Joy and Fear during the holidays

I recently published this piece in a couple of local newspapers.  I did already share this on Facebook but I thought pre-Yom Kippur, it would be good to reflect once again on this idea.

Joy and Fear during the holidays:

The Rosh Hashanah liturgy describes the Jewish New Year as a day consisting of two diametrically opposed images:  “Today is the birth of the world.  Today all creatures of the world stand in judgment – whether as children [of God] or as servants.  If as children, be merciful with us as the mercy of a father for children.  If as servants, our eyes [look toward and] depend upon You, until You be gracious to us and release our verdict as light, O Awesome and Holy One.”  How can a person simultaneously grasp these two images of a day of birth, a day filled with joy and expectations, and a Day of Judgment, a day filled with fear and trembling?   

As part of the preparation for the Jewish holidays of Rosh Hashanah, Yom Kippur and Sukkot, there is a tradition to recite Psalm 27 at the conclusion of the daily morning services  as well as either the daily afternoon or evening services.  The recitation of Psalm 27 commences at the start of the Jewish month of Elul, the month preceding the holidays, and continues through the end of Sukkot.  The words of Psalm 27 were King David’s prayer to G-d that he should merit dwelling in G-d’s midst, even when feeling abandoned and orphaned in the world.

In times of joy, it is fairly easy to find comfort and peace in life.  Most people feel a sense of elation and independence.  When in crisis, however, people often turn to those who have always provided strength and security for them in life.  For most, parents represent that security.  Yet, many of the crises faced occur when parents are no longer able to help.  I have heard many caregivers of a dying loved one express the wish that one or the other parent were still alive to be a rock during troubled times.  In the pre-holiday tradition of reciting Psalm 27, one of the verses recited reflects on the need for security during crisis.  King David said, “While my father and mother have forsaken me, G-d will gather me in (27:9).” 

The liturgy highlighted above focuses on the crisis moment of the holidays.  The image of standing in judgment is an acute reminder that every year, as time moves forward, we face the inevitable truth that for some, the past year was not meant to be completed.  As such, survivors are struck by a sense of loss during the liturgical points reminding them of the essence of Rosh Hashanah and Yom Kippur, namely the renewal for another year for some people while the conclusion for others.  And yet, hope remains, that when we feel forsaken, there is still something to protect us.     

Loss changes the fabric of one’s life.  It removes the sense of invincibility and security.  Yet, while reflecting on Judgment Day, one is also reminded that there will always be a security blanket.  The security blanket, G-d, can be cherished or can be discarded.  Either way, the blanket remains, accepting however one feels and reacts to happiness and sadness, joy and fear. 

Advertisements

Spiritual Care in Israel

Ynet recently had a piece on the growing field of Jewish Spiritual Care in Israel.  Having been an outsider witnessing the growth of the field in Israel, it is wonderful that the topic is being presented in the papers.  As the article indicates, the Israeli needs in spiritual care during crisis are distinguished from American Jewish needs, and as such, there is a need to develop a unique system.  Much of that has to do with the Israeli “secular population, that is not enamored by a rabbinic establishment, yet is becoming more spiritual, as has been described by, among others, Yair Sheleg, in his work, The Jewish Renaissance in Israeli Society: The Emergence of a New Jew [Hebrew].

 

When Rabbi Mike Schultz met Sharona (alias), she was a young mother of two girls, suffering of terminal cancer, and angry – mostly at God that is not planning to let her see her girls grow up.

 

Schultz, a Jewish spiritual care provider in profession, helped her understand that she can use the illness to prepare her daughters for life, and leave this world without anger.

 

After the personal coaching courses and the empowerment trend – it is now the turn of Jewish spiritual care. A relatively new profession, imported from the United States, is becoming an acceptable professional field. It is a complementary profession to mental and health treatments, when the crisis is big.

 

“I was an occupational therapist, working with chronic and terminal patients,” said Dvora Corn. “I felt that despite everything I can give the patient, there is still something missing.”

 

Corn founded Tishkofet foundation, and she serves as Chair of the Network of Foundations for Spiritual Care in Israel.

 

“It is possible to heal some of the people, or help them live with the illness, but there is an entire part left untouched – and that is the patient’s spiritual world,” Corn notes.

 

“The spiritual world is the purpose a person sees in his life. The therapy world deals with finding solutions for the illness, but there is very little reference to what happens beyond that.

 

“When a person experiences a crisis, his world changes. Sometimes the illness prevents physical functions. Sometimes he is forced to leave work. His relationships and abilities in the family change, and then he has to reestablish what his purpose is at the current time.

 

“That is the place of the spiritual counselor. He does not talk about religion, but rather he finds out what is the person’s beliefs, and how can he lead him to a place that has meaning, to a purpose.”

 

Rabbi instead of priest

In the US, spiritual care is a well-established and old profession. Its origins are in the Christian world, in the work of priests that accompany terminal patients in their final days.

 

About a quarter of a century ago, American Jews decided to create a Jewish counterpart, and established a group of rabbis that specialized in spiritually uplifting patients, basing their work on Jewish holy and literary sources.

 

Some five years ago, UJA-Federation of New York, the largest of its kind in the world, decided to bring the spiritual care to Israel. They initiated a conference of ten foundations that deal with various types of mental assistance for patients, and together they began creating programs that would train Jewish spiritual care providers.

 

Since the group was established, some 25,000 Israelis received spiritual care in various fields such as: Addiction, old age, victims of terror, and illness. Thanks to the UJA-Federation, some 10,000 Israeli professionals have already been exposed to the new field, encouraging future collaborations between them and spiritual care providers.

 

“UJA-Federation believed there is room here to bring a knowledge field that does not exist in Israel,” notes Elisheva Flamm-Oren, planning executive for UJA-Federation of New York’s Caring Commission, who works at UJA-Federation’s Israel office.

 

“The Jewish spiritual care provider expands the boundaries of treatment. He does not deal with the patient’s hurting leg, but rather gives him an embrace that can help the patient heal. The provider is in a place of being, not only doing, bringing the ability of connecting to another human being.”

 

Flamm-Oren, who is involved in the spiritual care project, reveals, “Since Jews in Israel experience their Jewishness in a different manner, we needed to take the Jewish content world and adjust to Israel. In the US, for instance, chaplains are mostly people who come from the religious world.

 

“In Israel – because of the sensitivity regarding religious figures – it was important to create a Jewish language coming from a more accessible place, and therefore, most care providers come from the therapeutic field, though they are familiar with the Jewish world.”

 

“We decided unanimously that spiritual care in Israel cannot be solely based on rabbis,” adds Corn. “The Jewish community in Israel is complex, and we couldn’t have brought the American model to Israel. The belief and needs of a Jew from Brooklyn are different from those of the Israeli Jew. There are people here that have no connection to religion, but they too need to search for meaning.

 

“There are all sorts of religious sects, and we did not want to be under a certain Rabbinate, so we could convey the message to the broadest circle as possible. That is why we built a unique Israeli model that relies on our culture, nature, and historic origins.”

 

Search of meaning

Currently, there are three institutes in Jerusalem where Jewish spiritual care can be learned: Shechter Institute, Hebrew Union College, and Shaare Zedek Medical Center. Studies are based on standards and programs from the US, combining studies in a clinic and in the hospital, in order to provide the spiritual care with all the necessary tools.

 

In the first stage, the therapist gets to know his patient. In the second stage, he suggests tools to the patient that would suit him personally, and bring him to a place in which he finds meaning. These tools could be from the world of music and song, Jewish texts, nature, holidays or Jewish history.

 

“Many people in a crisis feel as though they have no other options, or ability to choose,” notes Corn. “They feel that their world is growing smaller. Our purpose is to find new things that will open them up. We use painting and sculpture to give them power of expression. Others find it more suitable to study a text through which they could raise questions about themselves and find answers.”

 

“We take Jewish motives that, for instance, Jews in New York are less familiar with – but here in Israel, any child in kindergarten knows,” explains Flamm-Oren. “From that we connect to the illness. Before Rosh Hashana, the care provider finds out with the patient, where can he replenish? How can he recharge himself for the New Year? What will be sweet for him this year?

 

“On Hanukkah, the care provider checks with the patient on what are his sources of light? How can he banish darkness? How can the patient use his weak power to overcome the big things happening to him? On Passover, we examine what is freedom and what is enslavement. On Tu B’Shvat, we plant hope.”

 

“On just an ordinary day, we can take motifs from the Weekly Torah Section and check how we can leverage the biblical story into our life. There could also be joint study of Modern Hebrew poetry, guided imagery, or connection to nature.

 

“The spiritual care provider brings with him an entire content world that a social worker or other therapist does not. He touches a basic place of the spiritual world, and when a person is going through a crisis, he has the ability to reach such places, because even when the body is ill, we sometimes discover the spirit is strong.”

 

Seeing the scenery outside

Rabbi Schultz, a Jewish spiritual care provider, tells us, “The first thing is listening to them with an open heart, accepting everything they say. Only after you make a connection with the patient, you start to try to understand what is happening inside, what is going on in their spiritual world. In training, you learn how to reach the major points, and it is done through a lot of listening.”

 

“The attentiveness of the spiritual care provider demands that he does not escape the difficult things he hears. People don’t always immediately express the difficulty, they rather imply it. Some 70% of my help, I believe, is that the person in front of you accepts your difficulty.

 

“If someone feels fear, then your job is to enter that place of fear and uncertainty so he is not alone with his fears and then help him connect with his strengths.”

 

The spiritual care provider meets with patients in unpleasant places, and their purpose – as tour guides in the paths of life is to show them the scenery on the way.

 

“I received a telephone call from a social worker that one of her patients was diagnosed as a cancer patient, and refused to receive treatment,” says Rabbi Schultz. “The team had a hard time accepting her decision because she had good chances of recovery. This is a woman that has already been sick in the past, and underwent very difficult treatments, and she told me she does not want to go through them again.

 

“She said she feels like a prisoner that cannot get herself out of the prison, asking me to get her out. Of course I wanted her to do the treatments, but you cannot force her. When we talked about her ability to choose, she felt that her entire body is releasing, and decided to do the treatments. Today, she is in a good state.”

 

Light shining through great darkness

Corn tells us about a 47-year-old woman, suffering of terminal cancer, who wanted to know how she could end her life without destroying her family.

 

“Except for cancerous cells, her body was packed with guilt that instead of being a mother to her children and take care of them, they are taking care of her. She felt that she is a burden on her family, the spiritual care process was to return her to maternal function.

 

“During the process we showed her that she has power because of what she went through. We cannot say she passed away happy, because she wanted to live. However, at the end of her life, she taught her children that you couldn’t do everything alone.

 

“To her eldest daughter, who got engaged during her illness, she wrote: ‘I will not be at your wedding, but when you enter the relationship you will understand that from now on you depend on someone else as well, and it is a good dependency. You will get everything from this dependency. Do not see it as a negative thing.’

 

“She could write that from the illness of all places. The spiritual care provider taught her and her entire family that dependency can be seen as a system of give and take, and at the end of her life, she taught her children what should be important in life.”

Jewish spiritual care: Creating sound spirit

Sometimes, when things seem hopeless, room should be made for spirituality. What began in US with priests becomes Jewish spiritual care in Israel

Tzofia Hirschfeld

Published: 09.27.11, 14:14 / Israel Jewish Scene
When Rabbi Mike Schultz met Sharona (alias), she was a young mother of two girls, suffering of terminal cancer, and angry – mostly at God that is not planning to let her see her girls grow up. Schultz, a Jewish spiritual care provider in profession, helped her understand that she can use the illness to prepare her daughters for life, and leave this world without anger.

Self Improvement
Yeshiva offers students life coaching  / Kobi Nahshoni
Trained rabbis at Tel Aviv yeshiva help students realize their potential by dealing with personal problems
Full story

After the personal coaching courses and the empowerment trend – it is now the turn of Jewish spiritual care. A relatively new profession, imported from the United States, is becoming an acceptable professional field. It is a complementary profession to mental and health treatments, when the crisis is big. “I was an occupational therapist, working with chronic and terminal patients,” said Dvora Corn. “I felt that despite everything I can give the patient, there is still something missing.” Corn founded Tishkofet foundation, and she serves as Chair of the Network of Foundations for Spiritual Care in Israel. “It is possible to heal some of the people, or help them live with the illness, but there is an entire part left untouched – and that is the patient’s spiritual world,” Corn notes. “The spiritual world is the purpose a person sees in his life. The therapy world deals with finding solutions for the illness, but there is very little reference to what happens beyond that. “When a person experiences a crisis, his world changes. Sometimes the illness prevents physical functions. Sometimes he is forced to leave work. His relationships and abilities in the family change, and then he has to reestablish what his purpose is at the current time. “That is the place of the spiritual counselor. He does not talk about religion, but rather he finds out what is the person’s beliefs, and how can he lead him to a place that has meaning, to a purpose.”

Rabbi instead of priest

In the US, spiritual care is a well-established and old profession. Its origins are in the Christian world, in the work of priests that accompany terminal patients in their final days.

About a quarter of a century ago, American Jews decided to create a Jewish counterpart, and established a group of rabbis that specialized in spiritually uplifting patients, basing their work on Jewish holy and literary sources. Some five years ago, UJA-Federation of New York, the largest of its kind in the world, decided to bring the spiritual care to Israel. They initiated a conference of ten foundations that deal with various types of mental assistance for patients, and together they began creating programs that would train Jewish spiritual care providers. Since the group was established, some 25,000 Israelis received spiritual care in various fields such as: Addiction, old age, victims of terror, and illness. Thanks to the UJA-Federation, some 10,000 Israeli professionals have already been exposed to the new field, encouraging future collaborations between them and spiritual care providers. “UJA-Federation believed there is room here to bring a knowledge field that does not exist in Israel,” notes Elisheva Flamm-Oren, planning executive for UJA-Federation of New York’s Caring Commission, who works at UJA-Federation’s Israel office. “The Jewish spiritual care provider expands the boundaries of treatment. He does not deal with the patient’s hurting leg, but rather gives him an embrace that can help the patient heal. The provider is in a place of being, not only doing, bringing the ability of connecting to another human being.” Flamm-Oren, who is involved in the spiritual care project, reveals, “Since Jews in Israel experience their Jewishness in a different manner, we needed to take the Jewish content world and adjust to Israel. In the US, for instance, chaplains are mostly people who come from the religious world. “In Israel – because of the sensitivity regarding religious figures – it was important to create a Jewish language coming from a more accessible place, and therefore, most care providers come from the therapeutic field, though they are familiar with the Jewish world.” “We decided unanimously that spiritual care in Israel cannot be solely based on rabbis,” adds Corn. “The Jewish community in Israel is complex, and we couldn’t have brought the American model to Israel. The belief and needs of a Jew from Brooklyn are different from those of the Israeli Jew. There are people here that have no connection to religion, but they too need to search for meaning. “There are all sorts of religious sects, and we did not want to be under a certain Rabbinate, so we could convey the message to the broadest circle as possible. That is why we built a unique Israeli model that relies on our culture, nature, and historic origins.”

Search of meaning

Currently, there are three institutes in Jerusalem where Jewish spiritual care can be learned: Shechter Institute, Hebrew Union College, and Shaare Zedek Medical Center. Studies are based on standards and programs from the US, combining studies in a clinic and in the hospital, in order to provide the spiritual care with all the necessary tools.

In the first stage, the therapist gets to know his patient. In the second stage, he suggests tools to the patient that would suit him personally, and bring him to a place in which he finds meaning. These tools could be from the world of music and song, Jewish texts, nature, holidays or Jewish history. “Many people in a crisis feel as though they have no other options, or ability to choose,” notes Corn. “They feel that their world is growing smaller. Our purpose is to find new things that will open them up. We use painting and sculpture to give them power of expression. Others find it more suitable to study a text through which they could raise questions about themselves and find answers.” “We take Jewish motives that, for instance, Jews in New York are less familiar with – but here in Israel, any child in kindergarten knows,” explains Flamm-Oren. “From that we connect to the illness. Before Rosh Hashana, the care provider finds out with the patient, where can he replenish? How can he recharge himself for the New Year? What will be sweet for him this year? “On Hanukkah, the care provider checks with the patient on what are his sources of light? How can he banish darkness? How can the patient use his weak power to overcome the big things happening to him? On Passover, we examine what is freedom and what is enslavement. On Tu B’Shvat, we plant hope.” “On just an ordinary day, we can take motifs from the Weekly Torah Section and check how we can leverage the biblical story into our life. There could also be joint study of Modern Hebrew poetry, guided imagery, or connection to nature. “The spiritual care provider brings with him an entire content world that a social worker or other therapist does not. He touches a basic place of the spiritual world, and when a person is going through a crisis, he has the ability to reach such places, because even when the body is ill, we sometimes discover the spirit is strong.”

Seeing the scenery outside

Rabbi Schultz, a Jewish spiritual care provider, tells us, “The first thing is listening to them with an open heart, accepting everything they say. Only after you make a connection with the patient, you start to try to understand what is happening inside, what is going on in their spiritual world. In training, you learn how to reach the major points, and it is done through a lot of listening.”

“The attentiveness of the spiritual care provider demands that he does not escape the difficult things he hears. People don’t always immediately express the difficulty, they rather imply it. Some 70% of my help, I believe, is that the person in front of you accepts your difficulty. “If someone feels fear, then your job is to enter that place of fear and uncertainty so he is not alone with his fears and then help him connect with his strengths.” The spiritual care provider meets with patients in unpleasant places, and their purpose – as tour guides in the paths of life is to show them the scenery on the way. “I received a telephone call from a social worker that one of her patients was diagnosed as a cancer patient, and refused to receive treatment,” says Rabbi Schultz. “The team had a hard time accepting her decision because she had good chances of recovery. This is a woman that has already been sick in the past, and underwent very difficult treatments, and she told me she does not want to go through them again. “She said she feels like a prisoner that cannot get herself out of the prison, asking me to get her out. Of course I wanted her to do the treatments, but you cannot force her. When we talked about her ability to choose, she felt that her entire body is releasing, and decided to do the treatments. Today, she is in a good state.”

Light shining through great darkness

Corn tells us about a 47-year-old woman, suffering of terminal cancer, who wanted to know how she could end her life without destroying her family.

“Except for cancerous cells, her body was packed with guilt that instead of being a mother to her children and take care of them, they are taking care of her. She felt that she is a burden on her family, the spiritual care process was to return her to maternal function. “During the process we showed her that she has power because of what she went through. We cannot say she passed away happy, because she wanted to live. However, at the end of her life, she taught her children that you couldn’t do everything alone.

“To her eldest daughter, who got engaged during her illness, she wrote: ‘I will not be at your wedding, but when you enter the relationship you will understand that from now on you depend on someone else as well, and it is a good dependency. You will get everything from this dependency. Do not see it as a negative thing.’ “She could write that from the illness of all places. The spiritual care provider taught her and her entire family that dependency can be seen as a system of give and take, and at the end of her life, she taught her children what should be important in life.”

The use of humor in Medicine

In a recent article in the Hastings Center Report, Katie Watson presents a discussion she calls “Gallows Humor in Medicine.”  The concept of laughter in the face of challenging situations is one we often face in Hospice work.  And we laugh and find humor in our work, often as a means of coping with the harsh realities of life.  Yet, her discussion tries to look at the subject through the eyes of whether it is ethically problematic to express humor in the face of other’s trauma.  The biggest insight I found in the entire article is that humor in the medical profession is actually decreasing.  She points out that residents don’t play as many tricks on fellow residents using cadavers, and as with other places, hazing is down as well.  For many, these trends are not positive, to which I would agree.  It is true that we shouldn’t laugh at all problems and traumas, but it is important to, at least internally, have some levity in the face of the sadness.  I have quoted for you the introduction and conclusions of her piece. 

It was 3:00 am and three tired emergency room residents were wondering why the pizza they’d ordered hadn’t come yet. A nurse interrupted their pizza complaints with a shout: “GSW Trauma One—no pulse, no blood pressure.”

The residents rushed to meet the gurney and immediately recognized the unconscious shooting victim: he was the teenage delivery boy from their favorite all-night restaurant, and he’d been mugged bringing their dinner.

That made them work even harder. A surgeon cracked the kid’s rib cage and exposed his heart, but the bullet had torn it open and they couldn’t even stabilize him for the OR. After forty minutes of resuscitation they called it: time of death, 4:00 a.m.

The young doctors shuffled into the temporarily empty waiting area. They sat in silence. Then David said what all three were thinking.

“What happened to our pizza?”

Joe found their pizza box where the delivery boy dropped it before he ran from his attackers. It was face up, a few steps away from the ER’s sliding doors. Joe set it on the table. They stared at it. Then one of the residents made a joke.

“How much you think we ought to tip him?”

The residents laughed. Then they ate the pizza.

 

David told me this story fifteen years after he finished his residency, but the urgency with which he told it made it seem like it happened last night. “You’re the ethicist,” he said. “Was it wrong to make a joke?”

Gallows humor is humor that treats serious, frightening, or painful subject matter in a light or satirical way. Joking about death fits the term most literally, but making fun of life-threatening, disastrous, or terrifying situations fits the category as well. There is a fair amount of literature on humor in medicine generally, most of which is focused on humor in clinician-patient interactions or humor’s benefit to patients.1 There is relatively little specifically addressing the topic of this article: gallows humor in medicine, which usually occurs in interactions between health care providers.

Gallows humor is not a feel-good, Patch Adams kind of humor, but it is not synonymous with all cruel humor, either. As one physician put it, the difference between gallows humor and derogatory humor is like “the difference between whistling as you go through the graveyard and kicking over the gravestones.”2 Many health care providers witness or participate in gallows humor at some point. After reviewing over forty medical memoirs, Suzanne Poirier reports that “Anger and gallows humor are generally accepted forms of expression among undergraduate and graduate medical students . . . but expressions of serious self-doubt or grief are usually kept private or shared with only a trusted few.”3

David’s question intrigued me as a bioethicist because it is about moral distress, power imbalances between doctors and patients, and good people making surprising choices. But it also piqued my interest as someone who enjoys joking around—when not teaching bioethics, I teach improv and sketch writing at Second City, where I’m an adjunct faculty member. But David didn’t ask me if the tip joke was funny. He asked about it in ethics’ normative terms of right and wrong.

In this article, I consider whether some joking between medical professionals is actually unethical. The claim that being a physician is so difficult that “anything goes” backstage misuses the concept of coping as cover for cruelty, or as an excuse for not addressing maladaptive responses to pain. However, blanket dismissals of gallows humor as unprofessional misunderstand or undervalue the psychological, social, cognitive, and linguistic ways that joking and laughing work. Physicians deserve a more nuanced analysis of intent and impact in discussions of when gallows humor should be discouraged or condemned in the medical workplace. They also deserve deeper consideration of physician health than the professionalism lens might provide. Surely we can advocate for the humanity of patients without denying the humanity of those who treat them…

One of medical training’s first requirements is the violation of strong cultural taboos around death and dead bodies. Dissecting corpses has generated “cadaver antics” that many older physicians recall fondly—making jokes, clowning around with body parts, and pulling pranks to scare labmates. Joking like this helps turn corpses into cadavers by framing bodies as objects. Until recently, cadaver antics were a rite of passage, initiation, and enculturation into an ethos that said a doctor is a tough person who can laugh at death. Not just not cry about death. Laugh. Today cadaver antics are rarely tolerated, and the modern approach frames cadavers as former people. Students are commonly asked to imagine lives lived before these bodies died, and to journal or discuss their emotional reactions in small groups.26 Many classes end with a memorial service students create to thank the people they have dissected for donating their bodies, and sometimes they even meet the donor’s family members.27 The concept of performativity is helpful here: how must a person change the way she or he looks, acts, and feels to both perform the social role of doctor and to be recognized as one? The modern approach to anatomy lab represents a dramatic shift away from a macho joke-about-death performance of the role of doctor, and toward compassion and connection as being performative elements that help define the role of doctor.

The medical workplace may be changing, too. I’ve heard older physicians lament that the workplace is not as funny as it used to be, that practicing physicians do not joke around together like they used to. If that’s true, perhaps one reason is that the easy in-group joking they remember was based not just on being physicians, but on the broader bond of being straight white male physicians. The increasing diversification of medicine narrows the meaning of “it’s just us” to what’s truly distinctive about providing health care, versus simple differences in physician and patient demographics. It’s also possible that the dramatic increase in women physicians has unique effects on gallows humor. It’s a generalization rife with individual exceptions, but if there are differences in stereotypically male and female forms of humor, it stands to reason that the increased presence of women might cause a cultural shift in when and how backstage gallows humor is used in the workplace. This gender shift may also have made coping mechanisms that substitute for joking about fear and sadness (like verbal expressions of these emotions) more acceptable in the medical workplace.

I applaud the cadaver lab changes, and I strongly support the backstage changes that make a diverse workforce welcome. I also support efforts to define what I think of as HOG talk (“House of God talk”) as unprofessional because shallow bullying and derogatory slang coarsen the moral enterprise of medicine and cut providers off from healthier means of coping.

Yet in some areas, perhaps the hand wringing has gone too far. Condemnation of gallows humor is sometimes premised on a category mistake (such as lumping it together with all making fun of patients28) or a double standard. For example, an article titled “Humor in the Physician-Patient Encounter” contrasts a short treatment of “Destructive Gallows Humor” between providers, which frames all gallows humor as “‘sick’ wit and hurtful humor used to separate providers from patients,” with a long treatment of “Therapeutic Humor” between providers and patients, which is “grounded on a recognition of the human condition that is shared by patient and provider.”29 What the article fails to acknowledge is the human condition that is shared by provider and provider. Critics of backstage gallows humor who are admirably concerned with empathy for patients sometimes seem curiously devoid of empathy for physicians. Medicine is an odd profession, in which we ask ordinary people to act as if feces and vomit do not smell, unusual bodies are not at all remarkable, and death is not frightening. Moments when health care providers suddenly see the enormous gulf they’re straddling between medical and lay culture are one source of gallows humor. Being off-balance can make us laugh, and sometimes laughing is what keeps us from falling over.

Empathy for clinicians does not mean anything goes; it means clinicians must be conceptualized as human beings rather than as robotic systems for care delivery. Laughing and caring for others are both sources of joy. Suggesting physicians can only enjoy one of these pleasures in certain circumstances costs them something, and therefore deserves thoughtful justification.

Should They Joke?

Insights from the humanities and social sciences supply the context required to fully analyze David’s ethics question: Was it wrong to make the tip joke? When is behind-the-scenes gallows humor okay, and when should it cause concern? Underlying all this, the ethics question may be, “When is joking a form of abuse?”—abuse of a patient, abuse of trust, or abuse of power.

To answer, I would first want to think about who is harmed by the joking.30

 

  • Within the text of the joke, who or what is the true target? Does close reading reveal it to be a defenseless patient? Or is the joke really aimed at a doctor who is defenseless against death, decay, and chronic illness?
  • Could the joke harm the way future care is delivered? By using the power of humor to frame the patient in a way the patient cannot challenge, could the backstage joke bias listeners’ future interactions with that particular patient? Does the repetition of stereotyping jokes about “patients like these” contribute to making the health care provider calloused toward a particular demographic?
  • Could the joke harm the profession by diverting anger caused by structural problems (like caseloads so high that patients feel like the enemy, or scheduling that results in chronic sleep deprivation) and releasing it on the easy punching bag of patients rather than using it to make productive changes?
  • Who is listening to the joke? Gallows humor that seems ethical backstage can become unethical in front of patients, families, or others because it has the potential to harm them directly.

 

Next, I would want to ask about the health care provider’s relationship to the joking.

 

  • What’s the clinician’s underlying intent in joking? Is gallows humor being used as a helpful defense mechanism when circumstances limit the options for processing something difficult? Is the intent to get through the day by trying to lighten an oppressive situation, or is the intent to be a jolly bully?
  • What impact might this joking have on the clinician? Is it the type of joking that helps clinicians open up to difficult experiences or frees them from intolerable burdens? Or is it the type of joking that cuts clinicians off from experiences or patients that healthy clinicians should be able to engage with?
  • How often does the health care provider joke like this? If a doctor is joking about patients and death constantly, then (even if each can be justified individually) does she need help expanding her range of coping mechanisms? Or is this joking part of an ongoing pattern (say, of objectifying vulnerable patients) that suggests deeper provider biases?

 

David and his colleagues scattered across the country after residency, but in the fifteen years that passed before he told me the tip joke, they talked about the night the delivery boy died several times. The whole thing made them sad for years, he said. “Wasn’t that terrible?” they’d ask each other on the phone. “How could we eat the food that poor kid dropped?”

In the process of trying to do good, did they become bad? I do not think so.

To me, the butt of the doctors’ tip joke is not the patient. It’s death. The residents fought death with all they had, and death won. Patient care was not harmed—the patient in this case had received the best medical care they could deliver, and he was dead. It’s hard to imagine the joke hardening these residents toward a type of patient he represents (delivery personnel?) in the future. The neighborhood’s staggering rates of crime and poverty might represent an external obstacle upsetting the residents, but residents are usually powerless to alter that type of structural factor.

I think the motivation for telling the joke was to integrate this terrible event and get through the shift. This teenager lost his life bringing these young doctors dinner. “How much you think we ought to tip him?” is a macabre summary of all that’s owed in this world and all that can never be repaid. And it looks forward—it’s a moving-on question. In a situation that horrific and absurd, a joke is the rock you throw after the bad guy’s already gone—an admission of loss, and a promise to fight again another day.

It’s important that the tip joke was told in an empty area with no family, friends, or other patients who could be harmed by overhearing. I’m usually a fan of sunshine tests and total disclosure, so I find the idea of secrecy as an ethical plus startling. But when a compassionate professional gets overwhelmed, gallows humor may be a psychic survival instinct, and that’s why it is not an abuse of patient trust when it’s done backstage and for the right reasons. Something that looks maleficent toward one patient may actually be an act of beneficence toward the patients who will come next. So yes—if the delivery boy were my son and I heard the joke, I would want to tear their eyes out. But if I was the person in the next ambulance, hurtling toward their emergency room after my car wreck, my heart attack, my rape, I’d be glad they made that joke. Because they needed to laugh before they could eat, and they needed to eat to be at their best when it was my turn.

David is a brilliant, compassionate physician who will serve patients his whole life, so I told him two things about the tip joke: I’m glad he did what he needed to do to treat every patient he’d see that night. And I’m glad it still bothers him. Because it’s good to carry that tension that tells you when you’re on thin ice. When a terrible joke is the only bridge between horror and necessity, gallows humor can be a show of respect for the work that lies ahead. So tell your jokes. Tell them somewhere I cannot hear. Then treat me well when we’re together.

For those interested, the article is free if you register with the website.  They have free limited access to certain articles.

Souls Shining Through

Souls Shining Through.

I have to share this piece I received via email yesterday.  I think it gets to the heart of what humanity really is.  No matter how much or how little we are able to function cognitively, there is always something that remains.  I think this is good pre-Rosh Hashanah reading to get our minds focused on the day and on life.  There can be no illusion when standing in G-d’s presence on Rosh Hashanah. 

As an activity director at a day care center for the memory-impaired, I often ask myself what I have learned from being with people who suffer from Alzheimer’s.

One thing I realized is that the mind and the soul are separate. I have seen the soul of a person express itself despite a very clouded mind. In fact I have witnessed this so many times I have come to expect it.

The first time I saw the spiritual side of a memory-impaired person take over was during a personal crisis. My father had recently returned home from the hospital after heart surgery and he was very disoriented. It was Shabbat eve and several of us kids were sitting around the table, grateful and nervous at having him returned to us in such a fragile state. My father was not doing well cognitively. He couldn’t remember who was who and kept mixing us up. He demanded to know where the other children were and why they hadn’t come yet. My sister and I began weeping because everyone he was asking for was already there, right in front of his eyes.

My mother tried to calm him by explaining what was going on but that did nothing to ease my father’s agitation. Finally, in frustration, he struggled to his feet. As he held the Kiddush cup in his shaking hand, the wine began to spill. We stood silently in terrible pain as we witnessed his weakness and his strength. For in a voice strong with emotion he recited the prayer in a melodious voice without missing a beat. This man, who for the life of him could not make out his own kids, was able to praise God and sanctify the Sabbath.

I have seen this time and time again in my work. The other day I posed a moral dilemma to my clients: There is a man driving his car on a cold stormy night. He sees three people stranded at the side of the road. One is the woman of his dreams. The second is the doctor who once saved his life. The third is an old woman. He has room for two people. Who does he leave behind?

A man named Max, who is so far into his Alzheimer’s that he can’t find his way home although it’s next door to the center, ruined my game. Without even contemplating the choices, he said very simply, “I would get out of my car and give it to them.”

Another one of our members is a Holocaust survivor named Abby, who survived the war by living in a Christian orphanage. One morning the lady who sits next to her kept repeating, “Help me, help me. Somebody help me.”

Abby, who no longer recognizes her only son, leaned in close to the other lady. “What is it dear?” she asked. “Are you scared? Do you want to go home? We are all in this together. You just have to make the best of it and stay out of trouble.”

Then Abby picked up the other lady’s spoon and began to feed her some applesauce. I watched from the corner of the room, like I often do, observing the behavior of these old folks who live in a twilight zone. And I thought how well Abby had just described this world. Here we are together in this world of nonsense and materialism and our souls are not happy. They want to go home yet must live in a place full of difficult tests. The best we can do is help other people in need.

If I have learned one lesson from working with people suffering from dementia, it is this: Work on yourself and strive to perfect your character. Because when most of your intellectual powers are gone, the kernel that remains will be who you really are.

On Rosh Hashanah we will stand before the Almighty who has been in the corner observing us. All of our masks and personas, illusions and excuses will disappear. God sees through all that. All that will be left is who we really are – our soul. Our true inner self shines through, no matter how much fog descends upon it.

Dignity Therapy: For The Dying, A Chance To Rewrite Life : NPR

Dignity Therapy: For The Dying, A Chance To Rewrite Life : NPR.

One of the important pieces of working with the dying is to give them or their families an opportunity to rethink and relay their lives to others.  We are afraid that we will not have a legacy, and as such, some of our fear of death could potentially be alleviated through reflection and story telling.  There is a formal methodology for this, which is called dignity therapy.  Unfortunately, for many, reflection comes too late because of other concerns getting in the way, such as the fear of telling the person the truth because if someone knows he is dying, the person will get very depressed.  Instead, dignity therapy is a means of working through the depression to find a place of meaning that will outlast one’s life. 

For several decades, psychiatrists who work with the dying have been trying to come up with new psychotherapies that can help people cope with the reality of their death. One of these therapies asks the dying to tell the story of their life.

This end-of-life treatment, called dignity therapy, was created by a man named Harvey Chochinov. When Chochinov was a young psychiatrist working with the dying, he had a powerful experience with one of the patients he was trying to counsel — a man with an inoperable brain tumor.

“One of the last times that I went into his room to meet with him, on his bedside table was a photograph of him when he had indeed been young and healthy and a bodybuilder, and it was this incredible juxtaposition of these two images,” says Chochinov.

So in the bed there’s his patient — this skeleton of a man — very pale and weak. On the bedside table, there’s this portrait of a glistening, muscled giant. And Chochinov says that sitting there, it was very clear to him that by placing this photograph in such a prominent position, the man was sending a message: This was how he needed to be seen.

As Chochinov continued his work with the dying, he confronted this again and again — this need people have to assert themselves in the face of death. And he started to wonder about it…

“When you face death, it’s like facing a wall, and it forces you to turn around and look at the life that you’ve lived,” says William Breitbart, a psychiatrist at Sloan-Kettering Cancer Center in New York. He’s been trying to develop new psychotherapies for the dying. He says that many people have the wrong idea about the dying process.

“The prevailing mythology is that you die the way you live, and you can’t change yourself in any way,” says Breitbart. “The fact is that the last few months of life — because of the awareness of death — create an urgency that facilitates growth and change.”

This, he says, is why something like dignity therapy can be good. Though there’s no evidence that it relieves depression or anxiety, he thinks it can help us change in the very last moment of our lives. After all, he says, we’ve all lived imperfect lives.

“All of us fail, and the process, the task of dying, is to relieve ourselves of this guilt, whether it’s forgiving yourself or asking others to forgive you,” says Breitbart. “Or to remember your life slightly differently. But that’s the task of dying.”

As for Frego, she says she’s developed a strange relationship to the document her mother put together. Since her mother’s death, Frego says she’s actually carried the document around with her. She has the story of her mother’s life, always at her side, knocking around in the bottom of her bag.

My Worst Enemy’s Shiva

I found this today and felt it was quite important to share as a whole.  People have enough trouble paying a shiva visit in general.  How much more so when we think we need to visit someone we are in conflict with.  I am somewhat concerned by the Q and A here.  While I agree with the author’s response and strategies for visiting and how to visit, I would have started with a simpler question;  why do you feel the need to visit in the first place?  Is it out a sense of reconciliation, or a sense that the fighting was a mistake to begin with?  Or do you merely feel the need to fulfill the commandment of comforting the bereaved?  Nevertheless, consider the answer Hammerman offers for it does provide us a real sense of the appropriate timing and means of visiting while limiting the potential for fighting. 

Q. The mother of my worst enemy just died and I’m not sure whether to visit during Shiva. In truth, I sincerely see this as a chance to reconcile (we haven’t spoken in about five years but have a lot of friends in common). My only concern is that he would misinterpret the reason for the visit and kick me out of the house. I really don’t want to cause him any discomfort. What should I do?

A. Do you think this would be the first time that two people at a shiva had unresolved issues?  It happens all the time, usually involving people from the deceased’s family who are barely on speaking terms. I’ve seen amazing moments of reconciliation happen during the period of grieving. When someone says “over my dead body,” sometimes that’s precisely the most likely location for enemies to reunite, as happened to  Isaac and Ishmael when they buried Abraham.

So go.

But I add this disclaimer: If you poisoned his Akita or stole his birthright, I might hold off until the time is right. Jacob’s journey back to Esau was paved with gifts and trepidation. It took decades before each party was ready. In any event, if you do go to the Shiva, I’d avoid visiting during peak periods, when the mourner might feel you are simply making an appearance for show. If the guy shows signs of being uncomfortable with your presence, or worse, begins to make a scene, I’d make a hasty exit and not take it personally.  The rabbis explained that the second Temple was destroyed because of the resentment of a person humiliated in public by his worst enemy. Don’t let that happen to you. It’s also OK to wait until after shiva, when you might call and meet for coffee in a quite spot. Or maybe the best strategy would be to write a heartfelt letter.

I believe that all conflicts have an expiration date. Even the Hatfields and McCoys signed a truce just a few years ago. If you could reconcile with your worst enemy and become a true pursuer of peace, echoing the words of Psalm 34:15, you will make the world a better place. And an enormous weight will be taken off your shoulders.

Are we fooling ourselves?

I came across another of Rev. Jacob’s posts on Huffington Post revolving around end-of-life issues.  She focuses on an article written a month ago which I already wrote about here.  She uses the story to elicit from her readers the question of how we would want our own death to look like, assuming we don’t suddenly drop dead.  She poses the following questions for us to contemplate:

What would you do were you in Dudley Clendinen’s situation? I am not asking you to judge what he has decided is right for him. I am asking you to consider what you would want were you to find yourself in Dudley’s situation. Would you want to die the way he describes his mother, cousin and his aunts did, “… all of whom would have died of natural causes years earlier if not for medical technology, well-meaning systems and loving, caring hands”? Or would you prefer what Dudley has decided? Or something else?

Also, thinking about the prospect of only having several months to live (although death could occur for any of us at any time — whether it be while walking down the street, eating a meal or sleeping), I wonder how many of us could do what Dudley is doing while he is dying — living one day at a time? For those of us who have not done a 12-step program, are we able to live today and focus only on this day? Can we appreciate what we have before us right now? “Consider the birds in the fields” (Matt 6:26) “Behold the lilies of the field” (Matt 6:28) — Can we just “be still, and know” (Ps 46:10) — Can we see the “goodness of the Lord in the land of the living?” (Ps 27:13)

What do you think that God expects of us as we live this life — and await our time to die? And, then, as Ecclesiastes reminds us, there is a time for everything … “A time to be born and a time to die …” (Eccl 3:1-2) We know that we will one day die. And, what do you think that God expects of us as we are dying?

From the standpoint of the questions she poses, I am left with one thought.  There are times we, the healthy, look on the ill or the elderly and say, “I don’t want to end up this way.  I would rather no aggressive interventions to prolong my life.”  Yet, I would venture that for many of us, as we age, we will think somewhat differently when faced with the closeness of our own mortality.  This is not to suggest a lack of belief in G-d or an afterlife, a subject unto themselves.  It is rather to say that a part of what makes us who we are will never want to disappear.  Our self is afraid of not existing.  That is why contemplating death is a difficult spiritual practice.  I think many are too quick to say I would rather not live if… On the flip side, for those who are suffering, realize that my critique is not about any of the trauma and challenge of chronic or life limiting illnesses.  I am merely saying that it is easy for the young and healthy to prefer death over a partial life when it is a hypothetical decision as opposed to something that is current in his/her life.