Marianne Tanzer recently had to make difficult decisions about her elderly father’s medical care. Her father, 86, was already in poor health, and now he also had COVID.
Tanzer, her father’s legal healthcare proxy, wanted to honor her father’s end-of-life wishes. But it was also important for her to follow halacha, or Jewish law, with whatever decisions she would make.
“My father gave us an advance healthcare directive, but there was a lot of grey area to deal with in the moment,” Tanzer said.
An American-born married mother of five and yoga instructor living in the Efrat settlement south of Jerusalem, Tanzer turned to her local rabbi for help. Unfortunately, the rabbi himself had COVID and was unable to speak with Tanzer. He recommended she instead contact Through One Hundred Twenty, a program connecting people who have questions and hard decisions to make regarding sick and dying loved ones with specially trained teams of rabbis and social workers.
Through One Hundred Twenty is a year-old project of Tzohar, an Israel-based organization founded by religious-Zionist Orthodox rabbis to bridge gaps between religious and secular Jews by encouraging a more informed, accessible and compassionate understanding of Jewish tradition and identity.
Tzohar rabbis take a non-judgmental and non-coercive approach, which they use to assist Israeli Jews with numerous lifecycle events connected to Jewish practice and tradition.
“We started the program because we were getting more and more questions dealing with big ethical issues regarding the end of life,” said Rabbi Yuval Cherlow, head of the Center for Ethics at the Tzohar Rabbinical Organization, and director of Through One Hundred Twenty.
“Medical advances are keeping people alive for longer, even if they are not functioning. The mind and body are going at different times, and this gap between the soul and the body is creating ethical issues that people need to grapple with,” he said.
According to Cherlow, there is a misconception that Jewish law dictates that a person’s life must be extended as long as possible at any cost. He cited the example of the late Israeli prime minister Ariel Sharon, who was kept on a respirator for eight years while in a coma after suffering a series of strokes.
By Israeli law, the ultimate decision-making power regarding the treatment of terminally ill patients rests in the hands of physicians and medical institutions. However, in recent decades, the importance of also considering the wishes of the patient and their family has been recognized.
These situations are actually more nuanced than people assume
“These situations are actually more nuanced than people assume. According to halacha, there are cases when it is okay to say enough is enough. Not all rabbis know this,” Cherlow said.
This has left many within the Jewish population — including among the religiously observant — ill-equipped to feel fully confident in making decisions for themselves or loved ones.
According to Cherlow, Tzohar’s program is not designed to dictate whether to insert a feeding tube or attach a person to a respirator, for example.
“We don’t give orders. We are teachers. What we do is explain to people which choices, under what circumstances, would fall within the boundaries of Jewish law, and which would not,” he said.
This teaching takes place in sessions (conducted in Hebrew, or in English as needed) facilitated by a team comprised of a rabbi and social worker. Tzohar currently has 10 teams in place, who are available to families throughout the country on a 24/6 basis. In an emergency, they can also be reached on Shabbat.
Experienced geriatric social worker Debbie Braitbard supervises the program’s social workers, who receive specialized training in palliative and end-of-life care.
“This is a new model. The rabbis and social workers train together, and together we learn from hospital staff,” Braitbard said.
Tzohar social workers help with communication between families and physicians when needed, and ascertain that a family has provided all official medical documentation prior to the meeting so that the Tzohar team is fully informed.
In the sessions with families (which have so far been held only by Zoom because of COVID restrictions), the social workers calmly facilitate the discussion, which can be emotionally wracked in a time of crisis. The ultimate goal is to act in the best interests of the patient, with each case being unique.
“I make sure that everyone has a chance to talk. I also reflect back on what each person has said, and what the rabbi has said, so that people have another chance to take things in,” Braitbard said.
Braitbard noted that having to conduct these meetings on Zoom has been unexpectedly beneficial.
“I find it’s even better than meeting in person, because with video conferencing you can quickly get all the family members together no matter where they are in Israel or the world,” she said.
With families usually turning to Tzohar a week or two prior to when the patient enters an acute stage (or when the attending physician says it is time to start making some decisions), time is of the essence in setting up the consultations.
In Tanzer’s case, she called the Tzohar Through One Hundred Twenty hotline in the morning, and a session for her and her sister with a rabbi-social worker team took place that evening.
“It was a long meeting. We were literally dealing with life and death decisions, so we took a break in the middle. The rabbi took that time to consult with other rabbis, and then we reconvened,” Tanzer said.
“We felt heard and understood, despite the fact that these people were complete strangers to my sister and me. They took so much time with us, and we felt cared for,” she said.
In addition to meeting with around four different families per week, Through One Hundred Twenty works with hospital and home care staff who want to better understand the halachic implications of various actions and choices.
“Even judges are asking us questions,” Cherlow said.
The initiative also focuses on public education about ethical and halachic care for the elderly. Recently, the program held four related online forums that attracted close to 3,000 people.
According to Cherlow, there has been an increase in questions coming in about dementia. Adult children are grappling with issues such as whether to keep a parent with dementia at home or not, or whether it is permissible to lie to them so as not to upset them. Jewish law responsa to such questions appear on the Through One Hundred Twenty Hebrew-language website, and should soon appear on its English-language one, as well.
Cherlow also noted that individuals are turning to Tzohar with questions as they work on drafting their advanced healthcare directives, which the organization has encouraged people to put in place well ahead of time.
Dr. Elisha Waldman, a palliative care specialist at Lurie Children’s Hospital of Chicago and former Hadassah Medical Center pediatric oncologist, applauds Through One Hundred Twenty for making more space for the spiritual and religious dimensions of healthcare decision making.
“Advance healthcare directives are important, but even more so is a conversation taking a holistic approach. We want to honor who a person is — what are the aspects of their life that give it meaning?” Waldman said.
Waldman recognizes that nobody wants to talk about their own demise, or that of a loved one, but as a palliative care specialist, he would like to see discussions between patients, doctors, social workers and clergy take place well in advance of end-of-life scenarios.
“They should take place at plateaus like diagnosis or remission of an illness, not at the jagged, scary dips when the crisis is crashing down around you,” Waldman said.
Dr. Shoshana Ungerleider, founder of End Well, a US-based non-profit dedicated to the belief that everyone should experience the end of life in a way that matches their goals and values, believes it is time in Western society to reclaim death as part of life. This involves speaking early and often about how we want to die, as unnatural or uncomfortable as this may seem.
“The medical literature shows that the earlier a patient is referred to palliative care that addresses their psycho-social, medical, and spiritual needs, the longer they live and the better the life they have,” Ungerleider said.
Tzohar’s Cherlow acknowledged that palliative care is a relatively new medical specialty in Israel, and he welcomed the fact that more training programs are being introduced.
“The goal of those programs is quality of life, and we see ourselves as part of that,” he said.
Cherlow said that what most worries people is whether they are doing the right thing for their loved one.
“They want to know they are not letting go too early or too late. They don’t want to be left with questions later,” Cherlow said.
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