There are many reasons why it is difficult to talk about the period of time we call the end of life. Most obviously, it is a subject we would prefer to consider theoretical. But, like many aspects of life that are difficult to discuss, our approach to the end of life is an important topic that is often misunderstood.
In working with Seasons Hospice and Palliative Care as the director of Jewish Hospice Services, I have gained some insights into the end of life experience. Written with the encouragement of those involved in end of life within the frum community, this short series will shed some light on how we approach this part of life as frum Jews. Future articles will focus on how to plan ahead and on ways to find meaning and strength even when life is limited. In this article, we will provide an overview of the halachos, values, and practical realities that guide our thinking about this issue.
Different Approaches
For someone nearing the end of life or caring for someone in this situation, it is a time often marked by confusion, stress, and tension. In many ways, this has been exacerbated by the many innovations that modern medicine has made available to us. Having to learn about the relevant medical and halachic issues in the moment compounds the challenge and is hardly conducive to good decision making. In some ways, it provides a stark contrast to the way the Torah describes the last days of many of our tzadikim. From Yaakov Avinu to Moshe Rabbeinu, from Dovid Hamelech to Rabbi Shimon bar Yochai, their final days were a sacred opportunity to instruct their children and students, a natural final chapter of their life’s work. Obviously, not all of us can merit this zechus. But with a little education and preparation, we can hope to bring more peace, calm, and meaning to our loved ones’ final days.
When writing about such an important yet sensitive subject, a preemptive caveat is in order: there is no single correct approach to making the decisions that arise at the end of life. There are different halachic opinions about many critical issues, and there are different attitudes about when various approaches are appropriate. Each person will have different priorities as to what is most important to him or her: it may be a desire to be free from pain, to stay at home, or to attend a family simcha. In this article, our goal is to present the issues and options, as well as the mainstream halachic approach. Armed with this information and in consultation with one’s rav and doctor, we hope that each person will have more confidence and competence in approaching the questions that arise.
When Is the End of Life?
We often think of the end of life as the last few days before someone passes away. While there are many questions that are unique to those few days, many other issues are relevant weeks and months before that point. Hospice care, which will be discussed later, is accessible to people who have six months to live. And many questions will arise sooner than the very end. While our minds may change over time – and we can always revisit our decisions – it is never too early to begin considering a plan of care.
The Torah’s Values
The Torah values life: whether that life lasts for years or moments, whether that life is filled with joy, physical ability, and spiritual accomplishment, or whether it is accompanied by extreme physical limitations or even unconsciousness. When someone’s life is in danger on Shabbos, we violate Shabbos to preserve it, even if we know that the person will be able to survive for only a short time. Frum Jews will go to incredible lengths to pursue any treatment, chase any remedy, and amass any zechus that might help cure an illness that doctors have pronounced incurable. We have all heard stories of miracles, and they are real. Our devotion to life is a badge of honor.
At the same time, though, this often gives rise to the misconception that a person is required to do everything possible to extend his or her life in all circumstances. This is not the case. Over the past 40 years, as medicine has developed new interventions that can prolong life even at the very end, questions about how much needs to be done have been addressed by the gedolim of the past generation: Rav Moshe Feinstein, Rav Shlomo Zalman Auerbach, the Steipler Gaon, and many others. While there are differences among them, all agree that when a person is suffering from pain and there is no medical hope that the person will recover from their illness, one is not required, and is sometimes even forbidden, to provide treatments that will only extend the person’s suffering.
There are two important implications of this halacha. First, when someone is at the very end of life, the halacha is that some treatments designed to cure the illness or prolong life are stopped. The details of this are too intricate to delve into here. Broadly speaking, the Torah still requires us to provide those elements that our bodies need to function. Primarily, this means that everyone must be given food, water, and oxygen, as well as other important provisions in certain cases. On the other hand, other treatments – such as medications designed to slow the illness down, to prop up some of the body’s systems, or even, sometimes, resuscitation – are often not provided. It is important to underscore that the goal is never, chas v’shalom, to cause someone to die sooner. The goal is to avoid artificially prolonging a life of suffering when recovery is not possible.
The second implication can be more difficult but is also important to know. Often, people facing a serious illness have treatment options that are risky, painful, and are expected to extend their lives only by a limited amount. In many such cases, the halacha does allow a person to choose whether they want to pursue those treatments. Without question, in many circumstances, we would encourage someone to pursue treatment, especially when it can give them a period of time in which they can perform mitzvos and spend meaningful time with those they love. But it is important to know that there are situations when a choice is halachically sanctioned. Certainly, when someone is unsure about pursuing a course of treatment, it is better to ask than to assume what the answer will be.
It goes without saying that these halachic issues require a careful and detailed conversation with a rav. While the broad halacha is clear, the details are very complicated, and each situation requires an approach all its own. I have deliberately left out many of the halachic details to avoid their misapplication. I have tried only to outline when a question can and should be asked.
The Modern Health Care System
In conversations with rabbanim about this issue, I have heard a version of the following anecdote more than once: The rav receives a phone call from a doctor who works in the intensive care unit. The doctor is calling to say that one of the rav’s congregants is a patient in the ICU and has taken a turn for the worse. The doctor does not believe there is anything more he can do and is calling, at the family’s request, to find out what to do next. “Rabbi,” he says, “we have two options here. We can do it the cruel way or the compassionate way: we can be cruel and continue to provide every intervention, or we can be compassionate, disconnect everything, and allow the patient to pass away.”
This, unfortunately, is representative of a common attitude in today’s health care system. There are two elements to the doctor’s comment that should make us cringe. One, of course, is the idea that wanting to continue to provide some treatment should be considered “cruel.” The value we place on life and our devotion to continuing it is sacred, and we should never feel the need to be apologetic about it.
But the second problem is the notion that there are only two approaches: do everything or do nothing. The halacha tells us that there is a third, middle path. Even when we reach the point at which we decide not to try to cure the disease anymore, we do not stop every aspect of care. As mentioned before, we still provide oxygen, nutrition, and hydration. In many cases, we still provide antibiotics to help treat infections. We do not pursue all or nothing; we pursue a carefully nuanced, moderate approach.
This, however, can be hard to explain to those outside our community. Medical professionals without an appreciation for halacha see little point in continuing to provide hydration to a patient who has only a short time to live. They certainly see no point in continuing to provide breathing support through a ventilator. What follows are a few strategies for bridging this gap in perspective.
Be an Advocate
When a family member or friend is a patient, it is essential for you to be his or her advocate. It is always beneficial to be a visible and involved presence when a loved one is in a hospital, but it is especially important at this stage, when so many decisions have to be made. Advocacy is about more than just being assertive in seeking the best care for the patient, though this is sometimes required; it also means, when possible, being present at the bedside and developing a rapport with the doctors and nurses caring for the patient. This will let them know that someone is looking out for the patient and will seek what is best for him or her. A written health care directive, which will be discussed in the next article in the series, can also be an important asset in the effort to explain the patient's wishes.
It is also important to remember that effective advocacy involves demonstrating respect for the staff caring for the patient. Even when their values conflict with ours, we must remember that they believe in those values sincerely and that, from their perspective, what they are suggesting is reasonable. When a patient has little hope of recovery, for example, a nurse may genuinely believe that the most compassionate approach would be to stop everything and “let him go.” We may disagree and may even prove them wrong. But articulating our own position while showing a respect for theirs is the most effective way to achieve the best outcome.
Involve the Rav
In the modern hospital setting, care is provided by a team of professionals, not one person. This can include doctors, nurses, social workers, therapists, and a host of specialists. For a frum patient, we need to make it clear that the rav should be considered a part of the team. A doctor who is trained to collaborate and consult with other disciplines should be understanding of the need to consult with the patient’s rav as well. Assuring that communication with the rav is open and is a matter of course is a valuable accomplishment that allows situations to be addressed as they arise, not after the fact.
Hospice
Another way to reach the halachic middle ground can be the engagement of hospice care. For many reasons, frum Jews often have a preconceived notion about hospice that renders it outside the halachic pale. But in my work with Seasons Hospice, I have come to learn that hospice can be made compatible with halacha; what is more, it can, in many cases, provide for the best halachic approach.
Hospice is a modality of care that focuses on treating the patient, not the illness. There are a few criteria one must meet to be eligible for hospice: a patient must have a life-limiting illness; doctors must consider it likely that the patient will live six months or less; and the patient cannot be receiving treatment intended to cure the illness (as opposed to treatment intended to relieve symptoms from the illness). In our community, then, it is an option for people who have made the halachic decision not to pursue a cure for their illnesses (as discussed above) or who have an advanced illness like Alzheimer’s that is not reversible.
In hospice care, what is paramount is the patient’s comfort. Members of the hospice staff are experts in addressing pain, anxiety, and other symptoms that often accompany this stage of life. In most cases, hospice allows patients to be at home instead of in a hospital. Research shows that in many situations, by keeping people out of hospitals and focusing on their comfort, the hospice approach actually extends the average length of life. And my experience at Seasons Hospice has been that because hospice is focused on fulfilling the patient’s particular wishes, it is supportive of the middle ground that the halacha requires.
For example, hospice has helped patients receive artificial nutrition and hydration even when other treatments have been stopped. To accomplish this, the medical staff carefully calibrates what is provided so that it gives the maximum benefit to the patient and does not cause harm. Because they are attuned to the patient’s needs, it is natural for hospice professionals to include the patient’s rav in discussion. And compared to an ICU, the calm atmosphere of home or even a hospice unit can be more conducive to spending time together, performing mitzvos, and finding chizuk (strength) and meaning during the last months or days.
As has become clear, there is no right answer that fits every situation. But with the right structure and halachic consultation, hospice should be considered a viable and potentially beneficial option.
Conclusion
It is hard to avoid the conclusion that this subject is complex. In a sense, though, that is a very helpful conclusion to draw. Having a sense of the issues involved, the options available, the decisions that need to be made, and when a shaila needs to be asked puts us in the best position for facing this part of life. While this article contains only a broad overview, it will hopefully help move us closer to living life to the very end with emuna (faith) and in kedusha (holiness) and peace.
Rabbi Daniel Rose is the rabbi for Jewish Hospice Services for Seasons Hospice and Palliative Care. He is also the Assistant Rabbi at Congregation Bnai Jacob Shaarei Zion.
[1] Nor is the passing of tzadikim always peaceful and pain free; see the description of Rabbi Yehuda Hanassi’s passing in Kesubos.
