Issues

Spiritual and Ethical Issues Physicians Face in Serving the Over-80 Population: 

Spiritual and Ethical Issues Physicians Face in Serving the Over-80 Population Barry M. Kinzbrunner, MD Chief Medical Officer Vitas Hospice Services Miami, Florida

Melting Pot Society: 

Melting Pot Society Associated with US society in the 1950s and before through 1970s “Model” Immigrant Groups Shed their historic identities and adopt the ways of their new country Assimilation into one amalgamated culture with shared values and norms

Multiculturalism: 

Multiculturalism More recent phenomenon Started in late 1970s following popularity of “Roots” Increased interest in identifying with one’s “roots” or cultural/ethnic origin Has become increasingly important in US African American --Hispanic Asian --Eastern European Religious groups

Hospice Perspective: 

Hospice Perspective Original concept resembled “Melting Pot” Society Generic “Chaplain” to meet “Spiritual needs” Currently about 40% of dying patients receive hospice before death Ethnic and cultural barriers identified Mistrust of healthcare system Informing individual may hasten death Mandate to “preserve life” at all costs Proscription to concept of “giving up”

Hospice Perspective: 

Hospice Perspective Attempt to reach out to patient groups not already accessing hospice Chaplains of multiple faiths available either on staff or contracted Understanding needs of specific ethnic/cultural religious groups Diversity and access programs Inner City Language specific Teams for specific ethnic/cultural/religious groups

Jewish Hospice as a Paradigm: 

Jewish Hospice as a Paradigm Staff Education Jewish Medical Ethics Different levels of observance Prayer obligations and rituals Dietary Laws: Kosher Sabbath and Holidays Holocaust Survivor Issues Care at time of Death Mourning and Bereavement

Medical Ethical Values: 

Medical Ethical Values Autonomy Beneficence Non-Maleficence Justice Social Distributive

Autonomy: 

Autonomy The right of an individual to choose between various alternatives presented to them

Extent of Autonomy: 

Extent of Autonomy Autonomy is voluntarily limited Decisions are made that are consistent with God’s law The Rabbi, the expert in God’s law, provides advice and counsel regarding health care decisions.

Beneficence: 

Beneficence The obligation to provide and accept beneficial treatment

Beneficence: 

Beneficence Physicians are required to treat and assist every patient. The patient-physician relationship is considered as a covenant, rather than a contract. The physician is duty bound to treat any patient for his benefit. Man is obligated to care for his health and life

Non-Maleficence: 

Non-Maleficence Avoidance of harm Question of how much of an effect it plays in secular ethics since most treatments have risks

Justice: 

Justice Social Justice: Determining what is good for the society as a whole Distributive Justice: The distribution of limited resources.

Justice: 

Justice Social Justice Triage First come, first served If 2 patients come at the same time: the one in greatest medical danger takes priority If both are equal in medical needs-a hierarchy in social worth is stipulated

Justice: 

Justice Distributive Justice Gittin 45a “One may not ransom captives for more than their value, for the benefit of society.” Allows society to set financial priorities when resources are limited Allows for limited rationing of health care under certain conditions

End of Life Decision Making: 

End of Life Decision Making Only applies to patients who are terminally ill Guidelines: Decisions in Judaism, like hospice care in general, are made on a case-by-case basis Involvement of a Rabbi who is knowledgeable in the area

Terminal illness in Jewish Law: 

Terminal illness in Jewish Law Prognosis of 1 year or less Goses “Actively dying” Presence of “death rattle” Only basic needs may be provided Other interventions are prohibited

Assisted Suicide/Euthanasia: 

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

Refusal of Medical Treatment: 

Refusal of Medical Treatment Patients may refuse treatment if the treatment: is not proven to be efficacious is clearly futile entails great suffering or significant complications Steinberg, A: A Jewish perspective on the four principles. Chapter 7. Principles of Healthcare Ethics, John Wiley & Sons, Ltd, 1994.

Withdrawing and Withholding: 

Withdrawing and Withholding Secular Medical Ethics Withdrawal and Withholding are the same. Recently some ethicists are even advancing the argument that withdrawal is more ethically sound than withholding Jewish Medical Ethics Withdrawal and Withholding are different.

Withdrawing and Withholding: 

Withdrawing and Withholding WITHHOLDING is permissible when the active intervention will delay the dying process or the terminally ill patient is experiencing pain and suffering that will not be relieved by the intervention WITHDRAWING of life support and other interventions is generally not permissible according to Jewish law, unless the intervention is clearly viewed as an “impediment to death.” Iggros Moshe, Choshen Mishpat II:74 in Tendler MD: Responsa of Rav Moshe Feinstein, NJ, Ktav Publishing, 1996. Lamm M: Commentary in NIJH Jewish Living Will, California, NIJH, 1992.

Pain and Suffering: 

Pain and Suffering Judaism does not espouse pain and suffering as a virtue One may not hasten death, however one may withhold treatment or remove impediments to death that prolong life in the face of pain and suffering

Pain and Suffering: 

Pain and Suffering Treatment of physical pain with opioids and other medications is mandatory Opioids should NOT be withheld in the face of intractable pain, even if there is a concern that death may be hastened Judaism also recognizes the importance of treating mental anguish and suffering

CPR: 

CPR CPR may be withheld from or refused by terminally ill Jewish patients because: CPR is ineffective therapy for terminally ill patients CPR may cause harm in terminally ill patients

Nutrition and Hydration: 

Nutrition and Hydration Food and fluid are considered basic care by most Rabbis Therefore, even when provided by artificial means, most Rabbis do not consider their provision to constitute a medical intervention

Nutrition and Hydration: 

Nutrition and Hydration Iggros Moshe, Choshen Mishpat II:74 Translation I: “Quite clearly, providing food to the patient is beneficial.” Translation II: “Clearly, we must feed him food that will cause him no harm. I: Tendler MD: Responsa of Rav Moshe Feinstein, NJ, Ktav Publishing, 1996. II: Berman A: From the legacy of Rav Moshe Feinstein, z”l. Journal of Halacha and Contemporary Society 13:5, Spring, 1987.

Tube Feeding in Patients with DementiaA Review of the Evidence: 

Tube Feeding in Patients with Dementia A Review of the Evidence Review of published evidence regarding BENEFITS of tube feedings: No reduction in aspiration pneumonia risk No effect on clinical markers of nutrition No improvement in patient survival No improvement or prevention of decubitus ulcers No reduction in infection risk No improvement in functional status or slowing of decline No improvement in patient comfort Finucane TE, Christmas C, Travis K, JAMA 282:1365, 1999

Tube Feeding in Patients with DementiaA Review of the Evidence: 

Tube Feeding in Patients with Dementia A Review of the Evidence Review of published evidence regarding HARMFUL effects of tube feedings: Mortality Perioperative mortality 6-24% 30 day mortality 2-27% 1 year mortality > 50% Aspiration 0-66% Local infection 4-16% Occlusion 2-34% Leaking 13-20% 2/3 of NG tubes require replacement Fincune TE, Christmas C, Travis K, JAMA 282:1365, 1999

Nutrition and Hydration: 

Nutrition and Hydration Food and fluid should be provided in a fashion that provides benefit and avoids harm Competent patients may refuse artificial hydration or nutrition, but caregivers should try and convince the patients to accept the intervention

Nutrition and Hydration: 

Nutrition and Hydration If it is determined that the food or fluid is without benefit or harmful artificial support may be avoided after consultation with a Rabbi One may not forcibly feed or hydrate a goses

Informed Consent and Truth Telling: 

Informed Consent and Truth Telling The better informed a patient is, the easier it usually becomes to cope with reality. The patient has a legal and ethical right to know the truth. Patients who want to know will ask questions. Answers should be answered honestly and include hope for improvement, even it is improvement in symptoms rather than disease. Lamm M: Caring for the Jewish Terminally Ill. NIJH, California, 1990.

Informed Consent and Truth Telling: 

Informed Consent and Truth Telling Respect Denial Patients who do not want to know will not ask questions Avoid providing unrequested information Needs of the patient are primary. Decisions as to sharing information with family should be determined in this context. Lamm M: Caring for the Jewish Terminally Ill. NIJH, California, 1990.

Informed Consent and Truth Telling: 

Informed Consent and Truth Telling Jewish Law permits withholding facts about a patient’s condition if that will contribute to the welfare of the patient. Source: Shulchan Aruch. Yoreh Deah 337 The challenge is HOW to impart the seriousness of the condition to the patient, not whether to do so. Lamm M: Caring for the Jewish Terminally Ill. NIJH, California, 1990.

Advance Directives: 

Advance Directives Health Care Proxy: Designates who will make health care decisions if one becomes incapacitated. Living Will: instructions by the patient on interventions they desire or do not desire should they be in a terminal condition and cannot express their wishes.

Advance Directives: 

Advance Directives Health Care Proxy Permissable by most Includes designation of a Rabbi to advise the proxy agent on halachic matters Living Will More controversial Not accepted by all because of concern over lack of Rabbinic consultation

Different Levels of Observance: 

Different Levels of Observance Orthodox Conservative Reform Reconstructionist Secular

Prayer Obligations and Rituals: 

Prayer Obligations and Rituals Prayer 3 times a day, 7 days a week Tallit: Fringed Prayer Shawl Tefillin: Phylacteries Black leather boxes with leather straps Worn on left arm and forehead Worn during morning prayers, except on Sabbath and holidays Prayer Quorum Minyan: 10 men (orthodox) or persons Required for certain prayers including Kaddish

Dietary Laws: Kosher: 

Dietary Laws: Kosher Separate dishes for Meat and Dairy Not cooking meat and dairy together Meat: Cloven hooves and chews cud Properly koshered meat Ritual slaughter Inspection for defects Salting to remove blood Proper certification of store bought products Fish: fins and scales No mollusks or arthropods Availability of Kosher food in hospice inpatient units

Sabbath: Shabbat: Shabbos: 

Sabbath: Shabbat: Shabbos Friday evening 1/2 hour before sundown until Saturday 1/2 hour after sundown Candle Lighting, Kiddush, Shabbat meals Synagogue service, Torah reading Prohibited activities include: Cooking Electricity usage Travel Writing Havdalah service at the end of the Shabbat Suspension for life threatening situations or to relieve pain and suffering

Holidays: Yomim Tovim: 

Holidays: Yomim Tovim Three Biblical Festivals Passover Matzah No Chometz to be brought into the home Seder Shavuos: Ten Commandments Succos Lulav and Esrog Succah

Yomim Tovim:Holidays: 

Yomim Tovim:Holidays Rosh Hashana: Jewish New Year Shofar Yom Kippur and fast days Chanukah Chanukah candles Dreidle Purim Megillas Esther Shaloch Manos

Vidui: Confessional Prayer: 

Vidui: Confessional Prayer Special prayer said when death may be near Shulchan Aruch Yoreh Deah 338:1 When a man is about to die, we tell him to say Viddui. We tell him, ‘Many have uttered the confession and not died, and many have not uttered the confession and died. The reward for saying the confession is that you shall live, for whoever says the confession acquires a place in the afterlife.

Jewish Concepts of the Afterlife: 

Jewish Concepts of the Afterlife World of Souls Gan Eden: Paradise Gehinnom: Punishment and Purification Resurrection of the Dead Olam HaBah: TheWorld to Come The world of resurrected life after the Resurrection of the Dead Gilgul: Reincarnation

Care at time of Death: 

Care at time of Death Initial Care In last minutes no one should leave unless emotions uncontrolled or physically ill After death, eyes and mouth are closed, and face is covered with a sheet Feet should face the doorway, otherwise the body should not be moved Candle near the head of the deceased or all around the room (except on Shabbat) Lamm M; The Jewish Way in Death and Mourning. NY, Jonathan David, 1969

Care at time of Death: 

Care at time of Death Initial Care Cover mirrors in home Recitations of Psalms Respect for deceased Ask deceased for forgiveness No eating, drinking, or smoking Contact Rabbi and/or Chevra Kadisha Shomer: Watcher, a friend or family member who remains with the body until burial Lamm M; The Jewish Way in Death and Mourning. NY, Jonathan David, 1969

Care at time of Death: 

Care at time of Death Chevra Kadisha: Burial Society Jews who are knowledgeable in the proper care of the deceased prior to burial Physical cleansing and preparation of the body Prayers for the deceased Preparation should not be performed by non-Jews Lamm M; The Jewish Way in Death and Mourning. NY, Jonathan David, 1969

Care at time of Death: 

Care at time of Death Autopsy limited by Jewish law: Governmental Jurisdiction Hereditary diseases for benefit of survivors Help another specific person All body parts must be returned for burial Embalming generally prohibited Cremation forbidden even against deceased wishes Lamm M; The Jewish Way in Death and Mourning. NY, Jonathan David, 1969

Mourning and Bereavement: 

Mourning and Bereavement 5 Stages of Mourning Aninus: period between death and burial Shivah: 7 day period after burial Days 1-3: Intense mourning Days 4-7: Somewhat less intense mourning Sheloshim: 30 day period after burial includes Shivah 12 month period after burial includes Shivah and Sheloshim Lamm M; The Jewish Way in Death and Mourning. NY, Jonathan David, 1969

Mourning and Bereavement: 

Mourning and Bereavement Aninus Period between the death and burial Bereaved focuses final arrangements for the deceased. Bereaved is not obligated to participate in certain religious observances related to prayer. Bereaved refrains from the social and personal activities that are traditionally forbidden during shiva Lamm M; The Jewish Way in Death and Mourning. NY, Jonathan David, 1969

Mourning and Bereavement: 

Mourning and Bereavement Funeral Usually takes place within 24 hours Plain Wooden Casket with no metal Burial Shroud Body is not viewed Keriyah: Tearing of the Garment Men: by heart, women: left side near collar Use of black ribbon by Conservative and Reform Lamm M; The Jewish Way in Death and Mourning. NY, Jonathan David, 1969

Mourning and Bereavement: 

Mourning and Bereavement Funeral Special Prayers Psalms, including Psalm 23: “The Lord is My Shepherd” K’ail maleh rachamim: “God, full of compassion” Asks God to treat the returning soul with mercy, kindness, and peace. Eulogy Praises of the deceased Delivered by officiating rabbi and/or family Lamm M; The Jewish Way in Death and Mourning. NY, Jonathan David, 1969

Mourning and Bereavement: 

Mourning and Bereavement Funeral Complete Internment of the Body Dirt from Israel Mourners and others participate in burial of casket Burial should be completed under observation Kaddish: Mourner’s prayer praising God Recessional "May God console you among the other mourners of Zion and Jerusalem." Lamm M; The Jewish Way in Death and Mourning. NY, Jonathan David, 1969

Mourning and Bereavement: 

Mourning and Bereavement Kaddish Central prayer in Jewish liturgy Aramaic: Language of the people Motif of prayer: Blessing and praising of God’s name Recited a minimum of 13 times during morning prayer services Marks separation of parts of and end of service Completion of study of a Jewish source or text Requires a prayer quorum (10 men or individuals) to recite Different versions: Full Kaddish, Half-Kaddish, Rabbi’s Kaddish, Burial Kaddish, Mourner’s Kaddish Lamm M; The Jewish Way in Death and Mourning. NY, Jonathan David, 1969

Mourning and Bereavement: 

Mourning and Bereavement Shiva: 7 Day Period of Mourning Meal of Consolation First meal after returning from funeral Traditionally provided by others Days 1-3 Intense mourning No greetings aloud Days 4-7 Less intense mourning Greetings permitted Lamm M; The Jewish Way in Death and Mourning. NY, Jonathan David, 1969

Mourning and Bereavement: 

Mourning and Bereavement Shiva: Prohibited activities leaving the house shaving and grooming bathing for pleasure working or conducting normal business activities wearing new or freshly laundered clothes engaging in conjugal relations Lamm M; The Jewish Way in Death and Mourning. NY, Jonathan David, 1969

Mourning and Bereavement: 

Mourning and Bereavement Shiva Mourners wear torn garment or ribbon Prayer services are held in house of mourning Prayer Quorum (Minyan): 10 men or persons Kaddish Mirrors in home remain covered Candle remains lit for entire 7 days Shiva “suspended” for Sabbath Lamm M; The Jewish Way in Death and Mourning. NY, Jonathan David, 1969

Mourning and Bereavement: 

Mourning and Bereavement Shloshim: 30 Days 30 Days includes Shiva period Following Shiva: Mourners begin to reintegrate into society May leave house and work Avoid celebratory functions especially with music May not shave or groom Obligation to recite Kaddish with a prayer quorum Lamm M; The Jewish Way in Death and Mourning. NY, Jonathan David, 1969

Mourning and Bereavement: 

Mourning and Bereavement 12 Month Period Count includes Shiva and Shloshim Following Shloshim: For loss of parents only Avoid celebratory functions especially with music Obligation to recite Kaddish with a prayer quorum in all daily prayers for 11 months Lamm M; The Jewish Way in Death and Mourning. NY, Jonathan David, 1969

Mourning and Bereavement: 

Mourning and Bereavement Ongoing Memorialization Yahrzeit On anniversary of death 24 hour candle Recitation of Kaddish in a prayer quorum Yizkor Special Memorial services Held on Yom Kippur and on the final holy day of the 3 fesivals Lamm M; The Jewish Way in Death and Mourning. NY, Jonathan David, 1969

Mourning and Bereavement: 

Mourning and Bereavement Bereavement Support Shiva visit Support in observing shloshim and 11 months of mourning for parent Working with community rabbis Individual Counseling Groups Biblical narratives as a paradigm Lamm M; The Jewish Way in Death and Mourning. NY, Jonathan David, 1969 Cirlin: Leaving Egypt, A Jewish Model for Facilitating Bereavement Groups. NHO Conference, 1999.

Jewish Hospice: Programming: 

Jewish Hospice: Programming Rabbis on Staff Holiday Services Tallis and Tefillin Prayer tapes Viddui Yiddish Conversation

Jewish Hospice: Programming: 

Jewish Hospice: Programming Community Networking Bikur Cholim Chevra Kadisha Community Rabbis Synagogues Long term care facilities Jewish Federation

Patients and Families Come First: 

Patients and Families Come First There is no set approach to delivering culturally competent care, however we can respect and learn from our patients and families.