How do you deal with end-of-life issues?

Tzohar’s community service to help families

 The success of medicine has cast a shadow. (photo credit: UNSPLASH)
The success of medicine has cast a shadow.
(photo credit: UNSPLASH)

Jonathan Swift, the 18th century satirist and poet, wrote: “Everyone desires long life, not one old age.” While the birthday wish of “May you live until 120” (ad me’ah v’esrim) is well known, the vagaries of aging prevent us from reaching that lofty goal. 

Advances in medical science have enabled people to live longer than previous generations – the average life expectancy in Israel has increased from 72 years in 1971, to 83 in 2020 – but the last years of life are frequently accompanied by chronic illness, dementia, pain and suffering. 

Recently, Tzohar, the rabbinic organization that provides a variety of Jewish lifecycle programs for Israelis of all affiliations, introduced a new service for the community – “Ad Me’ah V’esrim” – to help families deal with the difficult end-of-life decisions that often need to be made by patients’ families. 

While the free service was opened during the height of the corona pandemic, when families were dealing with the deteriorating health of their loved ones, the underlying medical issues have been occurring with greater frequency for many years. Families frequently must deal with questions such as:

•Should CPR be continued at any cost?

•May feeding someone who is about to die be discontinued?

•Should treatment, when there is no hope for a positive outcome, be continued?

•Is it permissible to use pain relievers even if some carry risks of shortening the lifespan of the critically-ill patient?

•What should be done in the case of a patient who wants to cease treatment?

Rabbi Yuval Cherlow, who leads Tzohar’s Center for Jewish Ethics, and is one of the organization’s founders, explains the need for the service: “The success of medicine has cast a shadow. There is a longer lifespan, but the separation between body and soul is more common. Sometimes, the body can be healthy, but the mind is demented, or the opposite – the mind is sound, but the body rebels. This brings up many questions. 

 Tzohar is helping families make the difficult decisions (credit: UNSPLASH) Tzohar is helping families make the difficult decisions (credit: UNSPLASH)

“In addition, medicine can extend a person’s life for many years — such as the case of prime minister Ariel Sharon (who suffered a stroke in January 2006 and remained in a vegetative state until his death eight years later.) Over the years, the principle of the patient’s autonomy became a priority; today, doctors cast the major, difficult decisions on the family.”

Cherlow, who heads Yeshivat Hesder Amit Orot Shaul in Tel Aviv, and is a recognized decisor in matters of medical ethics and Jewish law, decided to develop a professionally trained staff at Tzohar that would meet the needs of those approaching end-of-life issues. 

Tzohar rabbis studied the medical, ethical, and halachic concerns in end-of-life issues, along with experienced social workers who have the skills to effectively communicate with families who find themselves dealing with traumatic life-and-death medical matters of their relatives. 

The organization has trained 10 teams of rabbis and social workers who respond to calls to its hotline, and meet with families to help them reach a decision on treatment for their loved ones from an ethical, halachic, and family standpoint. Cherlow emphasizes that the last point is particularly significant. 

“We need to remember that there is a ‘day after.’ If, after everything, the family will be torn apart (due to conflict or disagreement), we may have solved one problem, but we will have created another.”

A TYPICAL case that is referred to Tzohar, says Cherlow, is when someone suffers a stroke, is incapacitated, and cannot communicate. Frequently the patient did not leave instructions as to his treatment in the event of incapacitation. The patient may be critically ill, and the relatives do not know how to proceed. 

“The medical staff will ask the family what they want them to do,” says Cherlow. “This is the classic situation, but there is no one standard situation because each case has different aspects and circumstances.” In these cases, he explains, the family must choose whether to fight for the life of their loved one, or if the circumstances dictate, take a palliative approach. “It can be very difficult to reach a decision,” he notes. 

Cherlow continues: “We usually think that the family represents the best interests of the patient and knows what they would want. Occasionally, though, the family does not work for the patient’s best interest. Sometimes, the family wants to be able to say, ‘We did everything we could,’ so that they won’t have any pangs of conscience, even though what they did was not in the best interest of the patient.” 

It is not always advisable to take heroic measures. On the other hand, he says, “there are times when the family doesn’t do enough and will say, ‘We can’t take him home. It’s enough,’ and that may also not be in the best interest of the patient.”

Cherlow says that an essential part of the dynamic of the decision-making process that Tzohar provides is to encourage the family to make their decision based on the patient’s best interests, not only according to the family’s difficulties or mental distress.

Many families are under the mistaken impression, he says, that Jewish law obligates them to fight to save the patient’s life until the very end, no matter the circumstances. They are often surprised to learn that halacha (Jewish law) recognizes that a certain stage in the patient’s condition, “enough is enough,” and the patient is permitted to reach the end of life without heroic measures. 

DEBBIE BRAITBARD, a geriatric social worker for 30 years, manages the social workers in the Ad Me’ah V’esrim program. The training program consisted of four sessions, each between four and five hours, with doctors, nurses, rabbis and hospital social workers. Topics include medicine, palliative medicine, the study of the Jewish laws regarding the end of life, and the Israeli regulations regarding the treatment of terminal patients. Braitbard adds that a special meeting was dedicated to the connection between the social worker and the rabbi, and their joint work with families. 

Since the program started, all the meetings between Tzohar staff and families have been conducted on Zoom. While initially, due to corona, virtual meetings were a matter of necessity, Braitbard says that there are some distinct advantages in holding family meetings in this manner. First, she explains, Zoom meetings are logistically preferable when family members are scattered throughout the world. 

“In a Zoom meeting, I can see every face in the meeting and see their reactions,” she adds. “It makes a difference in how we answer, and they can all see each other.”

Braitbard says that the cooperative nature of the meetings has been beneficial for both the rabbis and the social workers. “We learn the halachot from the rabbis, and they learn from us to understand what the family is going through, amid the idea of being there for the family – not only to present the law but to show empathy.”

She mentions one case where an aged father was quite ill and had to be intubated each time he was hospitalized. The doctors told him he would require permanent intubation if the need for intubation arose again. The father’s four adult children had to decide if they should intubate their father or let nature take its course. Of the four children, three were not observant, and one had become newly religious. The family approached Tzohar, asking if they should intubate the father. 

The primary reason that they came to Tzohar, explains Braitbard, was because of their religious brother. “We sat with them for two hours, and in those two hours, they listened to their brother, and they heard each other.” Together, the members of the family reached the decision that they would intubate their father if it were needed. Their father died two days later, before any further intubation was performed. 

After their father’s death, family members thanked Braitbard and Tzohar, saying that they helped keep the family together. “The most important thing,” she adds, “is that the family remains a family. If a decision is made without everyone’s consent, there will be no family left afterward. If the family stays together, that means we did our job. That’s what we feel.” 

Prof. Charles Sprung, Director Emeritus, General Intensive Care Unit at Hadassah Ein Kerem Medical Center, is a member of the Advisory Committee of the Tzohar initiative. He has had extensive experience in intensive care and was the Director of the Medical Intensive Care Unit at the University of Miami for 12 years before making aliyah. After coming to Israel, he served as Director of the General Intensive Care Unit at Hadassah for more than 30 years, treating many critically ill patients and dealing with their families.

Sprung, who has been researching end-of-life decision-making and practices in Israel, Europe, and around the world in his academic work at Hadassah and as a professor at The Hebrew University of Jerusalem, says that “The two major ethical issues in the intensive care unit are triage and end-of-life decision making.” 

He adds that “The biggest problem in the ICU is that there are too many patients, too much work, and not enough time to spend doing the things we’d like to do – and one of them is dealing with families.” 

The Tzohar program, with the combination of a rabbi and a social worker, he says, can provide support in terms of knowledge and information and “getting the families to understand that there are no right answers in these difficult issues.”

Recalling his early years in Israel, Sprung says that 30 years ago, when he would meet with families whose father or husband was critically ill, he would ask them which course of treatment they preferred for their loved one. He would explain the patient’s condition and tell them that he could treat the situation aggressively, even if there was only a slight chance of success, or adopt a palliative form of treatment, in which case the patient might not survive but would experience less pain. 

“It was important for me to know what the patient would want,” says Sprung. “They would say to me, ‘You are the professor – you tell us.’” 

At that time, families did not discuss these issues beforehand, and the family usually had no idea what the patient wanted. Today, he reports, the situation has changed. “People are more knowledgeable, they ask more questions, and they are receptive to questions about ‘what do you think your loved one would have wanted?’” he says. 

He adds that rabbis, physicians, and nurses can help doctors responsible for treating patients by getting the information from them to make an informed medical decision. It is important, he says, that family members not think that it was their decision to limit therapy and perhaps let their loved one die. They need to understand that it was a medical decision, and they were providing the needed information for the physicians to make the right medical decision. 

CHERLOW, BRAITBARD and Sprung agree that having advanced medical directives – knowing what the patient wants beforehand – is extremely helpful. Conversely, not preparing any medical directives or instructions can lead to indecision and chaos.

“I emphasize,” says Sprung, “that by the time patients come to the ICU and doctors are having these discussions with family members, the ‘horse is out of the barn.’ So many patients have been seeing oncologists, hematologists, and cardiologists for months at a time, and no one has had these conversations. They should be happening at the doctor’s office.”

Sprung is referring to several documents – the durable power of attorney, known in Hebrew as yipui koach mitmashech, that allows individuals to plan for their future and appoint individuals to make financial, personal, and medical decisions, should they lose the mental capacity to make those decisions. 

The document, which must be prepared in consultation with a lawyer trained in this field, enables the individual to provide instructions as to what they want to be done in these three areas. In addition, Israel’s “Terminally Ill Law” enables individuals who have decision-making capacity to either appoint a proxy (yipui koach in Hebrew) or provide specific instructions regarding their care if they become terminally ill and are unable to make decisions themselves. The forms for these documents can be downloaded from the Health Ministry’s website (see box). 

The Hebrew Tzohar website (ad120.tzohar.org.il) on end-of-life issues features basic information and guidance on the subject, and is being translated into English and other languages. The English site is already accessible at www.ad120.tzohar.org.il/about/. While no one desires the difficulties that often accompany aging, Tzohar is attempting to provide the ethical and halachic guidance to make those moments more bearable.