Ari Ciment Halacha part 1-6

Withholding of care: Jewish approach 1/6 : 

Withholding of care: Jewish approach 1/6 Ari J. Ciment MD FCCP Pulmonary and Critical Care Attending Associate Professor of Medicine Mount Sinai Hospital and Nova Southeastern

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Special thanks to: Rav Avraham Steinberg E-daf.com Hebrewbooks.org Halakhah.com : online Soncino Babylonian Wikipedia Rav Akiva Tatz Dr. Daniel Eisenberg Rabbi Dr. Howard Apfel Rabbi Dr. Edward Reichman Rabbi Yochanan Zweig/Rabbi Yackov Gross Withholding of care: Jewish approach

Highlights of the History of Cardiopulmonary Resuscitation (CPR) : 

Highlights of the History of Cardiopulmonary Resuscitation (CPR) 1740 The Paris Academy of Sciences officially recommended mouth-to-mouth resuscitation for drowning victims. 1767 The Society for the Recovery of Drowned Persons became 1 st organized effort to deal with sudden and unexpected death. 1891 Dr. Friedrich Maass performed the first equivocally documented chest compression in humans. 1903 Dr. George Crile reported the first successful use of external chest compressions in human resuscitation. 1904 The first American case of closed-chest cardiac massage was performed by Dr. George Crile. 1954 James Elam was the first to prove that expired air was sufficient to maintain adequate oxygenation. 1956 Peter Safar and James Elam invented mouth-to-mouth resuscitation. 1957 US military adopted mouth-to-mouth resuscitation method  to revive unresponsive victims. 1960 Cardiopulmonary resuscitation (CPR) was developed. Withholding of care: Jewish approach

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“ DO NOT RESUSCITATE” or " DNR " : legal order written either in the hospital or on legal form to respect wishes of patient to not undergo CPR or ACLS if heart stopped or if they were to stop breathing. Requested by patient or POA Other places: "allow natural death" or "AND" or “DNAR” DNR sounds as if something important is being withheld Documentaton is tricky stuff…. 5 % of patients who require ACLS outside hospital survive 15 % of patients who require ACLS while in hospital survive Withholding of care: Jewish approach

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If DNR, no CPR and ACLS CPR guidelines Withholding of care: Jewish approach

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DNR doesn’t affect any Rx. other than that which would require intubation or CPR Possibly continue chemotherapy, antibiotics, dialysis, blood, pressors and antiarrythmics …. Withholding of care: Jewish approach

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Withholding- not starting a therapy that is not currently being given… Most lenient Sometimes allowed or even obliged Withdrawing- death is direct effect Mostly forbidden Withdrawing therapy administered intermittently- withdrawing during interval btwn administrations- intermediate btwn a and b… Pretty controversial Withholding chemo, not operating on high-risk patient Withdrawing ventilator on vent-dependent patient Stopping intermittent dialysis or stopping antibiotic between doses Withholding of care: Jewish approach

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5 key principles that commonly apply to medical ethics are: Autonomy Non-maleficence Beneficence Justice Professional-Patient relationship Withholding of care: Jewish approach

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Beneficence (QOL) and Autonomy Non-maleficence (can’t remove any life!!) Case of withholding or withdrawing ventilator on suffering patient… ETHICAL DILEMMA Withholding of care: Jewish approach

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Non-maleficence ( too much pain) Non-maleficence (can’t remove any life!!) Case of withholding or withdrawing ventilator on suffering patient… ETHICAL DILEMMA Withholding of care: Jewish approach

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Withdrawal of care: Jewish approach

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SYSTEMS GOVERNING HUMAN SOCIAL BEHAVIOUR Dr T. Thirumoorthy Singapore Medical Association Withholding of care: Jewish approach