End of Life Issues: A Jewish Perspective
An introduction to Jewish attitudes toward life support, ceasing medical care, living wills, and caring for patients in their final days
The following article, written for hospital or hospice workers, is primarily geared to educate them about end-of-life issues for Jewish patients. As such, it also provides an introductory overview of Jewish attitudes toward ceasing medical care for terminally ill patients, living wills, and other issues of Jewish medical ethics. Reprinted with permission from Ethnicity Online, a website with resources about medical care of people of different religious and ethnic groups.
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.
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.
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.
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.
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, 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.
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