It continues to be a sad state of affairs for doctors as they are continuously questioned about their emotional responses to patients. I think it is a very telling study in showing the challenge of being a doctor and caring for many people in different stages of illness. Training doctors in being empathetic is very important. Yet, to some extent, doctors lack empathy often not because they really do but because of the pressures of maximizing visitation instead of making each visit valuable unto itself. Ah, the joys of the insurance system.
I was talking with a Rabbi this evening about hospice and Jewish law. There are a couple of misperceptions which he shared that I thought were in need of clarification for people.
1. Hospices get paid per patient and thus have no incentive to keep people on service for a long time:
From a financial standpoint, hospice is government funded through Medicare and Medicaid. The way the funding works is that hospice is paid per patient, per day of care for the patient. Therefore, it would behoove hospices to have patients on service for longer periods than just for a couple of days. Being that it makes fiscal sense, it is sad to think that hospices do often act as if the goal is to provide a quick transition to death. I think hospices need to rethink their approach in presenting to people what care is being given and its benefits. People are still scared because they hear about how hospices stop all medications, etc. Of course, hospices do stop medications that are counter to comfort care or have no effect on the person’s well being at this point. In addition, many of the medications discontinued are only being taken because too many doctors prescribed too many things. I have often witnessed how stopping the over consumption of medication can prolong a person’s life.
2. Morphine is a problem because it shortens a person’s life:
Morphine is administered by hospices as one of many pain medication options. Morphine’s primary function is to relax labored breathing. Hospices are hopefully cautious in their use of morphine. Additionally, rarely is a lethal dose given, especially if the hospice is managed by competent medical personnel. Having said that, morphine has an unintended effect due to its ability to calm breathing, namely that a person might die “sooner.” Since that is the case, people make the observational conclusion that morphine kills, leading to the fear of morphine use and the anger of hearing the hospice suggest such a measure. From a halachic perspective, this is challenging, for while hastening death is considered murder, being that the quicker death was unintentional, it would be permissible to administer morphine.
One of the most challenging areas to write about is death and dying. While there is a plethora of literature on the subject, due to the humanness of the experience, there are always new ways and insights to be presented about the emotional and psychological states a person is going through while grieving the loss. The standard bearer in Jewish circles has always been The Jewish Way in Death and Mourning by R. Maurice Lamm. A recent attempt has been made to compliment his work, The Mind of the Mourner by R. Joel Wolowesky. R. Wolowesky’s goal is to present the psychological underpinnings behind Jewish mourning practices.
As someone who deals with death and dying on a daily basis, I am always looking for a new insight, a new way of thinking about how people experiencing the loss might be feeling. While that usually comes from the bereaved themselves, it is often helpful to have a knowledge base to further draw upon, not for the purpose of categorizing, but as a means of offering support if that is what the bereaved needs at the time.
R. Wolowesky’s book does not fulfill this need. Instead, it is a good summary of the thought of Rav Soloveitchik on areas of mourning and halacha. However, R. Wolowesky misses the underpinning of Rav Soloveitchik’s thought, namely that Rav Soloveitchik was writing and sharing his experiences in the form of philosophical treatises. His words were meant to describe his own suffering and difficulties in his losses, not necessarily as a means of conveying a psychology of the halachic systems view of grief and bereavement. Further, it is difficult to accept based on my experience his underlying theme, that if one fulfills the Jewish method of mourning, the grieving process will not be complicated. In fact, for many people, the ideas in this book would be counter to providing them with a halachic grieving experience.
Overall, I feel this work was disappointing and still leaves a hole for a work on how the Jewish methods of grieving may or may not provide a strong base for someone to experience a normal grieving process. Nevertheless, R. Wolowesky’s book does provide a good overview on the thought of R. Soloveitchik on mourning, and would make a good introduction to studying the depths of the emotional challenges that loss presented to that great Rabbi.
For any of you who have read this op-ed, did you also feel a sense of anger after? For anyone following the brain-death controversy, this particular opinion piece misses the boat completely. The argument that many are floating against the RCA relates to how we should relate to the morality of giving and receiving organ donations in light of the psaq that brain-death isn’t a clear cut decision of the moment of death. Instead, Rabbi Glatt has to get into a whole piece about the non-democratic nature of psaq, which seems completely irrelevant. Besides, as a Rabbi once shared, no halachic argument can be made in the vacuum of the Beit Midrash. If the argument cannot hold muster in practice, then the argument is not a true representation of the halacha.
This controversy does not, and cannot, have a simple scientific resolution, despite what anyone may claim. Science does not and cannot answer metaphysical questions. The definition of death according to science is, however, open for debate and can change by popular vote of the appropriate academies or respective legislative bodies.On the other hand, halacha is immutable, although its ramifications, based upon the available facts, may change. The “halacha lema’aseh” may in fact be different today than years ago for many issues, because of technological advances and/or better understanding of the problem. Halachic analysis requires taking the best scientific evidence available and using the halachic process to provide “lema’aseh” answers to real questions posed.Based on this unbiased straightforward approach, indeed the only possible current resolution to the brain death halachic controversy is “Ailu ve’ailu divrei Elokim chaim.” There simply is no overriding clear-cut halachic reaction that all gedolim agree is the correct lema’aseh response. And that is the one incontrovertible fact that seems to be forgotten amid all the tumult. Therefore it is very sad for me to see this beis midrash “controversy” itself take on a life of its own…Not every person (or rav) is entitled to a halachic opinion. Having knowledge in one area of science or halacha does not automatically provide expertise in another area. How much more so (kal va’chomer), then, the need for individuals to refrain from proffering opinions on matters about which they are not qualified. And the vast majority of Jews are simply not qualified to render a halachic opinion on brain death.A very undemocratic viewpoint, I know, but one I heard echoed many years ago in a class by a great rabbi. One of the students commented that the Taz appeared more correct to him regarding a particular halacha. The Rav quickly responded, “The Shach is not losing any sleep” because you agree with the Taz.One cannot simply vote and count up how many people think or feel a specific opinion is correct in the brain death controversy – it is an exercise in futility, even if all the voters have the title Rabbi or Doctor in front of their name. While politicians may do this (“acharei rabbim lehatos” in last week’s parshah), it does not mean we should poll the electorate and pasken accordingly.
The gist of this article is that oncologists are being encouraged to have conversations with patients about their treatments options, including the foregoing of aggressive treatments and just the provision of comfort, palliative measures. A few quotes:
Patients don’t want to hear that they’re dying and doctors don’t want to tell them. But new guidance for the nation’s cancer specialists says they should be upfront and do it far sooner.
“This is a clarion call for oncologists . to take the lead in curtailing the use of ineffective therapy and ensuring a focus on palliative care and relief of symptoms throughout the course of illness,” the guidance stresses.
But it’s part of a slowly growing movement to deal with a subject so taboo that Congress’ attempt to give such planning a nudge in 2009 degenerated into charges of “death panels.”…
“There is going to be, over the next few years, a groundswell of people telling physicians, ‘I don’t want to go out in excruciating pain, short of breath, alone, surrounded by lights and sirens and people pounding on my chest,'” predicts Dr. Jonathan Weinkle, a primary care physician who advises the program.
“Everybody wants a good death but not a moment too soon, but they don’t have the language to ask for it…”
There is a general fear of planning for our end-of-life needs. We often struggle with the recognition of the existence of death, and even for those who have accepted that death is inevitable, when facing one’s mortality, there is often an increased desire to avoid the topic. People believe that if talking about death is avoided, then death won’t happen.
As a Hospice chaplain, I often meet people who, even once they have decided on palliative Hospice care, still will not discuss their wishes out fear of depressing themselves or their loved ones. While this is to be respected, I get the sense that a frank conversation would be of emotional benefit, and that the long term benefit would outweigh the short term verbalization of the person accepting his/her mortality. Additionally, by the conversation being held with one’s physician, it could create a different dynamic that would be beneficial for the dying person. Studies have suggested that people still have greater trust in their physicians, more so than for friends and family who offer advice.
This is a must see, just because the bursting of light moving upwards is quite cool. I am not drawing any judgments either way.