating (cardiac arrest), the medical staff should not initiate CPR (cardiopulmonary resuscitation) through chest compressions or electronic defibrillation, but should instead allow death to occur naturally. Similarly, a DNR order usually indicates that if the patient stops breathing (respiratory arrest), the medical staff will not initiate artificial (mechanical) respiration by inserting a tube into the lungs (intubation) and then connecting that tube to a mechanical ventilator. Natural death is then allowed to occur.

Healthcare Agent (also sometimes referred to as “surrogate decision maker”): A healthcare agent is someone close to the patient who the patient trusts to communicate his or her healthcare wishes and make sure that the patient always has a say in their treatment plan. Different states have varying rules regarding who is the automatic decision maker on behalf of a patient if nobody has been selected ahead of time. If you are unable to (or choose not to) participate in decision making about your healthcare, your healthcare agent plays a very important role. Some of the things a healthcare agent may be asked to do include meeting with medical providers to talk about your health, medications and interventions, and then deciding when/where you will get care. A healthcare agent will also be the one to ensure that your wishes are followed (or speak on your behalf, if you have not expressed your wishes) about medical interventions, organ donation, autopsy and funeral arrangements etc. The healthcare agent should be identified in a patient’s Advance Directive.

Hospice Care: This service is specifically designed for patients who are expected to live six months or less. Hospice focuses on managing the pain and symptoms associated with dying, and patients being cared for by hospice must generally forgo all major curative treatments. However, hospice patients can in most cases still receive routine medical care, such as nutrition and hydration, as well as antibiotics and other medical interventions, if they choose to. Hospice commonly takes place in a patient’s home, but a hospice patient can also be in a setting such as a nursing home, residential hospice facility or inpatient hospice unit in a hospital.

Life Support: This refers to various forms of medical technology/interventions utilized when one’s vital organs, such as brain, lungs, heart or kidneys are not functioning properly. The goal of life support is to serve as a bridge to help a critically ill patient survive an acute experience until they can recover. Unfortunately, not everyone on life support improves and can survive the withdrawal of life support. This often leads to an ethical dilemma regarding what should be done. When the family of the patient decides to withdraw life support, that act is sometimes referred to as “pulling the plug.”

Palliative Care: This is interdisciplinary care that focuses on decreasing pain (both physical and emotional) and improving quality of life in order to provide additional support to patients. In contrast to hospice care, palliative care can be initiated at any point during the course of illness, including at the time of diagnosis, and for patients of any age who are living with any serious illness. In addition, palliative care may be provided along with all life-prolonging and disease-directed interventions. Thus, palliative care should not be viewed as pertaining only to end-of-life care, nor should it be assumed that palliative care implies that there is no hope for recovery or improvement in a patient’s condition. Palliative care is most frequently utilized in hospitals, but it can also be part of care in other settings, such as clinics, cancer centers, nursing homes and, increasingly, as part of home care.

Terminal/life-limiting illness: There is no standard clinical definition of “terminal,” although in contemporary medicine the word is often loosely used to refer to the prognosis of any patient with an incurable fatal disease. In hospice care, it is often defined as an illness expected to leave the afflicted with six months or less to live. Many clinicians suggest that “terminal illness” should be applied only to the condition of those patients who experienced clinicians expect will die from a lethal, progressive disease despite appropriate treatment and in a relatively short period of time, measured in days, weeks, or at most several months.

Jewish Terms

Bikkur Cholim (“bee-KOHR khoh-LEEM”): This refers to visiting the sick. In addition to being a nice thing to do, it is a mitzvah [meritorious religious act], assuming the patient is indeed up for visitors. Bikkur Cholim can be fulfilled in a variety of ways — in person, by phone, via Skype/Facetime or by sending a gift or a card. The goal should be providing support, assistance and companionship in the way that is most meaningful and beneficial to the patient. Many synagogues and Jewish communities have “bikkur cholim societies,” whose members visit the sick on behalf of the community.

Birkat Hagomel (“beer-KAHT ha-goh-MELL”: The “thanksgiving blessing,” traditionally recited by a person who has survived a life-threatening situation. It is often said in synagogue during the Torah service within a few days of one’s recovery. Find the text of the Birkat Hagomel here.

Chevra Kadisha “KHEV-ra ka-DEESH-uh”): This literally means “holy society.” It refers to the Jewish sacred burial society responsible for all matters related to ritual preparation of a body for burial.

Gosses (“GO-ses”): A dying person in their final moments or days of life, as their body begins to shut down. Jewish tradition mandates the utmost respect of a dying individual, particularly once they have been given the status of “gosses.”

Mi Sheberakh (“MEE-sheh-BAY-rakh”): Literally translated as “may the God who blessed…” referring to the first words of the prayer, a Mi Sheberakh is the traditional Jewish prayer for healing. Although commonly recited in a synagogue, it can be said anywhere, and typically includes a space to insert the name(s) of the person being prayed for. There is a classic Mi Sheberakh text, as well as many contemporary ones, in addition to numerous beautiful tunes that have been composed to its words. Find the words and listen to different versions here.

Neshama (“neh-shah-MAH” or neh-SHAH-mah): One of the Hebrew words for “soul.” Other words include “nefesh” and “ruach.” Judaism traditionally teaches that humans are made up of both body and soul, and that the immortal soul is our true self. The word neshama, in particular, refers to a human being’s animating life force, innermost essence and intellectual capacity, believed to have come directly from God having breathed life into our bodies. The Torah says in the account of creation:“God formed human out of the dust of the ground, and breathed into his nostrils a soul-breath of life (Nishmat Chaim). Human [thus] became a living creature (Nefesh Chaya).” (Genesis 2:7)

Nigun (“NEE-goon or nee-GOON”): A traditional Jewish melody, usually with no words, just the hum of various sounds. It is traditionally believed that because a nigun doesn’t have words, it isn’t constrained by the limitations of language and can thus be the holiest type of singing.

Olam Haba (“oh-LAHM hah-BAH”): These words mean “world to come” and refer to the afterlife, or heaven. While individual Jews and different denominations take varying positions on the existence of an afterlife, traditional Jewish belief affirms the notion of a spiritual world to come. What exactly that existence will be like, who gets to go there and who doesn’t, and various other questions are hotly debated. Judaism encourages us to maintain focus on this world and this life, which may be why the Torah doesn’t directly reference an afterlife. Nevertheless, the fact that historically Judaism does believe in an afterlife provides comfort for many people.

Shemirah (“sheh-MEE-rah or SHMEE-ruh”): Shemirah means to “guard” or “watch.” It refers to the traditional Jewish practice of ensuring that the deceased is not left alone prior to burial, by arranging for a shomer (guard) to watch over the body and recite psalms and prayers.

Siddur (“see-DOHR or SIDD-ur”): A Jewish prayer book. There are many types and formats and they contain various sorts of prayers. The word “siddur” comes from the root “seder,” meaning order, thus referring to the fact that it is a book containing the entire order of the prayers, including prayers for various occasions.

Tahara (“tah-HAR-ah”): This is the ritual washing of the body which is done by members of the chevra kadisha to prepare the body for burial. The word “tahara” literally means “purification” and includes cleansing, ritually washing and dressing the deceased’s body in burial shrouds (tachrichim). As tahara is being performed, it is customary to recite special prayers, asking God to bring the person’s soul to eternal rest in heaven.

Tehillim (“teh-HILL-im”): This literally means “praises” and refers to the biblical Book of Psalms. It is an ancient Jewish custom to recite various psalms during times of need or fear. Some believe that reciting psalms is so holy that even if one doesn’t understand what they are saying, simply reciting the words has power. Others have found comfort in relating their sorrow to the anxiety expressed by King David, who is traditionally credited with having written many of the psalms during challenging moments of his life.

Tzavah (“TZAH-vah”): Also known as an “ethical will,” this is an ancient Jewish practice in which a dying person documents the wisdom and lessons they have learned in their life, as well as their hopes and dreams for their family. An ethical will is often seen as both an opportunity to summarize one’s values and as a gift to one’s family to enable them to continue to learn from their loved one and be aware of what that person would want from them, even after he or she has left this world.

Viddui (vee-DOO-ee (oo as in boot)”): This literally means “confession,” and it generally refers to the prayer traditionally said at the end of life, in order for the dying person to leave this world in a state of purity, and to proclaim faith in God and God’s justice. Viddui is viewed as a way to repent, make amends and get one’s affairs in order before dying. The traditional Viddui text includes the hope that the patient will recover, such that Viddui may be recited again at a later point when necessary, and even many times throughout one’s life. Saying the Viddui can be seen as an opportunity to relieve some of the emotional burdens of unresolved conflicts or unrealized hopes so that one can experience a lightness of spirit and removal of regret. Viddui can be said as a beautiful and intimate prayer of affirming one’s beliefs, hopes, and values as one reaches a potential crossroads and focusing on making peace above and below. Find a Viddui text here.

The post Must-Know Words and Phrases Related to End-of-Life Care appeared first on My Jewish Learning.

Judaism, Hospice and Palliative Care: Questions and Answers

Jennifer Modlinger — Mon, 04 Dec 2017 16:10:25 +0000

Hospice is an approach to caring for individuals who are suffering from terminal illnesses and are expected to live for six months or less. Patients are typically referred to hospice care when further medical treatment is not expected to reverse the course of their disease. Patients who choose hospice care opt to forego aggressive medical care aimed at curing them in favor of therapies geared toward reducing pain and sustaining the highest quality of life for as long as possible. The decision to choose hospice care is a personal one, as is the amount in which Jewish tradition informs one’s choices for end of life care. The following is a general overview of contemporary Jewish perspectives on the topic.

Does Judaism require life-prolonging interventions in all cases?

No. While some Jewish authorities are very stringent in these matters, there is ample support in Jewish tradition for ceasing interventions that offer no hope of cure and serve merely to delay death. The Talmud (Avodah Zarah 18a) offers support for this idea in the story of the second-century sage Rabbi Hanina ben Teradion, whom the Romans wrapped in a Torah scroll and set afire as punishment for teaching Torah. A damp piece of wool was placed on his chest to prolong the agony of his execution. When the executioner asked the rabbi if removing the wool and allowing the rabbi to die faster would grant the executioner a life in the world to come, the rabbi said yes. At that point, the executioner removed the wool and leaped into the flames. After both of them perished, a divine voice called out that both the rabbi and the executioner had been granted life in the world to come.

A similar idea is conveyed in the ruling of Rabbi Moshe Isserles, known as the Rema, who in his commentary on the Shulchan Aruch writes that while it is strictly forbidden to take any active steps to hasten death, it is permissible to remove obstacles to the soul’s departure. The example given is of a sound — for example, the noise from a woodchopper — that can be stopped if it is preventing a dying person from departing.

Does Judaism allow a person to turn down medical intervention?

Jewish tradition generally requires that every effort be made to sustain and extend life, but that position is not absolute. In cases where diseases cannot be cured and medical interventions would be risky, painful, of uncertain efficacy or serve merely to prolong a life of unbearable physical or psychic pain, there is support in Jewish law for an individual’s right to reject such treatment.

Within the Conservative and Reform movements, the autonomy of individuals to make decisions concerning their health care, including the right to refuse such care, is given broad standing. Two 1990 Conservative papers allow a patient to refuse treatment if the patient believes they cannot bear it and its efficacy is in doubt. In 2008, the Reform movement’s rabbinic authorities stated that a lung cancer patient was not obligated to undergo treatment that offered only three months of life extension while causing significant pain and suffering. “One is obligated to accept treatment that offers a reasonable prospect of therapeutic effectiveness, the attainment of an accepted medical purpose,” the statement read. “The purchase of an additional three months of life in a pain-filled and dying condition does not, in our judgment, meet that standard.”

The 20th-century American Orthodox authority Rabbi Moshe Feinstein ruled that “those individuals whom the physicians recognize cannot be cured . . . but could receive medications to extend their lives, in which they would suffer, should not be given such medications.” The late Israeli authority Rabbi Shlomo Zalman Auerbach issued a similar ruling, stating that “it is reasonable that if the patient experiences great pain and suffering, or even extremely severe psychological pain … it is permissible to withhold medications that cause suffering to the patient if the patient so demands.” (Most Orthodox authorities do not consider nutrition, hydration and oxygen, even if artificially provided, to be medical treatments and generally do not permit them to be discontinued.)

Does hospice mean I’m giving up?

For many, the term “hospice” connotes resignation in the face of death and seems to run counter to the Jewish imperative to seek life and preserve it. However, various studies suggest that hospice patients often live longer and do better than those who opt for more aggressive treatment. A 2011 study of lung cancer patients found that hospice patients fared better on average than those who received more aggressive care. A 2007 study found that hospice patients diagnosed with congestive heart failure, lung cancer, pancreatic cancer and marginally significant colon cancer lived “significantly longer” than counterparts undergoing aggressive medical treatment. A 2010 study published in the New England Journal of Medicine found that for patients suffering from non-small-cell lung cancer, early palliative care after diagnosis appeared to prolong their life expectancy even as they received less aggressive end-of-life treatment.

“Any good hospice program is geared to stretch or lengthen or try to manage one’s time based on the limitations,” says Rabbi Charles Rudansky, the director of pastoral care at MJHS Hospice and Palliative Care. “There’s no hospice that’s accredited that is hastening anyone’s demise.”

How do I ensure that hospice decisions are made in accordance with my wishes – Jewish or otherwise?

Hospice professionals advise patients to take a range of preparatory steps well before major decisions need to be made, including speaking with family, identifying priorities for end-of-life care and naming a health care proxy and possibly a rabbinic adviser to assist in ensuring decisions are made in conformity with religious requirements. Choosing a specifically Jewish hospice program may also make it easier to ensure that Jewish traditions and customs are respected.

A number of Jewish organizations also offer advance directive forms (sometimes known as a living will or health care proxy) that allow patients to declare particular rabbinic advisers who should be consulted in making critical end-of-life care decisions.

Rabbinical Council of America (Modern Orthodox)

Agudath Israel of America (Haredi Orthodox)

Rabbinical Assembly (Conservative movement)

Living Wills for specific states

Is hospice discussed in Jewish texts?

Not explicitly. The modern concept of hospice care has been around only since the 1970s. However, in addition to the passages noted above, several other sources are commonly cited in support of a compassionate approach to palliating pain and allowing for a peaceful death.

Among the most frequently cited is a story recorded in the Talmud (Ketubot 104a) about Rabbi Yehuda Hanassi (Judah the Prince), the chief compiler of the Mishnah, who was dying of an apparent stomach ailment. The rabbis were praying for his recovery, but Rabbi Yehuda’s maidservant, noticing her boss’ distress, prayed for his death. Seeing that the prayers of the rabbis were acting as a sort of spiritual life-support keeping Rabbi Yehuda alive the maidservant ascended the roof of the house and threw down a jug — momentarily silencing the prayers and allowing the ailing rabbi to die. Commenting on this passage, the 14th-century Catalonian Talmud scholar Rabbenu Nissim observed: “There are times when one should pray for the sick to die, such as when the sick one is suffering greatly from his malady and his condition is terminal.”

Another story, recorded in the Yalkut Shimoni, a compilation of Midrashic commentaries on the Bible, concerns a woman who came before the second-century sage Rabbi Jose ben Halafta and complained that she was old and sick, could no longer taste food and drink, and wished to die. The rabbi asked her which commandment she is grateful to perform each day, and she responded that it is the commandment of going to synagogue. The rabbi instructed her not to go for three days, the woman complied, and on the third day she died.

Is hospice compatible with Judaism?

Jewish tradition regards every moment of human life as infinitely valuable.

Rabbis from the more liberal denominations view hospice as a legitimate Jewish option for those suffering from terminal disease. The Reform movement has long endorsed hospice as a practice consistent with Jewish values. And both of the Conservative movement’s major papers on end-of-life care, adopted in 1990, endorse hospice as a life-affirming and, perhaps, even Jewishly preferable option.

“One may not choose hospice so as to die more quickly, but, rather, only in order to live one’s remaining days in the best way possible,” Rabbi Avram Reisner wrote in one of the Conservative documents. “As such, instructions to the hospice should clearly state that while only palliation is in order for the immediate incurable condition, other unrelated and curable conditions that may arise, such as infections, should be treated in line with standard medical care. Jewish hospice must be an attempt to live one’s best with dignity, not an attempt to speed an escape into death.”

Some authorities hold that hospice is antithetical to Jewish tradition since it entails rejecting aggressive medical interventions to cure terminal disease in favor of a focus on pain reduction and enhanced quality of life. These authorities often cite sources in Jewish law indicating that efforts to extend human life should be made even in cases where life can be extended only by a few moments. The Shulchan Aruch rules that the Torah mandates healing and that a physician who withholds such treatment is guilty of causing harm.

Many contemporary authorities, however, argue that Jewish tradition allows a focus on comfort and pain reduction and the eschewing of aggressive medical interventions in certain circumstances. Rabbi Moshe Feinstein ruled that a patient may be referred to hospice if he or she requests it and is experiencing such intense physical or psychological pain that his or her quality of life is severely diminished.

Does hospice raise any other Jewish concerns?

Yes. Jewish law generally mandates that a patient never be deprived of the most elemental forms of human sustenance — food, water and oxygen — even if they are artificially provided. (This position is not universal — some authorities consider feeding tubes and the like to be forms of medical intervention that can be withdrawn or rejected under certain conditions.) For hospice patients concerned about complying with Jewish law, it may be necessary to ensure that hospice care continues to provide intravenous fluids and hydration as religiously required.

Jewish tradition also raises concerns about fully disclosing to a patient the fact that a condition is terminal, lest the patient be deprived of a will to live. Some contemporary religious authorities are emphatic that a patient should never be told explicitly that their condition is hopeless — a position that clashes with contemporary medical ethics, which considers patient autonomy a cardinal principle. Medical professionals familiar with the requirements of Jewish law in this respect are often able to transition a patient to hospice without fully disclosing the particulars of their diagnosis.

Other Resources

“Jewish Ritual, Reality and Response at the End of Life: A Guide to Caring for Jewish Patients and Their Families” by Rabbi Mark A. Popovsky

“End of Life: Jewish Perspectives” By Rabbi Elliot Dorff

“Advanced Illness and Orthodox Jewish Law: Approaches to Communication and Medical Decision Making”

Looking for a way to say Mourner’s Kaddish in a minyan? My Jewish Learning’s daily online minyan gives mourners and others an opportunity to say Kaddish in community and learn from leading rabbis.

The post Judaism, Hospice and Palliative Care: Questions and Answers appeared first on My Jewish Learning.

Words of Comfort for Mourners

Julie Wiener — Thu, 04 Jan 2018 22:52:58 +0000

When mourning a loved one, it is hard not to feel alone in the world and like no one will ever be able to fill the void that has been left.

Ironically, as lonely as grief can be, it is one of life’s most universal experiences. And from ancient times to the present, people have been writing about it. While nothing can take your pain away, many mourners get some comfort from reading poems and other texts that address loss, mortality and grief.

We encourage you to explore the Book of Psalms, which, as this article notes, Jews and others have for centuries turned to “for solace, guidance, catharsis, renewal, and much more.” Another popular biblical text at times of loss is The Book of Job, which addresses head on and often very poetically, the question of why God allows bad things to happen to good people. In addition, many people find the words of the Mourner’s Kaddish comforting.

A number of contemporary books, such as For Those Left Behind: A Jewish Anthology of Comfort and Healing and Grief in Our Seasons: A Mourner’s Kaddish Companion offer an array of inspiring poems, quotes and other readings.

Below are some of our favorite Jewish quotes, poems and texts for comforting mourners. Did we miss a special quote or a book that helped you get through a hard time? Leave it in the comments below or email us at community@myjewishlearning.com.

Don’t Be Afraid of Pain

We can endure much more than we think we can; all human experience testifies to that. All we need to do is learn not to be afraid of pain. Grit your teeth and let it hurt. Don’t deny it, don’t be overwhelmed by it. It will not last forever. One day, the pain will be gone and you will still be there. — Rabbi Harold S. Kushner, a contemporary American rabbi (from When All You’ve Ever Wanted Isn’t Enough: The Search For a Life That Matters)

There Is No Magic Answer

There is no magic answer to loss. Nothing, not even time, will make the pain completely disappear. But loss is transformative if it is met with faith. Faith is our chance to make sense of loss, to cope with the stone that rolls around in the hollow of our stomachs when something we loved, something we thought was forever, is suddenly gone. — Rabbi David Wolpe, a contemporary American rabbi (from Making Loss Matter: Creating Meaning in Difficult Times)

Rebuilding After Loss

“I will build an altar from the broken fragments of my heart.” — Rabbi Yehuda HaChasid, a Polish rabbi who, with a group of followers, moved to Jerusalem in 1700.

“Each Of Us Has a Name”

This Hebrew poem, by the Israeli poet known as Zelda (her full name was Zelda Schneurson Mishkovsky and she lived from 1914-1984) is translated here by Marcia Falk and is often read at funerals and memorial services, as well as at Jewish naming ceremonies.

What We Leave Behind

You can read the Hannah Senesh poem “There are Stars” (Yesh Kochavim, in the original Hebrew) in full here. The Hungarian-born Senesh was killed by the Nazis at age 23. She had moved to pre-state Israel but then returned to Hungary in 1944, in a doomed (and fatal) effort to help the anti-Nazi resistance fighters there. Here are the first few lines:

There are stars whose radiance is visible on earth
though they have long been extinct.
There are people whose brilliance continues to light
the world even though they are not longer among the living….

“If I Had Not Fallen”

This short passage comes from Orchot Tzadikim (The Ways of the Righteous), an anonymous book of Jewish ethical teachings written in 15th-century Germany:

If I had not fallen, I would not have picked myself up,
If I did not sit in darkness, I would not have seen the light.

(Orchot Tzadikim, Shaar Hateshuvah, Shaar 26)

“God Takes Nothing”

This proverb comes from Midrash HaGadol, a collection of Midrash texts that was compiled in the 14th century:

God takes nothing from the world until He puts something else in its place.

“Strange Is Our Situation Here on Earth”

This passage by physicist Albert Einstein comes from “My Credo,” an article he wrote in 1932, which is cited here.

Strange is our situation here on Earth. Each of us comes for a short visit, not knowing why, yet sometimes seeming to divine a purpose. From the standpoint of daily life, however, there is one thing we do know: that man is here for the sake of other men — above all for those upon whose smiles and well-being our own happiness depends.

Three Levels of Mourning

This is a Hasidic teaching that Rabbi Abraham Joshua Heschel often quoted, according to Heschel, Hasidism and Halakha:

There are three ascending levels of mourning: with tears — that is the lowest. With silence — that is higher. And with a song — that is the highest.

The post Words of Comfort for Mourners appeared first on My Jewish Learning.

How to Have Someone Buried in Israel

Julie Wiener — Wed, 30 Aug 2017 18:39:42 +0000

For Jews, burial in Israel is considered a highly virtuous practice, so much so that it is customary to sprinkle a little earth from Israel in the coffin of Jews who are buried elsewhere.

This tradition of burial in Israel is grounded in a number of Jewish sources, the best-known of which may be the teaching that during the time of the messiah, all Jews will be resurrected from the dead, and according to statements in the Midrash, those buried in Israel will be resurrected first. Those buried elsewhere will be brought to the holy land through underground tunnels, according to statements in the Talmud and elsewhere.
The practice has its roots in the Bible, which records the patriarch Jacob’s insistence (in Parashat Vayechi) that his son Joseph swear not to bury him in Egypt, but instead to bury him with his forbearers in Hebron. Though exhuming the body of a Jew who has been buried is normally barred by Jewish law, an exception is made for reinterment in Israel.
For some Jews, being buried in Israel is considered a symbolic statement of eternal attachment to the Jewish homeland. According to the Israeli Foreign Ministry, 1,590 people who died abroad were buried in Israel in 2016, a figure that includes Israeli citizens who died while they were out of the country. Some 4,900 Americans were buried in Israel between 2006-2016, and even more (5,100) from France.

How To Arrange for Burial in Israel

Burial in Israel requires both the purchase of a burial plot as well as the logistical arrangements necessary to prepare, transport and inter the body.

Plots can often be purchased directly from a cemetery, but it’s often easier to use an intermediary. A number of American synagogues and Jewish organizations own blocks of cemetery plots that they resell to their members, and at least one organization, Achuzat Kever, assists Jews from abroad who seek to purchase burial plots in Israel.

Once a plot is secured, arrangements for the body must be made. Some Jewish funeral homes in the United States offer the following services to those wishing to be buried in Israel:

Ritual preparation of the body for burial, known as tahara (usually done before the body is transported to Israel).
Arranging the necessary legal paperwork, including death certificates and authorization from the local Israeli consulate.
Transport of the remains to an air cargo facility.

Arrangements must also be made to have the body received at the airport in Israel and transported to the cemetery for interment. Typically, this is done by the burial society associated with the cemetery where the plot was purchased.

Where in Israel are Burial Plots Available?

Jerusalem has always been the most sought-after location for burial in Israel, but space in the city is increasingly hard to come by and prices are substantial. The city has two major cemeteries — one in eastern Jerusalem, on the Mount of Olives overlooking the Old City, and the other, Har Hamenuchot, at the western entrance to the city. Lack of space at Har Hamenuchot has prompted the building of a massive underground catacombs to meet demand.

Beit Shemesh, a city roughly 20 miles to the west of the Israeli capital, has emerged as a popular alternative. Various Jewish organizations from around the world have reserved sections of the city’s privately owned Eretz Hachaim cemetery, which will also sell plots directly to consumers from its Brooklyn office. Burial plots are available in other Israeli cities as well;, however increasing space pressure has made it difficult to secure a plot in certain locations.

How Much Does Burial in Israel Cost?

The price of a burial plot varies considerably. Plots in the millennia-old Jewish cemetery on the Mount of Olives with its direct views of the Temple Mount are the most coveted of all and can run in the tens of thousands of dollars. One New York-based group offers plots on the Mount of Olives for $19,000 each, but some people in the Jewish funeral industry say they have heard of particularly choice locations in the cemetery selling for more than twice that amount. Plots in Beit Shemesh’s Eretz Hachaim cost around $8,000. Additionally, the funeral and transportation arrangements in Israel often run around $2,000, and one must also factor in the costs of preparation and airport transfer of the body in the United States. In the New York area, preparing a body and transporting it to Israel typically costs between $3,000-$5,000. From locations in the United States without direct flights to Israel, it can cost as much as $10,000.

Can Non-Orthodox Jews Be Buried in Israel?

Traditional Jewish law generally prohibits burying Jews and non-Jews together. Therefore, those wishing to be buried in a Jewish cemetery in Israel will typically have to demonstrate they are Jewish according to Jewish law — generally by having some Orthodox rabbinic body vouch for the deceased’s Jewish status. In the case of a non-Orthodox Jew, or someone who is not Jewish according to Orthodox Jewish law, this can occasionally present an obstacle to Jewish burial in Israel, though in practice this situation is said to arise only rarely. Civil cemeteries, a recent development in Israel, offer alternatives to individuals who for whatever reason are unable to secure burial in a religious cemetery. ITIM, a religious pluralism organization in Israel, offers assistance in navigating the religious bureaucracy surrounding burial.

Can Non-Jews Be Buried in Israel?

Israel has numerous Christian and Muslim cemeteries, which serve the local Muslim and Christian populations, but it is rare for people from overseas to request burial in them and we were unable to identify any organizations or businesses that assist in this process.

The post How to Have Someone Buried in Israel appeared first on My Jewish Learning.

Jewish Prayer for the Sick: Mi Sheberach

MJL Admin — Thu, 09 Jun 2005 17:21:42 +0000

One of the central Jewish prayers for those who are ill or recovering from illness or accidents is the Mi Sheberach. The name is taken from its first two Hebrew words. With a holistic view of humankind, it prays for physical cure as well as spiritual healing, asking for blessing, compassion, restoration, and strength, within the community of others facing illness as well as all Jews, all human beings.

Traditionally, the Mi Sheberach is said in synagogue when the Torah is read. If the patient herself/himself cannot be at services, a close relative or friend might be called up to the Torah for an honor, and the one leading services will offer this prayer, filling in the name of the one who is ill and her/his parents. Many congregations sing the version of the Mi Sheberach written by Debbie Friedman, a popular Jewish folk musician who focused on liturgical music. (That version can heard in the video, and its lyrics read, at the top of this article.)

Increasingly, the Mi Sheberach has moved into other settings and other junctures. Chaplains, doctors, nurses, and social workers are now joining patients and those close to them in saying the Mi Sheberach at various junctures—before and after surgery, during treatments, upon admission or discharge, on the anniversary of diagnosis, and more. We present it to you here, in English translation and in transliteration from the Hebrew, as a resource for you as you confront the challenges of illness. The Hebrew text can be found here.

Sign up to join My Jewish Learning’s Misheberach Moment, a weekly communal recitation of Mi Sheberach.

Listen to Mi Sheberach (courtesy of Mechon Hadar)

Mi Sheberach in English Translation

May the One who blessed our ancestors —

Patriarchs Abraham, Isaac, and Jacob,

Matriarchs Sarah, Rebecca, Rachel, and Leah —

bless and heal the one who is ill:

________________ son/daughter of ________________ .

May the Holy Blessed One

overflow with compassion upon him/her,

to restore him/her,

to heal him/her,

to strengthen him/her,

to enliven him/her.

The One will send him/her, speedily,

a complete healing —

healing of the soul and healing of the body —

along with all the ill,

among the people of Israel and all humankind,

soon,

speedily,

without delay,

and let us all say: Amen!

Mi Sheberach in Hebrew Transliteration

The transliterated text below presents the prayer with correct pronouns for male and female patients. The word before the slash is for males, the one after for females.

Mi Sheberach

Avoteinu: Avraham, Yitzhak, v’Yaakov,

v’Imoteinu: Sarah, Rivka, Rachel v’Leah,

Hu yivarech virapei

et hacholeh/hacholah _____________ ben/bat ______________

HaKadosh Baruch Hu

yimalei rachamim alav/aleha,

l’hachalimo/l’hachlimah,

u-l’rap’oto/u-l’rap’otah,

l’hachaziko/l’hazikah,

u-l’chay-oto/u-l’chay-otah.

V’yishlach lo/lah bim-hera

r’fuah shlemah,

r’fu-at hanefesh u-r’fu-at hagoof,

b’toch sh’ar cholei Yisrael v’cholei yoshvei tevel,

hashta ba’agalah u-vizman kariv,

v’no-mar, Amen!

Reprinted with permission of the National Center for Jewish Healing, a program of the Jewish Board of Family and Children’s Services.

Sign up to join My Jewish Learning’s Misheberach Moment, a weekly communal recitation of Mi Sheberach.

The post Jewish Prayer for the Sick: Mi Sheberach appeared first on My Jewish Learning.

Talking About Death Over Dinner With Strangers

Jennifer Modlinger — Mon, 25 Jun 2018 20:50:51 +0000

Dinner with strangers can be awkward. It can be even more awkward if you’re there to talk about death. And even more so when the death is your own.

We were a group of Jewish educators gathered together for Death Over Dinner, a two-hour, facilitated conversation about something most of us aren’t talking about at all — death and dying.

The Jewish version of this gathering, made possible by Reboot and IKAR, includes remembering our dead, studying Jewish texts on death and dying, learning some practicalities of supporting loved ones through preparing for and living through death, and mindfully imagining the impossible: our own deaths.

Sounds like the most uncomfortable dinner party ever, right? Why would anyone sign up for that?

Because talking about death — and specifically one’s own death — can help us to avoid suffering now and later, and honor both our loved ones and ourselves. It is an important conversation that can’t happen as fully in the moments directly preceding or following death. And our own experiences with traumatic death in our respective families and communities illuminated how crucial it is to have these conversations.

The dinner began with a l’chaim – a toast. Each of us took turns raising our glasses in memory of a loved one who changed our lives. We told these stories over a lit yahrzeit (memorial) candle. We gave ourselves permission as a group, and as individuals, to mourn people who we felt we had not previously or adequately mourned — maybe because we thought others had more “official rights” to mourning, or because we felt anger that was best left unshared at the time of death, or because we hurt too much at the time to mourn the way we needed.

The gathering became a sort of sacred space and akin to a yahrzeit (an annual commemoration of a loved one’s death). We were a group of people who may never gather again sharing stories of tremendous intimacy.

Each of us had a chance to tell stories of our loved ones, of losses old and new. We acknowledged that we are all part of a larger story and that our loved ones — in fact, all people — are kept alive through stories that we tell. As Jews, we are accustomed to keeping memories alive through the telling of stories. Reading the weekly Torah portion and retelling the story of the Exodus from Egypt during the Passover seder are just two examples of how we use stories to maintain the collective memory of the Jewish people.

By this point, you must think we’re obsessed with death. Quite the contrary. As Jewish educators, we each had our own professional and personal experiences of being called to support others as they transitioned through the phases of life. We were aware of the abundance of available resources on death and of the need to cultivate and curate resources for people of all ages.

We asked ourselves: When do we talk about death? Do we wait for a moment when the conversation is specifically needed? Or do we tackle it as a community? How do we treat other kinds of loss, like pets? Over dinner, we worked together to develop a personal and Jewish vocabulary for these hard feelings so that we are prepared to be present in the moment when more urgent traumas emerge.

We came away with the realization that we can’t hold on to traditional definitions of mourning anymore. Modern psychology reinforces the wisdom of Jewish grief rituals, but it also shows us that pain is not limited to the people defined by Jewish law as mourners (typically immediate family members) or limited to the timeframes prescribed by Jewish law. The dinner gave us a framework to redefine what family means, to open up new and perhaps controversial ideas about who constitutes a mourner and how long we can mourn. What if our best friend dies? Can we sit shiva for them? What if a sibling or a newborn dies and we want to mourn them in a manner that goes beyond the traditional Jewish timeline? What if we want to say the Mourner’s Kaddish with a virtual minyan online instead of a real-life one?

Redefining mourning today within new formulations of community gave us permission to recognize our families as bigger and less bounded, our pain as real, and our voices as authentic. We were changed by this experience and think that you might be too. We highly recommend participating in a Death Over Dinner or Death Over Dinner Jewish Edition gathering.

You can also try it at home. Here are some questions to get you started.

When and how might I speak to my loved ones about death? What resources could assist me, and how might I access them?
How might I speak to my loved ones about my preparations for my own death? What resources could assist me?
How might I speak to my loved ones about preparations they might have already undertaken in preparing for their own death? What resources could assist me?

Why Jews Need to Talk About Death

How to Talk to Loved Ones About Your End-of-Life Wishes

The post Talking About Death Over Dinner With Strangers appeared first on My Jewish Learning.

What to Do When A Loved One is Dying

Dan Fendel — Thu, 29 Dec 2016 18:42:49 +0000

The hours, days, or weeks leading up to a death are usually stressful for everyone.

In addition to the medical issues that arise, we are often worried about what we should say and do. Are we acting properly? Can we do anything to help? What does Jewish tradition ask of us?

Regardless of how religious the dying individual is, there is often comfort in traditions that have been Jewish practice for centuries. Below are some Jewish traditions and resources to help guide you through this difficult time.

Recite (or Sing) the Mi Sheberakh and Other Prayers

Dying is often a stage on the continuum of illness, and it is appropriate to say prayers for healing, even when we know our loved one has a terminal illness and is not expecting to recover. The Mi Sheberakh prayer, the traditional Jewish healing prayer, focuses not just on healing of the body, but also healing of the spirit. You can say it alone or with your loved one. It can be recited or sung, and music can be especially soothing and comforting. For the text, along with several musical versions of the Mi Sheberakh, click here. Below is one of the most popular melodies.

You can also offer a more spontaneous and personal prayer (e.g., “God, I ask your compassion for _____ that he/she find peace in these difficult days”). Some people may find recitation of the Shema, one of Judaism’s most important (and short) prayers, comforting. If your loved one is atheist or agnostic, you can simply omit mention of God in reciting any of these prayers. E.g., replace “God, I ask your compassion…” with “We hope that ___ will find peace….”

Bring in Music, Including Niggunim

In addition to Mi Sheberakh, any comforting music can be helpful at this time, including live musicians with instruments as appropriate, humming niggunim (wordless Jewish liturgical melodies), or singing favorite songs to the dying.

Read or Chant Psalms

Psalms, the biblical poems believed to have been compiled (and in many cases written) by King David, are often read or chanted when a loved one is sick or dying.

Psalm 23, which begins “Adonai is my shepherd,” is perhaps the best known of all the psalms. Though often associated with funerals, it can also be comforting to the ill. Psalm 30, Psalm 121, and Psalm 150 are also appropriate choices. Another option is Psalm 119, which is an acrostic, and choose those verses whose opening letters spell out the individual’s Hebrew name.

Listen to Psalm 23 (courtesy of Mechon Hadar)

Recite the Viddui

Encourage and assist your loved one to recite the viddui (”confession”) prayer, or read one aloud on his or her behalf. While we do a form of viddui on Yom Kippur, there is a specific “deathbed” version. This version includes not only repentance themes, but faith and trust elements as well. For the traditional text in Hebrew, click here. For the text in English, as well as many non-traditional versions of viddui to download and print out, click here.

Help Write an Ethical Will

Encourage and assist your loved one to create an ethical will, a summary of the values and lessons beyond the material possessions that you wish to transmit to those who survive you.

Discuss Funeral Arrangements if Appropriate

If funeral arrangements have not been set (and especially if this may be your responsibility), delicately raise the subject. If the individual has not yet acknowledged that he/she is dying, you will need to be particularly circumspect. You might begin with an open-ended question like, “What do you understand about your medical prognosis?”

Once the prospect of dying has been acknowledged, you can ask an open-ended question like: “Have you thought about final arrangements?” The ensuing discussion can include whether the individual has a cemetery plot or has made other arrangements for disposition of his/her body and how traditional they want their funeral to be. It can also include questions about Jewish rituals such as tahara, the traditional practice of preparing a body for burial, and whether to bury or cremate. (Jewish law forbids cremation, but the practice has become increasingly common in recent years.)

While your loved one may not ordinarily observe Jewish traditions, he or she may derive comfort from observing rituals and traditions that his or her ancestors, and the larger Jewish community, have observed for centuries.

Other specific questions you may want to ask:

“Who would you like to have lead your service?”
“Are there specific people you like to give a eulogy for you?”
“Is there music or readings that you would like to have at your funeral?”
“Are there organizations to which you would like to have people give tzedakah (charitable contributions) in your memory?”

Don’t Make Religious Assumptions

Be cautious about providing theological responses to the situation [e.g., “This is God’s will” or “Soon you will be with God in Olam Haba (“the world to come”)], unless you are sure that you know the belief system of the dying individual.

If in doubt about the individual’s theological beliefs, simply ask questions or encourage the dying individual to share his/her thoughts, concerns, fears and hopes.

Be prepared for the individual to have challenging emotions and beliefs, such as being angry with God, or wondering why he or she is suffering. In this regard, Rabbi Harold Kushner’s When Bad Things Happen to Good People may be a useful resource for you or for the dying individual.

Just Be There

Offer him or her your presence, whether in person or in other forms. Visit, call, write. Communicate in whatever way is most appropriate for you and the dying individual. Listen, listen, listen. Encourage the individual to share thoughts and feelings.

Speak the truth to the dying individual. Do not hide your own emotions. At the same time, be sensitive and compassionate.

When the Dying Individual Is an Acquaintance

If the dying individual is an acquaintance rather than a family member or very close friend, offer personal support not only to the ill individual, but also to those who are the primary family members and caretakers. This can be emotional support (mostly, being an empathic listener) as well as logistical support (e.g., providing food, rides, child care, and other daily assistance).

Help make available the resources of your and the dying individual’s larger community. Such resources might include chaplaincy support, rabbinic support, family member support, music and thanatology options, legal and ethical document arrangements, etc.

Provided by Kavod v’Nichum, a nonprofit educational organization that promotes and assists the formation of bereavement committees and chevrah kadisha (Jewish burial society) groups in synagogues and communities throughout North America.

The post What to Do When A Loved One is Dying appeared first on My Jewish Learning.

Does Judaism Allow Organ Donations?

MJL Admin — Thu, 10 Nov 2016 20:48:11 +0000

Organ donation, the process of transplanting healthy human organs into sick patients, can be a life-saving procedure, which is why many Jewish authorities from across the denominational spectrum believe it to be a religious duty. Jewish tradition considers saving human life — pikuach nefesh in Hebrew — to be among the highest ethical obligations. Saving one life, the Talmud says in Mishnah Sanhedrin 4:5, is equivalent to saving an entire world.

Concerns about organ donation after death have traditionally rested on laws concerning the handling of dead bodies and the mistaken view that bodies must be buried intact if they are to be resurrected after the Messiah comes — the traditional belief known as techiyat hameitim. While taking organs from the dead is undoubtedly fraught with delicate ethical questions, the life-saving potential of organ donation is so great that nearly all restrictions of Jewish law can be suspended.

Below are some frequently asked questions about Judaism and organ donation:

Isn’t Judaism against organ donation?

That’s a common perception, and one of the reasons frequently cited for Israel’s low rate of organ donation. But on the whole, there is widespread support for organ donation across the spectrum of Jewish observance, from Reform to haredi Orthodox. Some authorities, citing the injunction in Leviticus 19 not to stand idly by the blood of one’s neighbor, go further in suggesting that Jewish tradition mandates organ donation in certain circumstances. The Conservative movement endorsed that position in 1995, when it established that post-mortem organ donation is not merely permissible, but required. Some Orthodox figures also consider organ donation obligatory.

So it’s OK to donate the organs of the dead?

Yes. Several traditional requirements — to bury the dead quickly, and avoid any defilement of or benefit from a dead body (the reason autopsies are generally not done) — would seem to preclude taking organs from cadavers. However, the lifesaving potential of organ donation is regarded as overriding those strictures. The key issue is the definition of death.

Yes, how does Judaism define death, particularly in this modern age of life-support systems?

Though by no means unanimous

, many rabbis hold that death in Jewish law occurs with the irreversible cessation of brain stem function. In brain death, a patient is unable to breathe independently without a mechanical ventilator, but his or her heart may still be beating, which creates a window for the harvest of vital organs like the heart and lungs. Authorities from all three major denominations — Orthodox, Conservative and Reform — maintain that in such cases organs may be taken for the purpose of saving another life.

READ: What Judaism Believes Happens After We Die

The Conservative movement has endorsed an even more expansive position. In 2010, the movement’s religious authorities ruled that in situations where a person is unconscious, dependent on a ventilator and has no hope of recovery — even if he or she may show some limited brain activity — the person can, under certain conditions, be removed from life support and their organs taken for transplant after the heart stops beating.

A more restrictive opinion held by some Orthodox rabbis maintains that death occurs with the cessation of heartbeat, a criterion that makes vital organ donation much more medically difficult. Under this opinion, any harvesting of organs from a patient whose heart is beating would be absolutely prohibited.

What about organs from live donors?

With live donors, the difficult question of determining death is moot, but other legal issues arise. Judaism prohibits placing oneself in unnecessary danger, and organ donation is never entirely risk-free. Authorities from across the denominations agree that if a live transplant would place the donor in mortal danger, it should not be undertaken. With kidney donation, the most common organ transplant procedure, the dangers are sufficiently low and the life-saving potential so great that risk is not generally seen as an obstacle. Other live organ donations, like the liver, are considered riskier and may even be prohibited by some rabbis.

Can you donate your organs for medical research?

Most rabbis say no, though there are exceptions. With research, the line between the donation of a specific organ and the saving of life is sufficiently indirect that most authorities do not believe it qualifies as pikuach nefesh. One Reform rabbi has written that if the body parts are “given to a scientific institution to study, and then are buried after the work on them is done, there can be little objection from the liberal point of view.”

Is it possible to become an organ donor and still adhere to Jewish law?

Yes. The Halachic Organ Donor Society, an Orthodox nonprofit dedicated to increasing organ donation in the Jewish community, has developed a halachic organ donor card. Though similar to the organ donor box that some people check when getting their driver’s license, the HODS card specifically states that any transplant procedures be conducted in consultation with the deceased’s rabbi. It also permits donors to decide which definition of death they wish to be applied — either brain stem death or cessation of heartbeat. The Conservative movement has a similar card.

Can an organ donor still be buried in a Jewish cemetery?

Yes. Though there is historical precedent for those who committed certain infractions being denied a Jewish burial, or buried in a separate section of a Jewish cemetery — suicide being a common one — in the modern era, it is exceedingly rare to deny any Jew (including those who have commit suicide) a traditional burial. According to HODS, there is no known case where a person was denied burial in a Jewish cemetery because they donated their organs. However, some aspects of the traditional preparation rituals for burial, known as tahara, may not be possible for donors.

What about selling one’s organs for money?

The sale of human organs for transplant is highly controversial, prompting fears of exploitation of the poor (who would have greater incentive to sell their body parts and thus be at greater risk of exploitation) and the privileging of wealthier recipients (who are better able to pay to save their own lives), among other considerations. For these reasons and others, it is illegal in most of the world, which renders the question of its permissibility under Jewish law effectively moot. However, some Jewish authorities believe that, in principle, there is nothing in Jewish law that prevents compensating donors for their organs provided certain conditions are met. Robby Berman, the founder of the Halachic Organ Donor Society, has personally called for a reversal of U.S. laws banning compensation for organ donors since that would almost certainly expand the number available. HODS has no position on the matter.

READ: Op-Ed: Allow Incentives for Donating Organs

The post Does Judaism Allow Organ Donations? appeared first on My Jewish Learning.

How to Plan a Jewish Funeral

MJL Admin — Sun, 17 Jul 2005 19:10:00 +0000

The time preceding a funeral (called “aninut“) is often the most difficult for mourners. On the one hand, they are not yet in the period of formal mourning, which begins immediately after the funeral; on the other hand, they are already grieving. Friends and family members must be notified. Funeral details must be worked out, if they have not been prearranged, and eulogies prepared.

Funerals are usually arranged by families in consultation with a funeral home and/or chevra kadisha and a rabbi, as well as a cemetery. In some places, the chevra kadisha, funeral home and Jewish cemetery may be seamlessly integrated; even when this is not the case, the three organizations generally communicate well with one another but should be notified of which organizations are being used.

Learning these details (particularly, before they are necessary) can make this painful time less confusing. The traditional time frame for a Jewish burial is quite brief. In North America, burial usually occurs within about three days of the death. It is helpful for mourners know what to expect from centuries-old Jewish burial and mourning practices. Learn more about the Timeline of Jewish Mourning here and get answers to Frequently Asked Questions About Jewish Death and Mourning.

Contact a Chevra Kadisha and/or Funeral Home

When a Jewish person passes away, the first task is to inform either a funeral home or the chevra kadisha. A chevra kadisha is a Jewish burial society; it will quickly send representatives to gather the body. A hospital, care facility, synagogue, funeral home or rabbi should be able to help you contact a chevra kadisha if you wish to use one. Learn more Jewish death and mourning terms here.

A chevra kadisha and a funeral home are both mortuaries, groups that prepares the body for burial. A cemetery, by contrast, is the place where the body is buried. Sometimes the mortuary is part of the cemetery, in which case one needs only to contact the cemetery. However, sometimes people choose to use a chevra kadisha that is separate from the cemetery (either because it is more traditional, cheaper or for other reasons), in which case the chevra kadisha should be contacted first. In either case, the process moves more smoothly if arrangements have been made in advance, but either way it can all be handled in a timely manner.

A representative of the chevra kadisha may ask if there is someone available to stay with the body until they arrive. That is because in the Jewish tradition, a dead person should not be left alone until their burial. A shomer, or guard, will watch over the body, often while reciting psalms. Although a family member may be willing to serve this role, it is not necessary that the shomer (or shomeret, if a woman) know the deceased person (though it is often considered best if they are Jewish and can recite prayers or psalms). Once the chevra kadisha or mortuary picks the body up, they can provide someone to do this task.

Most often, the chevra kadisha or funeral home will arrange for transporting the body of the deceased. Depending on the local situation, the chevra kadisha will either conduct its work at its own facility or at a separate funeral home. Trained volunteer members of the chevra kadisha bathe and dress the body with extreme care and respect (this is called a Tahara). A traditional burial also includes dressing the body in a plain white shroud (known as Tachrichim) and placing it in an untreated simple wooden coffin. Other than the shroud, the only item traditionally buried along with the dead person is a tallit (prayer shawl) with one of its corner fringes cut. With some chevra kadishas the tallit is provided and cut automatically; with others it must be requested and paid extra for. Learn more about Tahara here.

Larger Jewish communities may have separate burial societies for each synagogue or Jewish denomination (Reform, Conservative, Orthodox). In such a situation, each chevra kadisha will have a slightly different approach to the laws and customs connected to body preparation and burial. For example, one chevra kadisha may allow the body to be dressed in clothing rather than a simple shroud. Choose the organization that best matches your family’s preferences.

There may not be a burial society in your hometown. In some areas, there may be a set protocol by which Jewish funerals are arranged, even if there is no official burial society or Jewish funeral home. Jewish burials in such areas may be arranged by local Jewish families, sometimes through a synagogue. In other places, it may be best to call the closest synagogue or Jewish federation — whether it is in the nearest major city or a neighboring state.

Find a Burial Plot or Make Other Arrangements for the Deceased

Jews are traditionally buried either in a specifically Jewish cemetery or in a part of a general community cemetery designated for Jewish use. Jews traditionally are not cremated. However, a number of Jewish families nonetheless opt for cremation, and many Jewish cemeteries, funeral homes and clergy members will work with them. Learn more about cremation here.

If it is necessary to choose a funeral plot, it is frequently best to consider if there is a cemetery that has been used for other family members. It may even be possible to find an available plot for the deceased near the graves of loved ones. Other considerations may include costs and proximity to living family members who may want to visit the grave occasionally. If the deceased or one of the mourners belongs to a synagogue, you may be able to purchase in the synagogue’s cemetery or cemetery section.

Find a Funeral Officiant

This officiant, usually a rabbi or cantor, does not need to be someone who knew the deceased person, although this is preferred by most families. Most often, the officiant is a rabbi who either leads a synagogue where the deceased person was a member or the synagogue of other family members. Funeral homes usually have a list of potential officiants who serve families that are not affiliated with a synagogue.

Usually, the rabbi (or other officiant) will lead the funeral prayers and deliver a eulogy. Learn more about Jewish eulogies here.

In order to prepare for these tasks, the officiant will generally meet with family members before the funeral, either in their own home or at the synagogue. The rabbi (or other officiant) will want family members to provide an accurate description of the deceased person and the lessons that may be learned from that person’s life. Also, family members will sometimes assist in the selection of readings for the service. It is crucial that the rabbi be contacted before the time of the funeral is set, to ensure that the rabbi will be available.

Arrange for a Traditional Meal (Meal of Consolation) after the Funeral

Many families, including some who are not observing shiva, welcome visitors at the family home after the funeral service for a traditional meal, called a “seudat havra’ah” (meal of consolation). This meal is the first food eaten by the family after the funeral and generally consists of simple, round foods, such as a hard-boiled egg, symbolizing the cycle of life. This meal is mostly intended for the mourners, who may feel too saddened to eat if left alone. The community is present to provide the food for the mourners, encourage them to take care of their own needs and usher mourners into a new stage in their lives. This is also a time in which mourners may light a large candle (usually provided by the funeral home), which will burn in the home for the next week.

In addition to that small meal for the mourners, some families hire a caterer to provide a meal while people gather at their home after the funeral. However, it is nice for extended family members, synagogue members, or friends to arrange the meal. Mourners should not have to arrange for the food, greet or entertain guests, but simply sit and reflect on their loved one, if they are up for it.

Plan the Shiva

Before the burial, priority should be given to arranging a respectful farewell to the departed loved one. Once these efforts are in place, attention should turn to the details of mourning. If mourners will be sitting shiva (i.e. observing the seven-day-long period of mourning in a family home), preparations must be made, usually with the help of a rabbi or synagogue members. (Some families may observe a three-day mourning period, some just one day, and others a full week.) This full week of withdrawal from daily concerns provides a chance for mourners to grieve together, exchange memories of the deceased loved one, and be comforted by each other and the community. Learn more about shiva here.

Funeral Checklist

Although the most vital tasks and decisions must be made by family members, an excellent way to deal with other tasks is to recruit as many friends and non-first-degree relatives (in-laws can be excellent for this) as possible to make phone calls, help transport out-of-town relatives, arrange food for the meal following the funeral, and assist with other needed errands.

Burial Arrangements

Contact a chevra kadisha (burial society) and/or funeral home. If there is no local organization of this type, contact other local Jewish families, the closest synagogue, or Jewish Federation.
If the departed person has a pre-arranged burial and funeral plan, find the necessary information.
If the deceased owned a tallit (prayer shawl), decide if they should be buried with it. (It may also be kept as a family heirloom.)
The displaying of flowers is generally discouraged at a Jewish funeral. Instead, choose an appropriate charity for people to make donations to in their memory.

Sharing the Sadness

Inform–in person, if possible–the closest family members. For out-of-town members of the immediate family, do your best to make sure that the person being called is not alone or in an inappropriate location to receive the sad news of their loved one’s death. (For example, one should not notify a sibling that their sister has died while he or she is on their cell phone and driving.)
Make a list of people who should be contacted regarding the death. Include family members, friends, employers (of both the deceased and of family members), co-workers, community members, and neighbors.
Delegate family members and friends for making phone calls.

Funeral Service

Contact the synagogue of the departed person and/or of the mourners.
Decide who will conduct the funeral service.
Consult with the service officiant regarding the eulogy and the participation of family members and friends.
Estimate the number of funeral attendees.
Consult with the funeral home and/or cemetery regarding service locations for both the eulogy and burial. Decide if a chapel and/or graveside service will suit family needs.
Appoint pall-bearers (who will carry the coffin part or all of the way to the burial site). If there are individuals who may be unable to physically handle this task, you may designate them as “honorary” pall-bearers.
Decide who will be asked to deliver eulogies and inform them.
Prepare the eulogy one will deliver, if applicable.
Arrange for transportation to and from the ceremony for mourners and other family members. This is often done through the funeral home.
Some mourners may wish to practice reciting the Mourner’s Kaddish
If mourners would like to rip a garment (usually a shirt or sweater) for kriah, then they should wear that article to the funeral (with appropriate garments underneath, for the sake of modesty).
If children are to attend the funeral, arrange to seat them with a babysitter or other responsible adult who will not mind leaving the service if the children are restless or upset.
Prepare a handout with the shiva information, to be passed out at the funeral, that includes the address of (and maybe directions to) the home where shiva will be observed, hours during which visitors will be welcomed, and the times of the services.

Seudat Havra’ah (“Meal of Consolation”)

If the family will be observing this custom, the rabbi or members of the extended family or friends—but not the mourners—should make arrangements for a light meal.
Give out directions to the family home at the funeral if that is the place the gathering will occur.
Place a pitcher of water, a basin, and towel outside the front door, to be used by funeral returnees before they enter the home. (This may also be done outside the cemetery.)
Prepare hard-boiled eggs for eating during the meal. These eggs symbolize the cyclical nature of life.

Shiva Checklist

Notify employers of needs for family leave.
Contact the synagogue of the departed person and/or of the mourners regarding the shiva, in order set a schedule of services, to assure 10 adults at services (if applicable), and to ask for assistance with other practical arrangements.
Set a schedule for meal preparation by friends and extended family.
Create a door sign with visiting hours posted.
Notify neighbors of the presence of additional cars and people in the neighborhood.
It can be helpful to have groceries and other necessary items delivered over the course of the week.
If desired, borrow from the synagogue or funeral home low chairs or cushions for the mourners’ seating, prayer books for services, and kippot (head-coverings) for guests.
For mourners who wish to observe all the shiva traditions (such as covering the mirrors in the home), more information is available here.

Other To Do’s

Post an obituary in the local and/or Jewish newspapers. Obituaries may be posted either before or after a funeral.
Designate a charitable organization(s) to receive donations in the name of the lost loved one.

Sign up for a Journey Through Grief & Mourning: Whether you have lost a loved one recently or just want to learn the basics of Jewish mourning rituals, this 8-part email series will guide you through everything you need to know and help you feel supported and comforted at a difficult time.Looking for a way to say Mourner’s Kaddish in a minyan? My Jewish Learning’s daily online minyan gives mourners and others an opportunity to say Kaddish in community and learn from leading rabbis.

The post How to Plan a Jewish Funeral appeared first on My Jewish Learning.

Death vs. Brain Death in Judaism

MJL Admin — Thu, 04 Jul 2002 00:00:00 +0000

For most of human history, determining death was not very complicated. As all bodily systems shut down within a relatively brief time span of one another, intricate nuance in defining death was unnecessary. However, as modern medical technology has enabled some bodily systems to function independently of others, and with the development of the ability to retrieve organs from bodies, the need for a precise definition has become crucial.

How one defines death affects decisions such as when to declare a patient dead, when to remove them from artificial respiration, and at what point a person’s organs may be retrieved.

Although the understanding of science and medicine was far less advanced when the Talmud was compiled, Rabbinic law presents general case material and principles that can be applied throughout generations. Thus, although the Talmud does not directly address contemporary definitions of death, it provides the principles that help contemporary rabbinic thinkers determine a Jewish definition of death.

The question of determining death arises in the Talmud (Yoma 85a) in the context of a discussion about what to do when a building collapses on Shabbat and it is uncertain if anyone is trapped in the rubble or whether the person is alive or dead. Because of the principle of pikuach nefesh, in which saving a life takes priority over Shabbat observance, the Talmud permits violating Shabbat in order to determine if anyone is under the rubble and then to continue rescue efforts if anyone is found to be alive. The Talmud then asks which area of the victim’s body one must examine to determine if he or she is alive or dead. One option is to uncover the rubble-buried victim until reaching the nose, seemingly indicating that the rescuer must look for signs of breathing. The second option is that one must uncover the victim until reaching the heart, seemingly indicating that one must look for signs of heartbeat. The Talmud concludes that when searching from the head down, it is sufficient to check only until the nose; when searching from the feet up, one opinion states that it is sufficient to check up until the victim’s heart, while another nevertheless requires checking up to the nose.

The traditional codifiers of Jewish law all rule that the primary test in determining whether a person is alive or dead is of the nose. The verse that the Talmud quotes to support this requirement is, “All in whose nostrils was the breath of the spirit of life” (Genesis 7:22), which implies that the “breath of the spirit of life” is what defines life.

Based on this foundation, widely divergent conclusions have been drawn about the Jewish definition of death and the correlating criteria. This topic is highly complex, with numerous opinions and many fine nuances. For the sake of clarity, we can divide Rabbinic approaches into

Those who believe this talmudic passage defines death as the irreversible and complete cessation of all vital bodily motion (including heartbeat), and
Those who conclude from this source that irreversible cessation of breathing is what determines death.

Opinion 1: Death Requires Cessation of All Bodily Motion

Rabbinic authorities in the first category, such as many Orthodox thinkers including Rabbi J.David Bleich of Yeshiva University, require complete cessation of bodily motion, including cessation of both cardiac and respiratory functions, to define death. Their argument is that although the Talmud seems to be concerned with respiration, breathing is merely the necessary test, but not the criterion for death. They read this Talmudic ruling as teaching that the criterion for death is actually the irreversible cessation of heartbeat, and that checking for breathing is not as the definition or criterion for death, but merely as one indication of death. However, they argue, a heartbeat is often imperceptible through a superficial chest exam, whereas checking for breathing in the nostrils is a more sensitive and accurate determination of continued cardiac activity.

Opinion 2: Death Requires Cessation of Breathing Only

Rabbinic authorities in the second category, such as the Israeli Chief Rabbinate, many Modern Orthodox rabbis and most non-Orthodox denominations, understand the simple reading of the Talmud to be determining death solely based upon respiratory criteria. This claim is especially supported by the conclusion of the Talmud and its proof text (mentioned above), as well as the fact that many textual variants and the version in the Jerusalem Talmud debate checking up until the nose or the abdomen, but do not mention the heart at all. (There are two versions of the Talmud: The Babylonian one, which is more widely referenced, and the Jerusalem one.) Because they interpret this text to mean that irreversible cessation of breathing is itself the proper criterion for pronouncing death, and not merely a test to determine other morbidities, some argue that brain death is death according to Jewish law, because one who is brain dead breathes only with help from a respirator.

Thus, there are very different ways of reading this seemingly simple talmudic text.

Does Brain Death = Complete Death?

Authorities who understand the Talmud passage as elucidating the proper criteria for determining death generally favor the respiratory criterion, and thus rule that brain death is death. However,those who see it merely as referring to appropriate tests would argue that brain death is not death, since brain dead patients may still have a heartbeat.

Another potentially relevant Talmudic teaching that is quoted by Rabbi Moshe Feinstein, a 20th-century American Orthodox scholar, may add a third possibility for defining death according to Jewish law. This teaching, based on a passage in the Mishnah (Mishnah Oholot 1:6), rules that the ritual impurity engendered by a corpse begins once a head is severed, even if the body is still convulsing. Based on this passage, some rabbinic authorities have argued that since the loss of neurologically controlled integrated motion in a decapitated person renders one dead, one who is brain dead is in fact dead according to Jewish law. Although the brain is still physically attached to the body, if it can be definitely demonstrated that brain functions have ceased, the patient is considered dead by Jewish law, even if one’s heart continues to beat.

Some Jewish scholars, such as Rabbi Moshe Tendler (an American Orthodox rabbi and Yeshiva University professor), have argued that both of these talmudic teachings — the one on the potential victim of a building collapse and the one on decapitation — are based on the same underlying thesis, which is that when the brain no longer integrates or controls the body’s function, a person is dead. In Talmudic times, these scholars argue, checking for respiration or cardiac criteria was simply the best way of indicating brainstem dysfunction – brain death – and therefore death.

Practical Implications

Determining death is thus predicated on how one understands the above talmudic principles.

Those who believe death is defined by complete cessation of all vital bodily motion, including heartbeat, will require confirmation that the heart has stopped beating and that there is no evidence of any possible signs of life remaining.
Those who focus on irreversible cessation of spontaneous respiration will look for proof that independent respiration will never return by showing that either the heart or the brainstem (which controls respiration) have ceased to function.
Those who define death as complete absence of the head will require confirmation that the head has been completely separated from the body. This would mean the death of each and every cell of the entire brain, which is much stricter than the legally (according to American and Israeli law) accepted definition of brain death (and recent research and sensitive diagnostics have shown that this state is exceedingly rare).

Since neurological criteria for determining death — the view that brain death is death — is recognized in American and Israeli law, the withdrawal of medical support and interventions, as well as the process of organ retrieval, often ensue after this determination. This is usually acceptable to Reform, Conservative, some Modern Orthodox rabbis as well as the Israeli Chief Rabbinate.

Nevertheless, some others, including many Orthodox rabbis, do not accept brain death as death and for them and their adherents hospitals are encouraged — and in some places required — to provide reasonable accommodation for a brief period of time to families who do not accept this determination for religious reasons. If this time has passed (usually ranging between one to three days) and a family is still at odds with the medical team, hospitals in most jurisdictions may unilaterally withdraw medical interventions. The only ways to avoid this would either be to transfer the patient to another facility that is willing and able to take them, or to buy more time by petitioning the court for a temporary restraining order if one has a legitimate claim.

The post Death vs. Brain Death in Judaism appeared first on My Jewish Learning.

Preparing for Death

MJL Admin — Mon, 11 Nov 2002 14:03:58 +0000

Jewish tradition invites us to think about our mortality long before our own deaths. The tradition of writing an ethical will–a letter to one’s children and descendants expressing the deepest principles and most important actions we hope they will carry on–demands that we anticipate and accept the fact that our lifespan is finite.

Jewish ethical wills may be said to have begun with the biblical patriarch Jacob delivering his wishes orally to his children gathered around his deathbed. Jewish texts ancient to modern contain many examples of ethical wills that parents have left to their children.

Hasidic Tradition of Deathbed Wisdom

If dying must be faced, then perhaps–like living–it must also be taught. From the world of Hasidism come many tales of rebbes (rabbinic spiritual leaders) who consciously–or simply by the legacy of the stories of their deaths–teach their followers about how to face death. Many of these stories reflect the belief that one can and should approach the process of dying consciously. One rabbi says, “I am learning how to leave this world.”Another goes to visit his closest disciples to say farewell. A third teaches his followers a new nigun (a wordless tune), asks them to sing it back to him, and departs this world.

According to one story, the Baal Shem Tov, the founder of modern Hasidism, gathered his disciples in his room one morning and instructed them in how to care for his body after his imminent death. His great-grandson, Rabbi Nahman of Bratslav, is said to have had his disciples wash and dress him even in preparation for death. Through the example of their own deaths, they taught the importance of squarely facing one’s own death, and the virtue of attending to another’s burial.

Importance of Being at the Bedside of a Dying Loved One

Some contemporary thinkers argue that the traditional emphasis on being at the bedside of the dying is of immense value, not only for the dying person but also for those about to be bereaved–and for all of us, who must learn to face death. Such presence–along with the full range of Jewish customs around dying, death, and burial–counters societal pressure to avoid death and isolate the dying. In Jewish law, a dying person is nevertheless a complete person, to be treated as part of the human community. Being with the dying also helps the would-be survivors avoid the denial of their grief.

Finally, the bedside vigil can also serve the purpose of encouraging the dying person to recite a traditional last confessional, perhaps her or his last rite of passage. This type of confessional occurs throughout the Jewish lifecycle at moments of transition.

Many people are surprised to learn that there is a Jewish deathbed confession, or viddui. Lest the suggestion to a dying person induce fear or lack of confidence in his or her medical care, we are encouraged to remind the person: “Many have said the viddui and not died, and many have not said the viddui and have died.”

The viddui may be said by the dying person or by someone on his or her behalf. It ends with the Shema, perhaps the best known Jewish prayer and the core statement of God’s oneness. In this context, by implication, it can also be viewed as a statement of faith in one’s re-union with the Divine.

The post Preparing for Death appeared first on My Jewish Learning.

End-of-Life Care in the Bible

Jennifer Modlinger — Tue, 05 Dec 2017 20:40:25 +0000

The Torah is called Etz Chayim, a tree of life, because it provides values, ethics and laws by which Jews are commanded to live. But how we die is also part of how we live. And so when we face death, our biblical ancestors can serve as models for how we approach the end of life. Below are some key examples from the Torah and what they teach us about dying.

Jacob

Is there such a thing as a good death? Today much of the research around this question says yes, and it looks like this:

Death at home or in one’s place of choice
Death surrounded by loved ones or whomever one desires
Death with closure in all relationships

Hospice organizations, palliative care teams and family members of those who are dying are finding that these components can ease anxiety and pain and create peace at the end of life.

In the Torah, Jacob has a famously good death. Not only does he know that his death is imminent, he has the mental clarity to call each of his children to his bedside to bless them and give them advice for life after he is gone. (Genesis 47:28) He rebukes those who need it and tells his own life story. Jacob even tells his children exactly where to bury him — alongside his ancestors. In contemporary terms, he models a life review and legacy work, and provides an ethical will — all things that healthcare professionals, therapists and clergy so often encourage. Jacob does not get the life he wanted — as he says to Pharaoh: “Few and evil have been the days of the years of my life.” (Genesis 47:9) But he does get the death he wanted. He ties up his loose ends and makes sure everyone he needs to speak with hears him. He does this all in the comfort of his home.

Of course, the type of death Jacob has is not always possible. Some deaths are unexpected and unplanned. Some deaths happen in the hospital because that is the only place a person is able to get the care they need. Sometimes a person who is dying is no longer conscious or cognitively capable of imparting their wishes. And because we don’t know what our own death will be like, it is important to prepare for it as early as possible, even before we are ill. Telling a loved one whom we want at our beside or what medical measures we want to be taken or how we want to be remembered can be done at any age. These conversations are uncomfortable, but they are also the ultimate expression of love.

There is wisdom for us all in Jacob’s death. There is even a famous teaching (Rashi on Genesis 49:33) that says Jacob did not really die. The lesson being: When we leave behind instructions, a legacy, and blessings, we never truly die.

Sarah

Can a person die of a broken heart? In the Torah, Sarah does.

After struggling to bear children, Sarah finally gives birth to her beloved son, Isaac. One day God commands Sarah’s husband, Abraham, to sacrifice this cherished child as a test of faith. When Sarah finds out that her son was being prepared for slaughter, “her soul went out from her and she died” (Rashi on Genesis 23:2) although Isaac would not, ultimately, be harmed or killed. The Torah portion in which Sarah dies is called, “Chayei Sara,” or “The Life of Sarah,” underscoring that how she died reveals much about how she lived and how she is to be remembered.

What can we learn from Sarah’s death? Rabbi Kalonymus Kalmish Shapira, a 20th-century Polish rabbi known as the Aish Kodesh in the Warsaw Ghetto, tells us that Sarah’s death is a prayer to God — and a plea that a person should not be expected to suffer unlimited pain and anguish. If Sarah, one of the most virtuous, giving and faithful people in our tradition, could not withstand such pain, no one can or should have to. The story of her death is a prayer to God to step in and hold us, comfort us and save us when we cannot continue on.

When we are faced with unbearable sorrow in our own lives, perhaps as we face our own illness and death or that of a loved one, we can think of Sarah. We can imagine her sitting with us in our pain, holding our hand — and maybe even crying along with us. When we have nothing to say to God, Sarah is our voice, demanding that God make our lives and deaths better than hers. Let us learn from her story and say in our prayers, “God, this is enough! Please give me the strength to get through this. Please let Sarah’s death not be for nothing. Please heal my broken heart.”

Moses

“It is not up to you to finish the work, but you are not free to desist from it.” (Pirkei Avot 2:16)

We often think that we have to do everything ourselves, that if we don’t, it won’t get done. At the end of his life, Moses — a leader used to doing it all — learns that this way of thinking is counterproductive.

To this day, we say that no one will ever be like Moses in his character or in his relationship with God. But even Moses was human and died. If Judaism had ended with Moses, if the work stopped with him, we would not be here today. If the Torah only existed in the life of one person, it would not be eternal. And so, in the final moments of his life, Moses is told by God to focus on passing his leadership on to Joshua. (Deuteronomy 31:14) He has to accept that he will not, in his lifetime, get to enter the land of Israel; in this acceptance, Moses learns that passing on the tradition is the greatest way of keeping it.

Our job is not to finish the work, but to be a link in the chain. This is a lesson we often accept only when we face death — and thus the loss of time, opportunities and dreams. And yet this same tough realization is a source of hope. There is more than just now; we are part of a greater story. We do not have to worry about finishing everything because we will have help from future generations. This truth is humbling and freeing. It allows us to let go.

At the end of life, sometimes a person feels tethered to this world, worried about children or a spouse, unable to let go of the things he or she wants to finish or take care of. Or perhaps a loved one will not leave the bedside or practice self-care for fear that no one else will look out for the patient. In such situations, it is a wise and compassionate gift to ourselves and to our loved ones to give permission to let go and accept help.

In your own life right now, reflect on letting go and accepting that your unfinished work will be carried on by others. What would it feel like to say (to yourself at the end of life or to a loved one at the end of life): “You did not desist from the work. You did it every moment of your life. You took care of everyone and are loved. But you don’t need to finish it, you don’t need to do it all yourself. Your legacy will continue; your story will go on. I give you permission to let go.”

Though in death we lose life in this world, we also gain the gift of legacy, of a story that is greater than ourselves. By passing on his leadership, Moses made sure we could do the same.

The post End-of-Life Care in the Bible appeared first on My Jewish Learning.

The Text of Final Confessional Prayer: Viddui

MJL Admin — Fri, 01 May 2009 20:40:26 +0000

My God and God of my fathers and mothers

May my prayer come before You.

Do not ignore my plea.

Please, forgive me for all of the sins

That I sinned before You throughout my lifetime.

I am ashamed of deeds that I have committed.

I regret things that I have done.

Now, O God, take my pain and suffering as atonement.

Forgive my mistakes, for against You have I sinned.

May it be Your will, Adonai, my God and God of my ancestors

That I sin no more.

In Your great mercy, cleanse me of the sins I have committed

But not through suffering and disease.

Send me a complete healing along with all those who are ill.

I acknowledge before You, Adonai my God and God of my ancestors,

That my healing and my death are in Your hands.

May it be Your will to grant me a complete healing.

If it be Your will that I am to die of this illness,

Let my death be atonement for all the wrongs that I have done in my life.

Shelter me in the shadow of Your wings.

Grant me a place in the world to come.

Parent of orphans and Guardian of widows

Protect my dear ones,

With whose souls my soul is bound.

Into your hand I place my soul.

You have redeemed me, O God of truth.

Shema Yisrael, Adonai Elohenu Adonai Echad.

Hear O Israel, The Lord our God, The Lord is One.

Adonai Hu Ha’Elohim. Adonai Hu Ha’Elohim.

Adonai is God. Adonai is God.

Excerpted with permission from Saying Kaddish: How to Comfort the Dying, Bury the Dead, and Mourn as a Jew (Schocken Books).

The post The Text of Final Confessional Prayer: Viddui appeared first on My Jewish Learning.

Does Judaism Believe in the Right to Die?

MJL Admin — Thu, 24 Mar 2005 14:14:58 +0000

As a general rule, all denominations of Judaism prohibit suicide (including assisted suicide) and euthanasia. However, there is some room for nuance on the matter.

Judaism teaches that we do not own our bodies; our bodies belong to God, and we do not have the right to destroy them. Furthermore, our lives are not simply needed for utilitarian purposes. Each person is sacred, having been created in the image of God, and there is thus a value to life regardless of one’s relative quality or usefulness. Not only is human life itself sacred, but every moment of life is valued, and there is thus an obligation to attempt to save all life, regardless of how much time a person has left to live.

The Mishnah, in the fouth chapter of Sanhedrin, explains:

It was for this reason that Adam was first created as one person, to teach us that anyone who destroys a life is considered by Scripture to have destroyed an entire world; and anyone who saves a life is as if he saved an entire world.

Because of the belief that God owns us and that we thus have limited autonomy, and the ruling of Maimonides (Hilkhot Rotzeah 2:7) that a murderer is liable for capital punishment “whether they killed a healthy individual or a sick person on the verge of death, or even a dying person,” Jewish law prohibits most forms of bodily damage, suicide and assisted suicide. Jewish law also prohibits euthanasia and physician-assisted suicide. Indeed, even “passive euthanasia” (in which the the doctors don’t take the patient’s life but simply allow him or her to die) is sometimes prohibited when it involves the omission of certain therapeutic procedures or withholding medication, since physicians are charged with prolonging life.

Not only do all Orthodox rabbis prohibit physician assisted suicide (sometimes referred to as “medical aid in dying”), but the Conservative movement’s committee on Jewish law and standards has validated Rabbi Elliot Dorff’s opposition to euthanasia and physician assisted suicide (in Matters of Life and Death, 185 ). Although Reform Judaism grants its adherents much more personal decision-making autonomy than other denominations do, the Reform Central Conference of American Rabbis (CCAR) has issued a responsum “On the Treatment of the Terminally Ill” in which it prohibits euthanasia, though there are individual Reform rabbis who have defended assisted suicide .

While assisted suicide and euthanasia are taboo, there are certainly situations in which Jewish law permits withholding aggressive life-sustaining treatments, and according to many Conservative and most Reform rabbis, this even includes withdrawing life-sustaining interventions.

Furthermore, although most rabbis prohibit physician-assisted suicide, it is still possible to have compassion for the suffering of terminally ill individuals who are contemplating such a decision without endorsing or condoning it. After all, there are certain cases of suicide, such as that of King Saul recorded in the book of I Samuel, when he falls on his sword in order not to be captured by the Philistines (I Samuel 31:3–4), that Jewish law does not endorse, but for which it offers sympathy and permits traditional burial and mourning practices. Learn more about Judaism and suicide here.

In fact, there are even times when Jewish law may permit praying for a suffering terminal patient to die, while at the same time obligating us to do everything possible, including violate the laws of Shabbat, to prolong his or her life. Thus, even while prohibiting this behavior in practice, there is room for showing some level of understanding and compassion to the patient.

This permission to pray for a terminal patient to die is based on the story of the death of Rabbi Yehudah Hanasi, the author of the Mishnah and one of the greatest Talmudic rabbis. The Talmud (Ketubot 104a) tells us that as he was dying in bed:

The maidservant of Rabbi Yehuda HaNasi ascended to the roof and said: The upper realms are requesting the presence of Rabbi Yehuda HaNasi, and the lower realms are requesting the presence of Rabbi Yehuda HaNasi. May it be the will of God that the lower worlds should impose their will upon the upper worlds. However, when she saw how many times he would enter the bathroom and remove his phylacteries, and then exit and put them back on, and how he was suffering with his intestinal disease, she said: May it be the will of God that the upper worlds should impose their will upon the lower worlds. And the Sages, meanwhile, would not be silent, i.e., they would not refrain, from begging for mercy so that Rabbi Yehuda HaNasi would not die. So she took a jug and threw it from the roof to the ground. Due to the sudden noise, the Sages were momentarily silent and refrained from begging for mercy, and Rabbi Yehuda HaNasi died.

We see from this text that although physician assisted suicide may not be advocated by most rabbinic authorities, we can have compassion for the suffering of a dying patient. We must do everything to prolong life, but do nothing to prolong the dying process. As we can keep a patient alive, we must do so, unless the benefit of such actions is counterbalanced by their causing extreme pain and suffering. At that point, Judaism permits a compassionate response of allowing the death process to occur with appropriate palliative care, if this is what the patient or their surrogate desires and their rabbi has ruled accordingly for that specific case.

The post Does Judaism Believe in the Right to Die? appeared first on My Jewish Learning.

Viddui: The Deathbed Confession

MJL Admin — Mon, 11 Nov 2002 19:28:34 +0000

Many people are surprised to learn that there is a Jewish deathbed confessional prayer called the Viddui. During the Yom Kippur Viddui, the whole congregation rises and symbolically beats its chest while confessing to an alphabetical series of sins. The Viddui recited at the end of life is very different; personal rather than communal, it acknowledges the imperfections of the dying person and seeks a final reconciliation with God.

Unlike the better-known Catholic ritual, reciting the Viddui has nothing to do with insuring the soul’s place in the “world-to come.” Nor does [its recitation], in any way, tempt fate. In the words of the [law code the] Shulchan Arukh:

“If you feel death approaching, recite the Viddui. Be reassured by those around you. Many have said the Viddui and not died, and many have not said the Viddui and have died. If you are unable to recite it aloud, say it in your heart. And if you are unable to recite it, others may recite it with you or for you.”

The prayer is recited when death seems imminent; it may be said by the [dying person], by family members, or by a rabbi. It can be read in Hebrew or English or in both languages. A formal Viddui can be read in sections, with pauses to let people speak from their hearts, to voice regrets or guilt, to ask forgiveness of one another, and to say “I love you.”

The Viddui can also be seen as a model for a less formal farewell. People at the bedside can sing a wordless melody–a niggun–saya few personal words of goodbye, and recite the Shema together: this, too, is a [kind of] Viddui.

However, as in all matters concerning the dying, the [dying person] is the one to decide on whether she wants to say or hear this prayer. The Viddui should never be imposed.

The central element of the Viddui is the Shema, the most familiar of all Jewish prayers and the quintessential statement of faith in God’s unity. The Shema is the last thing a Jew is supposed to say before death–which is also why it is recited before going to sleep at night (in case “I should die before I wake”). The Shema is not a petitionary prayer, nor does it praise God. It is a not really a prayer at all, but the proclamation of God’s oneness. It is also an affirmation of Jewish identity and connection.

The Shema ends with the word Echad, which means “One.” Uttered with “a dying breath,” it suggests the ultimate reconciliation of the soul with the Holy One of Blessing, Echad, whom Jews also call Adonai. In many ways, the Shema says “Yes.” In its own way, the Shema says “Amen.”

How To Say Viddui

מודה אני לפניך ה’ אלהי ואלהי אבותי שרפואתי ומיתתי בידך. יהי רצון מלפניך שתרפאני רפואה שלימה ואם אמות תהא מיתתי כפרה על כל חטאים ועונות ופשעים שחטאתי ושעויתי ושפשעתי לפניך ותן חלקי בגן עדן וזכני לעוה”ב הצפון לצדיקים

I acknowledge before You, Adonai, my God and God of my ancestors, that my recovery and my death are in Your hands. May it be Your will to heal me completely. And if I die, may my passing be an atonement for all the sins that I have committed, and grant me my portion in Gan Eden, and allow me to merit the World to Come, which has been reserved for the righteous.

If a person is too weak to say this entire paragraph, they can recite this sentence:

יהי רצון שתהא מיתתי כפרה על כל עונותי

May it be Your will that my death be an atonement for all my sins.

Excerpted with permission from Saying Kaddish: How to Comfort the Dying, Bury the Dead, and Mourn as a Jew (Schocken Books).

The post Viddui: The Deathbed Confession appeared first on My Jewish Learning.

On Being with Those Who Are Dying

MJL Admin — Mon, 11 Nov 2002 14:02:56 +0000

The concept of wisdom (hokhmah) in the Bible is not that of sage philosophy or metaphysical abstraction. Wisdom in the Bible means doing what is right in each situation. It is in this sense that the Jewish perspectives on death and the Jewish mourning practices are “wise.” They are wise because they provide a total framework within which [humanity] learns to accept death, to mourn completely, and to live again fully.

When the family and community are faced with the prospect of the death of one of its members, Jewish law reminds us that “a dying man is considered the same as a living man in every respect.” But in American culture today, dying is treated as if it were a separate realm of existence. America is essentially a death-denying society; consequently we treat the dying differently from the way we treat the living. We avoid them, or avoid honest communication with them. We try to spare them the problems of everyday living, and we thereby deprive them of its joys. The dying person lives alone in an artificial environment created by those who do not wish to cope with the fact of death and its inevitable call to every living being.

Halacha [Jewish law] forbids this dishonest approach. The dying person must be treated as he was always treated, as a complete person capable of conducting his own affairs and able to enter fully into human relations even unto death. Further, the Jewish tradition of never leaving the bedside of the dying is of immense value, not only to the dying person but also to those about to be bereaved. How helpless and how guilty we must feel when we hear of the death of a loved one, especially if no one was there to ease the fear of uncertainty and the pain of separation.

All kinds of questions spring to mind from the wellsprings of guilt: “Was everything done that could have been done?” “Why didn’t the doctor or nurse get there sooner?” “What could I have done to prevent this?” “Did he suffer?” “Why was he alone?” And underneath these questions lie another series of questions: “Will I suffer?” “Will I be alone?” “Will anyone care for me though I didn’t care for him?”

Judaism shields mourners from being overwhelmed by this kind of guilt because the community shares in the care of the dying so that they are never left alone. The community provides reassurances that everything appropriate was done. To the extent that I am a part of the community, part of me was there when he died, and so I need not fear.

The bedside vigil serves one more purpose. As death approaches, a crisis of faith occurs as the life cycle draws to an end. A personal confessional is encouraged from the dying as a rite of passage to another phase of existence. This type of confessional occurs throughout the Jewish life cycle whenever one stage has been completed. So we confess on the Day of Atonement as we end one year of life and begin another. So grooms and brides traditionally said the confessional and fasted on their wedding day, for they sensed that it marked the end of one stage in their lives and the beginning of another.

The confessional on the deathbed is the recognition of the ending of one cycle and the beginning of another. This and the recitation of the Shema in the last moments before death help to affirm faith in God precisely when it is most challenged, and help the dying person focus on those most familiar rituals of his life just at the moment when he enters the most mysterious and unknowable experience of his life. This comforts him together with those who share his vigil.

The wisdom in actually observing the death is that the reality cannot then be denied. Psychiatrists know that the relatives of those missing in action or those who are lost in battle and whose bodies are never recovered have the hardest time recuperating from grief, for they have no body around which to focus and express their grief and so they are vulnerable to the temptation to deny the reality of the death. Judaism does not permit the mourner to escape the reality of death; it bids him see it, and then it leads him through a whole network of burial and mourning procedures whose purpose is to help him come to terms with it.

In doing this it is in harmony with psychiatric literature, which abounds with examples of the fearful consequences of death-denial and repression of grief. The talmudic sages centuries ago seem to have sensed the same truth that psychiatrists now articulate, which is that the recognition of death is a necessity for continuing life, and grief is a necessary and unavoidable process in normative psychological functioning. (Vivian M. Rakoff, “Psychiatric Aspects of Death in America,” in Arien Mack, ed., Death in American Experience)

Excerpted with permission from “The Psychological Wisdom of the Law” in Jewish Reflections on Death, edited by Jack Riemer (Schocken Books).

Audrey Gordon is assistant professor of community health science in the University of Illinois at Chicago School of Public Health, and is an expert on current thinking about death and dying. As a graduate student, she worked with Elisabeth Kubler-Ross. She is the co-author of the book They Need to Know: How to Teach Children about Death.

The post On Being with Those Who Are Dying appeared first on My Jewish Learning.

Writing and Reading Ethical Wills

MJL Admin — Mon, 11 Nov 2002 13:32:27 +0000

There is a lovely Jewish custom, one that is unfortunately not sufficiently known in our time, of writing what is called an ethical will. Parents would write a letter to their children in which they would try to sum up all that they had learned in life, and in which they would try to express what they wanted most for and from their children. They would leave these letters behind because they believed that the wisdom they had acquired was just as much a part of the legacy they wanted to leave their children as were all the material possessions.

The first ethical wills are found in the Bible. Jacob gathers his children around his bedside and tries to tell them the way in which they should live after he is gone. And Moses makes a farewell address, chastising, prophesying, and instructing his people before he dies. David prepares Solomon before he goes to his eternal rest by warning him whom to be wary of when he becomes king, and by asking him to complete the task he had begun and was unable to complete. The Apocrypha, the Talmud, medieval and modern Hebrew literature all contain examples of ethical wills parents left their children.

Many years ago Israel Abrahams published a splendid collection of these medieval wills entitled Hebrew Ethical Wills. We hope [our] book, which brings together some modern and contemporary wills, will be a fitting continuation of the Abrahams work.

An ethical will is not an easy thing to write. In doing so, one confronts oneself. One must look inward to see what are the essential truths one has learned in a lifetime, face up to one’s failures, and consider what are the things that really count. Thus an individual learns a great deal about himself or herself when writing an ethical will. If you had time to write just one letter, to whom would it be addressed? What would it say? What would you leave out? Would you chastise and rebuke? Would you thank, forgive, or seek to instruct?

An ethical will is not an easy thing to read. There is a sense of being a voyeur, of eavesdropping on an intimate conversation, of reading a love letter from the beyond. Those who read these documents should do so with reverence and with gratitude. We tread carefully here, and we read with a sense of privilege.

An ethical will is not an easy thing to receive. There is the temptation, an almost irresistible one, for parents to try to persuade after death what they were unable to persuade during life. There is the temptation to repeat once more, to plead once more, and to impose a burden of guilt from the grave.

The famous and much-quoted letter of Ibn Tibbon is an example of such a castrating and guilt-producing will. Over and over again in his will he berates his child and reminds him how much he has done for him, and then he ends with the instruction that the child should read this will regularly. One can only shudder to think of how much harm such a will can do. One must be able to accept a will as well meant, even if its instructions are sometimes burdensome. One must be able to take it as words that come from the heart and that hopefully enter the heart. One must be able to accept it as an adult receiving instruction from an adult, or else the ties that bind become ties that choke and cripple.

[The wills of our time] come from many countries and from many kinds of people. Some were written by scholars, some by simple men and women. Some were written in freedom and safety, from the comfort of a desk, and some were written in trenches and bunkers. Some were written in English, some in Hebrew, Yiddish, or German. All are precious spiritual documents–windows into the souls of those who wrote them.

[Our book reflects] the four worlds in which the Jewish people have lived in this century: the world of faith and piety; the world of agony and anguish; the world of return to power and statehood; and the world of freedom. Each of these worlds has presented the Jewish people with a different challenge [reflected in the ethical wills each produced].

Excerpted with permission from the introduction to Ethical Wills: A Modern Treasury edited by Jack Riemer and Nathaniel Stampfer (Schocken Books).

Rabbi Jack Riemer is one of American Jewry’s outstanding teachers. His congregation, Beth Tikvah of Boca Raton has quadrupled its membership in the last four years and has become a model to other synagogues around the U.S. He is the author of several books and a resource to rabbi throughout North America.

(c) Jack Riemer and Nathaniel Stampfer, 1986, Schocken Books.

The post Writing and Reading Ethical Wills appeared first on My Jewish Learning.

Two Conservative Jewish Views on End-of-Life Issues

MJL Admin — Thu, 31 Mar 2005 10:48:05 +0000

The following is a summary issued by the Rabbinical Assembly, the association of Conservative rabbis, to summarize the Conservative movement’s positions on end-of-life issues. In the Rabbinical Assembly’s Committee on Jewish Law and Standards (CJLS)–which decides issues of halakhah (Jewish law)–multiple legal opinions on a single topic may be accepted if each receives a certain amount of support among committee members.

On Dec. 12, 1990, the CJLS debated two papers submitted by Rabbis Elliot Dorff and Avram Israel Reisner, members of the CJLS’ sub-committee on biomedical ethics, on end-of-life issues. Both papers were adopted by the Committee, Rabbi Dorff’s by a vote of 11-2-5, Rabbi Reisner’s by a vote of 13-14 (members were given the option of voting for both papers). Thus both positions are valid views. The key points of each are summarized below.

However, the papers are very detailed and complex, and what follows cannot substitute for careful study of the authors’ writings. Both papers, as well as two responses from other sub-committee members, appear in the Spring 1991 issue of Conservative Judaism.

The Rabbinical Assembly has also published a living will, entitled Advanced Medical Directives. This living will is accessible here.

Rabbi Dorff’s Position

The key category for dealing with end-of-life issues is the terefah [a halakhic designation for someone who has an incurable disease but may life for an extended period].

a. When the patient has an irreversible, terminal illness, medications and other forms of therapy may be withheld or withdrawn. Artificial nutrition and hydration may be considered a sub-category of medication in such circumstances, and therefore may also be withheld or withdrawn.

b. The category of terefah may also be applied to the person in a permanent vegetative state, and it would be permissible to remove artificial nutrition and hydration.

c. Terminally ill persons may, if they choose, engage in any medical regimen which has the slightest chance of reversing their prognosis. So long as the intention is to find a cure, they may do so even if they thereby simultaneously increase the risk of hastening death.

d. Jewish law includes permission for the patient to refuse any treatment he/she cannot bear, including forms of therapy which, though life-sustaining, the patient judges not to be for his/her benefit.

e. Terminally ill patients may choose hospice or home care.

f. A patient may reject CPR and/or issue a DNR [Do Not Resuscitate] order when these measures are unlikely to restore the patient to meaningfully healthy life.

g. Pain medication may continue even if its probable effect is to hasten the patient’s death.

(Teshuvah by Rabbi Elliot Dorff: http://www.rabbinicalassembly.org/teshuvot/docs/19861990/dorff_care.pdf.)

Rabbi Reisner’s Position

The critical category for dealing with terminally ill patients is the goses [a halakhic designation for a terminally ill patient expected to die within 72 hours].

a. That which is of the body, of natural function, should be allowed to function. Thus, the withholding or withdrawing of medication, nutrition, or hydration is prohibited, so long as they are believed to be beneficial for the prolongation of life. That which is not of the body, but rather which mechanically reproduces, supersedes or circumvents the body’s functions (for example, respirators, mechanical pumps, blood purifiers), may be removed as an impediment to death.

b. Feeding tubes may not be removed from those in persistent vegetative states, as they are not terminally ill.

c. The patient has autonomy to choose between treatment options in a situation where risk and uncertain prognosis exist. If, however, a particular treatment guarantees a cure, it may not be refused. The only choice which is barred is the choice to die.

d. Terminally ill patients may choose hospice or home care.

e. A patient may reject CPR and/or issue a DNR order when these measures are unlikely to restore the patient to meaningfully healthy life.

f. Pain treatment should be pursued, but pain medication must be capped at that point at which its probable effect would be to hasten the patient’s death.

(Teshuvah by Rabbi Avram Israel Reisner: http://www.rabbinicalassembly.org/teshuvot/docs/19861990/reisner_care.pdf.)

Reprinted with permission of the Rabbinical Assembly.

The post Two Conservative Jewish Views on End-of-Life Issues appeared first on My Jewish Learning.

End of Life Issues: A Jewish Perspective

MJL Admin — Thu, 24 Mar 2005 14:19:56 +0000

Dealing with death is always a traumatic time for patients and their family. Medical advances made within the past 50 years or so have created situations that were never thought of at the time the Torah became the basis of Jewish law, and so there are some situations associated with the processes of death and dying that may not have clear resolutions. It is strongly suggested that when dealing with terminal illness, life support, organ donation, and the potential for resuscitation that the advice of a rabbi skilled in Jewish medical ethics is sought and that matters are then discussed with the patient and family as early as possible. However, it is also necessary to show great sensitivity at this time and respect the wishes of patient and family, whatever they might be.

Jews have a responsibility to accept medical treatment when there is a possibility of treatment saving their life. However, opinion becomes divided about whether treatment artificially prolonging life falls under this therapeutic category and therefore whether a patient has an obligation to accept such treatment.

Before death, a patient may fall into the category of being a goses. During this state, no action can be taken that will either hasten or delay death, and so, medically speaking, no treatment may be started to delay death and no treatment may be stopped if it would hasten death. Exactly how this translates into medical care may need to be discussed with the family and a rabbi; dealing with the death of a Jewish patient can be a complex affair.

Terminal Illness

The diagnosis of a terminal illness brings with it some complications in terms of medical treatment. If a treatment holds out hope of a recovery, or an extended period of life (that is, life that would not be possible if treatment was not given), then most authorities agree that a Jewish patient has a duty to accept the treatment. However, if the illness has advanced to the state where no cure is possible, then opinion becomes divided about whether the acceptance of pain relief, life support, nasogastric feeding and other treatments is obligatory. The issue of “quality of life” is not as important as the requirement to preserve life for as long as is possible without heroic efforts.

Essentially, the way forward in this circumstance, and the associated steps taken (for example, whether to inform the patient of their condition truthfully or whether to leave that to the family to decide), will largely depend on the style of Judaism practiced by the patient. It is important to speak to his or her rabbi about the matter or to seek help from a rabbinical authority.

Living Wills

Situations may arise where a patient no longer has control over the course of his or her own death owing to unconsciousness or disability. The creation of a “living will” is a matter open to much debate among various Jewish groups (for example, does this constitute thoughts about suicide, which is also forbidden under Jewish law?).

However, some Reform groups suggest that a living will relieves medical staff and family of the responsibility of making difficult decisions and allows a patient to die in peace. It may be better to discuss this issue with family members if present, or talk to the patient’s rabbi if possible, rather than introduce the subject directly to the patient.

Life Support

The use of life support is regarded in different ways not only by each of the varied Jewish groups, but also as a reflection of the purpose of its use. For example, the use of life support in the case of temporary coma brought on by head trauma or recovery from major surgery would be seen as a good thing that helps to preserve life, because there will be a point in the future when it can be turned off and–hopefully–the patient will resume breathing and circulation functions for themselves.

The situations where the use of life support causes the most trouble are those where the patient has become reliant on the machinery, such that if the machine were turned off, the patient would probably not begin to breathe unaided. Some authorities subscribe to the idea that prolonging this state of supported life when there is no hope of a cure is not the same as attempting to save a life, and so need not be done. However, it is likely that each case will have to be treated on its own merits according to the beliefs of the patient concerned and the wishes of their family.

Resuscitation

Where resuscitation would possibly result in the saving of a life, it is imperative that it is carried out–even if that life were to last only a few minutes before death. If efforts have been made to resuscitate a person but no independent signs of life are seen, it is important to make sure that the moment of death is determined according to halakhah [Jewish law], rather than relying solely on brain death as a determinant.

Before Death

Before death, a Jewish patient will want to see as many of their family and friends as possible, so expect many visitors and make provision for them. Some of these visitors may be Jewish, some may not.

If possible, try to get a family member to discuss arrangements for visitors with you; for example, try to establish whether the visitors will need to be fed. If so, determine whether the family will make provision for the visitors, or whether they wish to purchase kosher food at the hospital. Don’t forget to warn the kitchen manager of the need for additional kosher meals to be provided if necessary.

Traditionally observant visitors that arrive on Friday may need to be accommodated if they do not manage to leave before the sun sets; they will not be able to travel once the Sabbath begins. You may need to provide a pillow and blanket so that they can sleep in a chair.

Other arrangements may need to be discussed with the patient or their family. A rabbi may need to visit the patients to hear their confession (viddui) and pray with them, so try to provide a quiet area or some privacy for this.

Talking to the Family

Because of the requirement to neither hasten nor delay death, some groups of Jews may feel that discussing impending death with a patient is a sinful activity, likely to worry them prematurely into death. It may be worth talking to a patient and their family before a diagnosis is made, about whether to reveal the full extent of a condition. This is an ethical minefield, and it is suggested that as much advice as possible is sought from medical peers and rabbinical sources to help you in this matter.

A dying Jew might request the presence of a rabbi at any time to go through the ceremony of viddui and to pray with him or her. Make sure that such requests are respected, and that the patient and rabbi are given peace and quiet to talk and pray together.

Reprinted with permission from Ethnicity Online, a website with resources about medical care of people of different religious and ethnic groups.

Looking for a way to say Mourner’s Kaddish in a minyan? My Jewish Learning’s daily online minyan gives mourners and others an opportunity to say Kaddish in community and learn from leading rabbis.

The post End of Life Issues: A Jewish Perspective appeared first on My Jewish Learning.