Palliative Care Conversation

I recently met an Orthodox palliative care nurse working on the West Coast who discussed the implications of her work.

She discussed how various stages 4-5 cancers are already about choosing a good death rather than the power of doctors to keep one alive. Does one want to die from a narcotic shot after having lots of tubes inserted or does one want a non-invasive death? (We already discussed some of these issues here.)

She claimed that 20% 25% of all cases would not get into a brain stem death or heart death situation if there was more palliative care. On the other hand, she said that the organs of those who die from aggressive cancers are never used for organ transplants, they always inform those who do transplants of the deaths and they are never chosen. (These are her statistics; I cannot verify them. I am neither doctor nor medical ethicist).

She mentioned that Orthodox Jews are the biggest believers in the medical model that things can always be solved even when it is empirical that a stage 5 cancer cannot be helped. And that the Rabbis are playing doctor rather than chaplain.

I was surprised when she discussed a Chabad seminar in medical ethics that she attended and she said it was great. It was given by a Chabad rabbi who is in the forefront of knowledge of palliative care. The rabbi discussed palliative care cancer patients as terefah and had a real empirical based category of goses. She compared this with the NY orthodox rabbis who have a 1965 image of medicine based on Dr Kildare who can solve everything. (For those too young to remember, Dr Kildare was a TV show in which the doctor always knew best and more medical treatments were always good things.) Now we live in a world where people tell the joke “why do they seal the coffin? To stop the doctors from continuing to administer the profitable chemotherapy.”

The nurse compared the lack of knowledge of the Yeshivish and Centrist rabbis to this Chabad rabbi. She did not remember his name and I could not find it online in any combination of the words Chabad, medical, rabbi, seminar. I do want to know who it is and if Chabad is developing their own medical ethics. I had never heard that Chabad was getting into original medical ethics. If anyone knows, then let me know. She found this Chabad rabbi relevant with real categories of terefah and goses, which acknowledge that we all die.

She compared this with the local rabbis who when consulted on end life care insist on painful procedures that bring no benefit. She told a story of an Orthodox woman who said “her husband was good so he cannot die. He did everything right he cannot die.” When I asked her how does she explain it, at first she would not answer the question and then only answered it with my repeat of the question. She said that the Orthodox (in this case referring to a Engaged Yeshivish or Centrist Orthodoxy) are more irrational than other patients. They have a complete dependence on a certain life, and the woman with the dying husband was dependent on husband. No contingency, no sense of end of life.

Finally, she noted the increasing convergence with Catholics positions, for example that food and hydration is necessary. And both need more actual knowledge of the end process of each specific disease or end life situation. (See my prior post here on the convergence).

6 responses to “Palliative Care Conversation

  1. Wow. Really quite surprising. In the context of my work and interests I have attended medical ethics meetings in NY and in Jerusalem. My experience has been quite different from what she reports. In fact, it would be shortest to say that what she heard from the Chabad rabbi (who IS he?) is the sort of explorative thinking I heard from other rabbanim.

    Do you have a contact for her? I’d like to know more about her experience.

    I might note that Israel is way behind on palliative care and on chaplaincy roles. The first dedicated palliative care dept. I know of is the one at Shaarei Tzedek in Jerusalem. They’ve also started a chaplaincy training program. Both initiated by the same doctor on staff. Last July I heard from him that it was quite a battle; some of it because the hospital rav/rabbanim didn’t understand the importance of both roles.

    • Can you explain more about your different experience? What were you surprised at? What does “explorative thinking” of the rabbis mean?
      What is your experience as a palliative chaplain?
      About contact: I would have to find her info and ask if she wants to be contacted. Contact me offline for that.

  2. In terms of the issue of Chabad and there interest in palliative care, at their shluchim convention this year, my father, the chief medical officer of the largest hospice in the US, gave a lecture on Jewish medical ethics at the end of life. From what he told me, it was well received. Chabad tends to be the most engaged in this subject due to their being widespread and encountering more diverse types of Jews as congregants. It is possible that this other lecture was similar in scope to the one at their shluchim convention. My father has also lectured this past year at the Talmudic University in Miami, better known as R’ Zweig’s Yeshiva.

    Regarding the issue of Rabbis acting as doctors instead of pastoral counselors, this is one the greatest challenges I face as a chaplain. While an Orthodox rabbi, I find myself at times in the pastoral role instead of their own rabbi, who is more worried that the hospice is out to kill the person instead of caring for them in a palliative manner. In my area, I am beginning to work with the community rabbis to find a common ground to make them more hospice friendly while also being flexible with what hospice provides under the rubric of comfort care.

    I remember hearing R. Tendler years ago say that all Rabbis need an extensive background in biology so as to be able to better deal with the specifics of the myriad of medical issues congregants face. The problem is that these same rabbis then believe they know the medicine enough to then make decisions with consulting with the medical authorities. Unfortunately, this often leaves the hospice in the lurch, because if the hospice suggests an intervention is harmful, there is that same sense that hospice is there to end life sooner. Much of this fear is old, but it also gets spurned on by current events and how they are misunderstood, such as Terry Schiavo’s case. With that said, what people don’t realize is how comfort care, palliative care/hospice care, can often prolong life and provide a better life as one comes to the end.

    Re: Israel and palliative care – Palliative care as a means of comfort care for the dying exists in Israel. The model is different than the American one in that they do not utilize chaplaincy. Most of the palliative care groups believe that Social Worker can provide spiritual support in addition to psycho-social support. While there is some truth to that, the lack of chaplaincy is more due to the perceived dati/hiloni divide and a lack of funding than to a sense of territorialness. Additionally, the question of chaplaincy qualifications is a hot button item because most people training to be spiritual care providers in the Israel system are non-Orthodox, thus leading to a whole set of other questions.

  3. There was a great article in the New Yorker a few months ago about palliative care by Atul Gawande. No Jewish content but a very worthwhile read.

    http://www.newyorker.com/reporting/2010/08/02/100802fa_fact_gawande

  4. For people wondering what this MO approach looks like you can read David Feldman’s short book “Where There’s Life, There’s Life”.

  5. The Chabad initiative the woman was referring to was probably this: http://www.myjli.com. It’s called the Rohr Jewish Learning Institute. It’s website says – very quietly: “JLI is associated with Merkos L’Inyanei Chinuch, the educational arm of Chabad-Lubavitch.” I learned about it from the Chabad shaliach in Stockholm, where I live. A woman who is a nurse and also davens at the great (=Conservative) shul in Stockholm said that the classes were wonderful, but didn’t get into specifics.
    All of the classes are the same, in English – even in Helsinki and Stockholm – and they’re taught according to a structured standard curriculum, in a book students are supposed to buy. They also cost money (!). Students can go to classes in different cities each week, because they’re all the same.

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