It took a Jerusalem geriatrician to turn a six-century-old commentary on Torah passages by a Polish rabbi into a contemporary guide to honoring and taking care of one’s elderly parents. The 161-page, Hebrew-language book is the fifth volume written by Dr. Ephraim Jaul, the director of complex nursing care at the capital’s Sarah Herzog Memorial Hospital.The modern Orthodox physician dedicated a previous book to his mother Rahel, who died in 2008 at the age of 85. A Hungarian- born Holocaust survivor who lived through Auschwitz and Bergen- Belsen, she was widowed and had a stroke, but nevertheless commented to him about chapters he was writing.His latest softcover volume, Hebetei Briut Ve’zikna Befeirush Kli Yakar La’Torah (Aspects of Health and Aging in Kli Yakar’s Commentary on the Torah), gives a voice to Rabbi Shlomo Ephraim ben Aharon Luntschitz.The one-time rabbi of Prague who was born in the Polish town of Lenczyk (Lunschitz) in 1550 and served as the dean of a yeshiva in Lvov (Lemberg) was dubbed the Kli Yakar (Precious Vessel) after his homiletic work that alluded to Proverbs 20:11. The commentary is still printed in many editions of the Five Books of Moses and continues to be popular in the observant community.A sickly man whose name Shlomo was added to Ephraim when he suffered a life-threatening illness, Lunschitz “had a socialist view and cared about the weak and the poor,” said Shaare Zedek Medical Center director-general Prof. Jonathan Halevy, who spoke at the book launching almost two weeks ago at Herzog.“The Kli Yakar became more gentle to others over the years, and he vowed to write his commentary on the Torah within a single year after recovering from his illness,” said Dr. Yehezkel Caine, Herzog’s director- general. “He had a very realistic but and optimistic view.”“The way one’s parents, when younger, devotedly took care of their elderly parents is a good model for you to give respect to your own parents and for your grown children to do the same for you,” said Shamai Keinan, voluntary chairman of the psychogeriatric hospital’s executive board for the last 15 years. “This volume is an inspiration for all of us on how to treat one’s parents properly when they age.”THE SELF-PUBLISHED book, which begins with a rabbinical endorsement from Chaim Yehoshua Zemel, the rabbi of Jerusalem’s Talpiot/ Arnona neighborhoods, is based on almost 100 verses from the Pentateuch on which the Kli Yakar comments.Never forced, Jaul’s elaborations on this commentary focus on maintaining good health in one’s youth to enjoy a healthier old age, how to honor one’s parents, and ways to avoid debilitation in one’s final years.Near the end of Genesis, Pharoah meets Jacob and, instead of simply querying about the age of the old-looking patriarch and father of his viceroy Joseph, asks: “How many are the days of the years of your life?” The Kli Yakar notes that Pharoah saw how weak, thin and wrinkled Joseph was, and thought that he “could die today or tomorrow.” Jacob was not so old, but he looked older because of the many fears he endured – of fleeing his angry brother Esau, his wife Rachel’s premature death, of mourning for his beloved son Joseph who, he thought had been torn apart by wild animals, of the years of famine at home and so on.The author goes on to describe how the skin ages; with the atrophy of muscle tissue the skin becomes thinner. But the aging process can be slowed by eating plenty of protein, and by doing aerobic (using the lungs) and anaerobic (utilizing the muscles) exercise.On the verse in Leviticus “You shall rise before a venerable person and you shall respect the elderly, and you shall fear your God. I am the Lord,” the Kli Yakar notes that one rises for the elderly because of the wisdom they have accumulated during their lifetime.Jaul notes further that we should not only rise, but also give aged family members our place and be concerned with their daily welfare, such as making sure they are dressed, bathed, fed and able to get about. We should also consider their emotional wellbeing, such as being able to continue to study. The Kli Yakar, said Jaul, clearly distinguishes between a person’s chronological age and one’s biological age (both physical and intellectual). Geriatricians can assess their functional ability.“When the doctor examines his functions, he should always learn the patient’s medical history, and the last question he should ask him is how old he is.”The passage in Deuteronomy that prohibits eating the raw blood of animals is expanded on by the Kli Yakar, who says that children learn goodness from their parents’ personal example, and they may imbibe cruelty from their example as well. Jaul refers to the “highrisk gene” discovered by his Herzog geneticist colleague, Prof. Richard Ebstein, in 2006. Parents may hand this gene down to their children.“It may be that in the future, a gene of cruelty may also be discovered,” Jaul suggested.“Most elderly persons function when living in the community and experience successful aging in their home with the support of family and community. Old age can be a source of power and vitality. It is a period when the person can discover himself/herself while performing introspection and searching for purposes and meaning, and channeling them towards giving to others, teaching and learning.”The aging process is accompanied by a decline in the function of various organs and systems, and in the prevalence of morbidity and mortality. Physiological age-related changes cause bone, muscle and joint weakness, and a decline in mobility. Their hearing, vision and reaction time are also affected. All of the above impede movement.Various diseases target the heart, blood vessels, brain and kidneys, and numerous types of medications need to be taken. The result is a decline in physical, mental and behavioral functions of the parents, and the children should know how to deal with the consequences.THE HERZOG geriatrician notes that “the medical care of old parents is a component of respecting one’s parents. Sometimes children do not know how to act when their parents present a decline in functioning.”As a result, Jaul compiled 10 rules of conduct relating to their medical and functional status, based on what he learned from Kli Yakar and from his decades of experience working with patients and observing families at Herzog.Rule #1 relates to adult children’s involvement in the care of parents.The children should be in contact and in various levels of involvement according to the parents’ functional state. Contact with the children is a source of vitality, happiness and satisfaction to the parents, he writes, and it gives purpose and meaning to their lives and prolongs their days.“Most medical consults I perform are initiated by children who notice health decline in the parents. In the ward as well, there is a lot of family involvement, resulting from sincere caring about the parents.Sometimes it is the family members who identify a problem first, while the caring team has not taken notice of it yet. The family is a source of information for understanding the medical, psychological and social background in order to plan an optimal continuum of care.”Rule #2 is that the elderly parents’ autonomy should be guarded.“One must set boundaries and consider the parents’ points of view. One must not reach decisions opposed to the parents’ views. For example, parents should not be forced to accept decisions considering changes in living arrangements, introducing unwanted caregivers and various decisions that the children deem correct.”Issues should be put on the table, heard, explained and justified according to the need. Sometimes the involvement of a neutral, professional and authoritative person is needed, with the parents’ approval, such as a doctor, social worker, or religious person, who can examine the situation and express his/her view considering the need for change.Rule #3 involves communication between family members and the elderly person.“The conversation should be suitable to the parent’s functional level. When there exists a cognitive decline, one should talk loudly and clearly, while using hand gestures and allowing lip reading.One should avoid using contemporary phrases and jargon they don’t understand, but instead should talk in simple words and clear, uncomplicated messages. It is helpful to sing songs from the past, use pictures and other illustrative measures and bring back memories from the distant past. The children need to be attentive and focused, show interest and make the parent take an active part in the conversation.Rule #4 encourages adult children to invest in quality time.“One must prepare and invest time in the visit. The children should prepare themselves prior to meeting with their old parents.They should think about topics for conversation, give attention and ‘treats.’ I remember that when I used to come to meet my mother in her twilight years, I would prepare myself for several minutes before entering by drawing several deep breaths and by silencing my mobile phone.“In the ward I see family members who come to visit and struggle to initiate contact and to fill the visiting time, sometimes sitting and reading a newspaper instead of speaking to them.I recommend that they communicate not only by talking, but also by touching, caressing, massaging, applying lotions and singing a childhood song that the patient relates to.”Rule #5 involves role changes.One should internalize the gradual functional decline of old parents, he advises.“Children often find it difficult to deal with their parents’ functional decline, their slowness and limitations in performing daily living activities. Children still see the parent as omnipotent and the family’s anchor. Parents currently require their children’s help in making decisions, while children struggle to cope with the new status of decision makers for their parents.”PHYSICAL CARE is the subject of Rule #6. Jaul advises adult children (and daughters- or sons-in law) to refrain from performing physical care of their parents by themselves (bathing, dressing and feeding).Paid caregivers should be employed to do this.“Respecting the parents means also being modest in front of their offspring. Children who presume that respecting the parent requires them to bathe and dress the parent are mistaken. It is better to pay for extra care and not have a daughter or daughter-in-law bathe or diaper the mother, or a son bathe or dress the father. Children should provide accessories to enable easier functioning, and pay for additional care hours beyond those provided by law,” Jaul writes.One should refrain from distributing the parents’ possessions prior to their death, says Jaul in Rule #7.“Financial issues are complicated and highly emotional. Some parents need help and involvement of their children in managing their affairs, in fear of being mistreated by strangers.” On the other hand, one must ascertain that there is no exploitation by the children regarding money and property.“An appropriate legal tool, such as a guardian or a legal power of attorney, or advance directives, should be in place. Elderly functioning parents will guard their money for their twilight times and will not distribute to their children in fear of want.”The dilemma of leaving parents in their home or relocating them to a home suitable to their needs or to a home for the elderly is dealt with in Rule #8.“After the death of a spouse, because of medical and functional decline when the sense of loneliness and detachment worsens and when the sense of personal safety is shaken,” the difficult question of whether to sell their personal home comes up.“Sometimes parents prefer to remain at home and are fearful of change and of becoming a burden on their children. The children, on the other hand, see that the function has deteriorated and the needs have changed. In either case, the decision concerning relocation or adjusting the housing should be based upon medical/functional criteria and be social and respectful, in order to provide the optimal quality of life and care.”The change to be made should aim to improve the quality of life and adjusting the housing to the decline in functioning, and to the changing needs of the old parent, he recommends.Adult children should make an effort to understand their parents’ medical conditions, according to Rule #9.“Be well-informed concerning the parents’ illness and the medications they take. Do not hesitate to request a second opinion if the complaints or medical conditions do not improve or when there is suspicion of side effects from medications,” writes Jaul.“Seek medical treatment for their complaints such as pain, discomfort or constipation – and do not accept replies such as ‘they are old, and there is nothing to do.’ Be on the alert for any suspicious incidents of violence or neglect from caregivers; don’t hesitate to install hidden cameras.Finally, children should be kind to parents, writes Jaul about his Rule #10.“Don’t try to re-educate them, correct them over meaningless points that don’t endanger them or contradict or confront them.”Relate happy news about the grandchildren and themselves rather than complaining about problems that occur.“Simply be kind to them, and the kindness will be reciprocal.”Dr. Ephraim Jaul can be contacted by email at firstname.lastname@example.org.