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Rabbi Edward Reichman, M.D. Associate Professor, Emergency Medicine Associate Professor, Philosophy and History of Medicine Albert Einstein College of Medicine of Yeshiva University. Is this the Jewish viewpoint?. Objectives. Understand the medical issues that pertain to end of life care. - PowerPoint PPT Presentation
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Rabbi Edward Reichman, M.D.Rabbi Edward Reichman, M.D.
Associate Professor, Emergency MedicineAssociate Professor, Emergency Medicine
Associate Professor, Philosophy and History of MedicineAssociate Professor, Philosophy and History of Medicine
Albert Einstein College of Medicine of Yeshiva UniversityAlbert Einstein College of Medicine of Yeshiva University
Is this the Jewish viewpoint?
ObjectivesObjectives
Understand the medical issues Understand the medical issues that pertain to end of life care.that pertain to end of life care.
Appreciate the medical and Appreciate the medical and cultural milieu in which medical cultural milieu in which medical
decisions are made.decisions are made.
Facilitate psak halakha for end Facilitate psak halakha for end of life issues.of life issues.
TopicsTopics
DNR/DNIDNR/DNI
General Withholding of CareGeneral Withholding of Care
Coma and PVSComa and PVS
Nutrition and HydrationNutrition and Hydration
Disconnecting a VentilatorDisconnecting a Ventilator
Pain Management at the End of LifePain Management at the End of Life
Active EuthanasiaActive Euthanasia
Do Not ResuscitateDo Not ResuscitateDo Not IntubateDo Not Intubate
Mr. B. Cohen, 66 y.o., is a chronic smoker and was Mr. B. Cohen, 66 y.o., is a chronic smoker and was recently diagnosed with lung cancer. He has completed recently diagnosed with lung cancer. He has completed chemotherapy with no improvement and further chemotherapy with no improvement and further therapy is deemed futile. He now presents to the therapy is deemed futile. He now presents to the hospital with shortness of breath. The hospital staff hospital with shortness of breath. The hospital staff asks the family if they wish to sign a DNR order. asks the family if they wish to sign a DNR order.
The Cohen family calls the rabbi and asks, The Cohen family calls the rabbi and asks,
โโCan we sign a DNR?Can we sign a DNR?โโ
The Rabbi then calls the doctor to discuss the case.The Rabbi then calls the doctor to discuss the case.
Medical and Cultural IssuesMedical and Cultural Issues
Do Not Resuscitate(DNR) Do Not Resuscitate(DNR)
andand
Do Not Intubate(DNI)Do Not Intubate(DNI)
Does DNR mean DNT (Do Not Treat)?Does DNR mean DNT (Do Not Treat)?
J American Geriatric Society 2002 Dec;50(12):2057-61.J American Geriatric Society 2002 Dec;50(12):2057-61. The effect of do-not-resuscitate orders The effect of do-not-resuscitate orders
on physician decision-making.on physician decision-making.
The effect of do-not-resuscitate (DNR) orders on physicians' The effect of do-not-resuscitate (DNR) orders on physicians' decisions to provide life-prolonging treatments other than decisions to provide life-prolonging treatments other than
cardiopulmonary resuscitation (CPR) for patients near the end of life cardiopulmonary resuscitation (CPR) for patients near the end of life was exploredwas exploredโฆโฆ.The presence of a DNR order may affect .The presence of a DNR order may affect
physicians' willingness to order a variety of treatments not related to physicians' willingness to order a variety of treatments not related to CPR. Patients with DNR orders may choose to forgo other life-CPR. Patients with DNR orders may choose to forgo other life-prolonging treatments, but physicians should elicit additional prolonging treatments, but physicians should elicit additional information about patients' treatment goals to inform these information about patients' treatment goals to inform these
decisions.decisions.
Story of Rabbi Yehudah HanasiStory of Rabbi Yehudah Hanasiโโs s DeathDeath
ืชืืืื ืืืื ืืกืืช ืืชืืืืช ืืฃ ืงื ืขืืื ืืชืืืื ืืืื ืืกืืช ืืชืืืืช ืืฃ ืงื ืขืืื ื ืกืืืงื ืืืชืื ืืจืื ืืืืืจื, ืืืจื: ืขืืืื ื' ืืืงืฉืื ืกืืืงื ืืืชืื ืืจืื ืืืืืจื, ืืืจื: ืขืืืื ื' ืืืงืฉืื
ืืช ืจืื ืืืชืืชืื ื' ืืืงืฉืื ืืช ืจืื, ืืื ืจืฆืื ืฉืืืืคื ืืช ืจืื ืืืชืืชืื ื' ืืืงืฉืื ืืช ืจืื, ืืื ืจืฆืื ืฉืืืืคื ืชืืชืื ืื ืืช ืืขืืืื ืื. ืืืื ืืืืื ืืื ืืืื ื ืืขืืื ืชืืชืื ืื ืืช ืืขืืืื ืื. ืืืื ืืืืื ืืื ืืืื ื ืืขืืื
ืืืืช ืืืกื, ืืืืฅ ืชืคืืืื ืืื ื ืืื ืืงืืฆืืขืจ, ืืืืช ืืืกื, ืืืืฅ ืชืคืืืื ืืื ื ืืื ืืงืืฆืืขืจ, ืืืจื: ืืื ืจืฆืื ืฉืืืืคื ืขืืืื ืื ืืช ืืชืืชืื ืื. ืืื ืืืจื: ืืื ืจืฆืื ืฉืืืืคื ืขืืืื ืื ืืช ืืชืืชืื ืื. ืืื ืืื ืฉืชืงื ืจืื ื ืืืืืืขื ืจืืื, ืฉืงืื ืืืื ืฉืืืื ืืื ืฉืชืงื ืจืื ื ืืืืืืขื ืจืืื, ืฉืงืื ืืืื ืฉืืืื
, ืืืฉืชืืงื ืืจืืื ืื ื ื ืคืฉืื ืืจืื., ืืืฉืชืืงื ืืจืืื ืื ื ื ืคืฉืื ืืจืื.]]ืืืจืขืืืืจืขื[[ืืืืืจื ืืืืืจื
Quality of Life- Rabbinic SourcesQuality of Life- Rabbinic Sources
ืจ"ื ืืกืืช ื ืืจืื ืืฃ ื ืขืืื ืืจ"ื ืืกืืช ื ืืจืื ืืฃ ื ืขืืื ื
- ื ืจืื ืืขืื ื ืื"ืง - ื ืจืื ืืขืื ื ืื"ืง ืืื ืืืงืฉ ืขืืื ืจืืืื ืื ืฉืืืื ืืื ืฉืืืืชืืื ืืืงืฉ ืขืืื ืจืืืื ืื ืฉืืืื ืืื ืฉืืืืชืคืขืืื ืฉืฆืจืื ืืืงืฉ ืจืืืื ืขื ืืืืื ืฉืืืืช ืืืื ืฉืืฆืืขืจ ืคืขืืื ืฉืฆืจืื ืืืงืฉ ืจืืืื ืขื ืืืืื ืฉืืืืช ืืืื ืฉืืฆืืขืจ
ืืืืื ืืืืื ืืจืื ืืื ืืคืฉืจ ืื ืฉืืืื ืืืืืจืื ื ืืคืจืง ืืืืื ืืืืื ืืจืื ืืื ืืคืฉืจ ืื ืฉืืืื ืืืืืจืื ื ืืคืจืง ืื ืืฉื )ืืชืืืืช ืงื( ืืืืื ืืืืื ืืืชืื ืืจืื ืืขื ืืื ืืืื ืื ืื ืืฉื )ืืชืืืืช ืงื( ืืืืื ืืืืื ืืืชืื ืืจืื ืืขื ืืื ืืืื ืื
ืืืืช ืืืกื ืืื ื ืชืคืืืื ืืงื ืืฆืืขืจ ืืืจื ืืื ืจืฆืื ืฉืืืืคื ืืืืช ืืืกื ืืื ื ืชืคืืืื ืืงื ืืฆืืขืจ ืืืจื ืืื ืจืฆืื ืฉืืืืคื ืืขืืืื ืื ืืช ืืชืืชืื ืื ืืืืืจ ืืืืืืช ืจืื ืืืฉ"ื ืงืืืจ ืืขืืืื ืื ืืช ืืชืืชืื ืื ืืืืืจ ืืืืืืช ืจืื ืืืฉ"ื ืงืืืจ
ืืืืืงืจ ืืืื ืืืขืืื ืืชืคืืชื ืืคื' ืืืืืช ืืคื ื ืฉืืื ืชืคืื ืืืืืงืจ ืืืื ืืืขืืื ืืชืคืืชื ืืคื' ืืืืืช ืืคื ื ืฉืืื ืชืคืื ืืืชืจ ืืืขืืช ืืื ืฉืืื ื ืืืงืจื ืืื ืฆืจืื ืืืืจ ืฉืืื ื ืืืขืืื ืืืชืจ ืืืขืืช ืืื ืฉืืื ื ืืืงืจื ืืื ืฆืจืื ืืืืจ ืฉืืื ื ืืืขืืื
ืืืืืช ืืื ืืคื' ืืืื ืืืืื ืืื ืื ืื ืืืืชื ืืคื' ืืืชื ืืืืืช ืืื ืืคื' ืืืื ืืืืื ืืื ืื ืื ืืืืชื ืืคื' ืืืชื ..ืืืืจืชื ืืื ื ืืื ืืืืืืจืชื ืืื ื ืืื ืื
Praying for a patientPraying for a patientโโs deaths death
Story of a WomanStory of a Womanโโs Requests Request
ืืืงืื ืฉืืขืื ื ืชืืจื ืคืจืฉืช ืขืงื ืจืื ืชืชืขืืืืงืื ืฉืืขืื ื ืชืืจื ืคืจืฉืช ืขืงื ืจืื ืชืชืขืืืขืฉื ืืืฉื ืืืช ืฉืืืงืื ื ืืจืื ืืืืช ืืคื ื ืืขืฉื ืืืฉื ืืืช ืฉืืืงืื ื ืืจืื ืืืืช ืืคื ื
ืจืื ืืืกื ืื ืืืคืชื ืืืจื ืืื ืจืื ืืืงื ืชื ืืืชืจ ืจืื ืืืกื ืื ืืืคืชื ืืืจื ืืื ืจืื ืืืงื ืชื ืืืชืจ ืืืื ืืืขืืฉืื ืืืื ืฉื ื ืืื ืื ืฉืืื ื ืืืขืืช ืื ืืืื ืืืขืืฉืื ืืืื ืฉื ื ืืื ืื ืฉืืื ื ืืืขืืช ืื
ืืืื ืืื ืืฉืงื ืืื ื ืืืงืฉืช ืืืคืืจ ืื ืืขืืื, ืืืื ืืื ืืฉืงื ืืื ื ืืืงืฉืช ืืืคืืจ ืื ืืขืืื, ื"ื ืื ืืฆืื ืืช ืืืืื ืืขืฉืืช ืืื ืืื, ื"ื ื"ื ืื ืืฆืื ืืช ืืืืื ืืขืฉืืช ืืื ืืื, ื"ื
ืืืืื ืื ื ืืคืืื ืืฉ ืื ืืืจ ืืืื ืื ื ืื ืืช ืืืชื ืืืืื ืื ื ืืคืืื ืืฉ ืื ืืืจ ืืืื ืื ื ืื ืืช ืืืชื ืืืฉืืืช ืืืืช ืืื ืกืช ืืื ืืื, ื"ื ืื ืขื ืขืฆืื ืืืฉืืืช ืืืืช ืืื ืกืช ืืื ืืื, ื"ื ืื ืขื ืขืฆืื
ืืืืช ืืื ืกืช ืฉืืฉื ืืืื ืื ืืืจ ืื, ืืืื ืืืืช ืืื ืกืช ืฉืืฉื ืืืื ืื ืืืจ ืื, ืืืื ืืขืฉืชื ืื ืืืืื ืืฉืืืฉื ืืืชื ืืืชื ืืขืฉืชื ืื ืืืืื ืืฉืืืฉื ืืืชื ืืืชื
Halakhic IssuesHalakhic Issues
Is it ever permitted to withhold care?Is it ever permitted to withhold care? If yes, what is the halakhic framework for If yes, what is the halakhic framework for
withholding? withholding? How is a gosses defined How is a gosses defined bizman hazeh, bizman hazeh, and does and does
this definition have practical halakhic application?this definition have practical halakhic application? Are the wishes of the patient taken into Are the wishes of the patient taken into
consideration?consideration? Can a family member decide on behalf of a patient Can a family member decide on behalf of a patient
without decision-making capacity?without decision-making capacity?
Halakhic Framework For Halakhic Framework For Withholding Care: GossesWithholding Care: Gosses
ืฉืืืื ืขืจืื ืืืจื ืืขื ืกืืื ืฉืื ืกืขืืฃ ืืฉืืืื ืขืจืื ืืืจื ืืขื ืกืืื ืฉืื ืกืขืืฃ ื. ืืื ืงืืฉืจืื ืืืืื, ืืืื ืกืืื ืืืชื, ืืืื ืืืืืื . ืืื ืงืืฉืจืื ืืืืื, ืืืื ืกืืื ืืืชื, ืืืื ืืืืืื ืืืืกืก, ืืจื ืืื ืืื ืืื ืืืจืืืืืืกืก, ืืจื ืืื ืืื ืืื ืืืจืื
ืืืชื, ืืืื ืคืืงืงืื ืืช ื ืงืืื, ืืืื ืฉืืืืื ืืืจ ืืชืืชืื, ืืืื ื ืืชื ืื ืืืชื ืขื ืืืชื, ืืืื ืคืืงืงืื ืืช ื ืงืืื, ืืืื ืฉืืืืื ืืืจ ืืชืืชืื, ืืืื ื ืืชื ืื ืืืชื ืขื ืืื ืืื, ืืื ืขื ืืื ืืจืกืืช ืืื ืขื ืืื ืืืื, ืืืื ื ืืชื ืื ืขื ืืจืืกื ืื ืืื ืืื, ืืื ืขื ืืื ืืจืกืืช ืืื ืขื ืืื ืืืื, ืืืื ื ืืชื ืื ืขื ืืจืืกื ืื
ืงืขืจื ืืื ืืืจืืคื ืืื ืฆืืืืืช ืฉื ืืื ืืื ืืจืืืจ ืฉื ืืื, ืืืื ืืฉืืืขืื ืงืขืจื ืืื ืืืจืืคื ืืื ืฆืืืืืช ืฉื ืืื ืืื ืืจืืืจ ืฉื ืืื, ืืืื ืืฉืืืขืื ืขืืื ืขืืืจืืช, ืืืื ืฉืืืจืื ืืืืืื ืืืงืื ื ืืช, ืืืื ืืขืืฆืื ืขืื ืื ืขื ืฉืชืฆื ื ืคืฉื. ืขืืื ืขืืืจืืช, ืืืื ืฉืืืจืื ืืืืืื ืืืงืื ื ืืช, ืืืื ืืขืืฆืื ืขืื ืื ืขื ืฉืชืฆื ื ืคืฉื.
ืืื ืืกืืจ ืืืจืื ืืืช ืฉืืืืช ืืื ืืกืืจ ืืืจืื ืืืช ืฉืืืืช ืืื ืืืขืืฅ ืขื ืืฆืืืช ืื ืคืฉ, ื"ื ืฉืืคื ืืืื.ืืื ืืืขืืฅ ืขื ืืฆืืืช ืื ืคืฉ, ื"ื ืฉืืคื ืืืื.ืืืจื, ืืืื ืื ืฉืืื ืืืกืก ืืื ืืจืื ืืื ืืืื ืืืคืจื, ืืกืืจ ืืืฉืื ืืืจ ืืืจื, ืืืื ืื ืฉืืื ืืืกืก ืืื ืืจืื ืืื ืืืื ืืืคืจื, ืืกืืจ ืืืฉืื ืืืจ ืืืืกืช ืืชืืชืื, ืืื ืฉืืืืจืื ืฉืืฉ ื ืืฆืืช ืืงืฆืช ืขืืคืืช ืฉืืืจืืื ืื ืืื ืื ืืืืกืช ืืชืืชืื, ืืื ืฉืืืืจืื ืฉืืฉ ื ืืฆืืช ืืงืฆืช ืขืืคืืช ืฉืืืจืืื ืื ืืื ืื ืืืืื ื ืืืงืืื. ืืื ืืกืืจ ืืฉืื ืืคืชืืืช ื"ื ืชืืช ืจืืฉื, ืืื ืฉืืคืจื. ืืื ืืืืื ื ืืืงืืื. ืืื ืืกืืจ ืืฉืื ืืคืชืืืช ื"ื ืชืืช ืจืืฉื, ืืื ืฉืืคืจื. ืืื ืื ืืฉ ืฉื ืืืจ ืฉืืืจื ืขืืื ืืฆืืืช ืื ืคืฉ, ืืืื ืฉืืฉ ืกืืื ืืืืชื ืืืช ืงืื ืื ืืฉ ืฉื ืืืจ ืฉืืืจื ืขืืื ืืฆืืืช ืื ืคืฉ, ืืืื ืฉืืฉ ืกืืื ืืืืชื ืืืช ืงืื ืืืคืง ืืืื ืืืื ืขืฆืื ืื ืฉืืฉ ืืื ืขื ืืฉืื ื ืืืื ืืขืืืื ืืฆืืืช ืื ืคืฉ, ืืืคืง ืืืื ืืืื ืขืฆืื ืื ืฉืืฉ ืืื ืขื ืืฉืื ื ืืืื ืืขืืืื ืืฆืืืช ืื ืคืฉ,
ืืืชืจ ืืืกืืจื ืืฉื, ืืืื ืืื ืืขืฉื ืืื, ืืื ืฉืืกืืจ ืืืื ืขืืืชืจ ืืืกืืจื ืืฉื, ืืืื ืืื ืืขืฉื ืืื, ืืื ืฉืืกืืจ ืืืื ืข
ืื"ื ื' ืกืืื ืขืืื"ื ื' ืกืืื ืขื ืฉื"ืช ืืืจืืช ืืฉื ืฉื"ืช ืืืจืืช ืืฉื
ืืคืฉืื ืฉืื ืกืืืจ ืืจื"ื ืืื"ื ืกืืื ืฉื"ื ืกืขืืฃ ื' ืืคืฉืื ืฉืื ืกืืืจ ืืจื"ื ืืื"ื ืกืืื ืฉื"ื ืกืขืืฃ ื' ืฉืืชืืจ ืืื ืืฆืจืื ืืืกืืจ ืืืจืื ืืืขืืืื ืืฆืืืช ืื ืคืฉ ืฉืืชืืจ ืืื ืืฆืจืื ืืืกืืจ ืืืจืื ืืืขืืืื ืืฆืืืช ืื ืคืฉ
ืืฃ ืฉื ืืฆื ืืืืจืืื ืฉืืืืช ืืืืื ืืื ืงืื ืงืืื, ืืฃ ืฉื ืืฆื ืืืืจืืื ืฉืืืืช ืืืืื ืืื ืงืื ืงืืื, ืืคืฉืื ืฉืืื ืืฆื ืืืกืืจืื ืฉืืฉ ืืืืืกืก ืืื, ืืืืืื ืืคืฉืื ืฉืืื ืืฆื ืืืกืืจืื ืฉืืฉ ืืืืืกืก ืืื, ืืืืืื
ืืกืืจืื ืื ืืืื ืฉืื ืืขื ืฉืืชืืจื ืืฃ ืืกืืง ืืืจืื ืืกืืจืื ืื ืืืื ืฉืื ืืขื ืฉืืชืืจื ืืฃ ืืกืืง ืืืจืื ืืืขืืืื ืืืฆืืืช ืื ืคืฉ, ืืื ืืืจืื ืืื ืื ื ืืืืื ืื ืืืขืืืื ืืืฆืืืช ืื ืคืฉ, ืืื ืืืจืื ืืื ืื ื ืืืืื ืื
ืืืื ืืก. ืืื ืืืื ืฉืืื ืืฆื ืืืกืืจืื ืฉืืฉ ืืืืืกืก ืืืื ืืก. ืืื ืืืื ืฉืืื ืืฆื ืืืกืืจืื ืฉืืฉ ืืืืืกืก ..ืืืืืื
Halakhic Framework For Halakhic Framework For Withholding Care: Intractable PainWithholding Care: Intractable Pain
ืฆืืฅ ืืืืขืืจืฆืืฅ ืืืืขืืจ
ืืืง ื ืกืืื ืืืืืง ื ืกืืื ืื
ืื"ื ื ืืื ืืื ืขื ืืื ืืืืจ ืงืืคืื ืืื ืืื ืื"ื ื ืืื ืืื ืขื ืืื ืืืืจ ืงืืคืื ืืื ืืื ืื ืืฉืฉืจืื ื"ืข ืืืืืื ืืืืื ืืืืงืงืื ืื ืืฉืฉืจืื ื"ืข ืืืืืื ืืืืื ืืืืงืงืื ืืืชื, ืืืฉืจ ืื ืืืืฉืืช ืืืื ืืืื ืืฉืจ ืืืชื, ืืืฉืจ ืื ืืืืฉืืช ืืืื ืืืื ืืฉืจ
ืืืจืื ืคืขืืื ืืข"ื ืืื ืื ื"ื ืืืืื ืจืง ืข"ื ืืืจืื ืคืขืืื ืืข"ื ืืื ืื ื"ื ืืืืื ืจืง ืข"ื ืืืืช ืื ืืคื ืฉืขื ืืืช ืืืฆืืช ืืืข"ื ืืขืื"ื ืืืืช ืื ืืคื ืฉืขื ืืืช ืืืฆืืช ืืืข"ื ืืขืื"ื
..ืืื ืืื ืืขืื"ื ืืื ืืืื ืืื ืืืจื ืืืชืืื ืืื ืืขืื"ื ืืื ืืืื ืืื ืืืจื ืืืช
Withholding of Specific TreatmentsWithholding of Specific Treatments
AntibioticsAntibiotics Blood transfusionsBlood transfusions โโpressorspressorsโโ- medicines to - medicines to
maintain blood pressuremaintain blood pressure DialysisDialysis
Existing DocumentsExisting Documents
Two current health care decision Two current health care decision documents:documents:
1)1) RCA Living WillRCA Living Will
2)2) Agudah Health Care ProxyAgudah Health Care Proxy
Coma or PVSComa or PVS
Epitaph for Terry SchiavoEpitaph for Terry SchiavoSchiavoSchiavo
Theresa MarieTheresa MarieBorn December 3, 1963Born December 3, 1963
departed this earth, departed this earth, February 25, 1990February 25, 1990
At Peace March 31, 2005At Peace March 31, 2005
Medical IssuesMedical Issues
Does a comatose patient Does a comatose patient experience pain?experience pain?
A comatose patient is not A comatose patient is not brain dead.brain dead.
A comatose patient per se A comatose patient per se does not have a terminal does not have a terminal condition.condition.
Halakhic IssuesHalakhic Issues
Is a comatose patient treated differently in Is a comatose patient treated differently in the eyes of halakha?the eyes of halakha?
Is a comatose patient considered to be Is a comatose patient considered to be suffering from intractable pain such that suffering from intractable pain such that treatments can be withheld?treatments can be withheld?
Is the requirement for food or to treat Is the requirement for food or to treat infections different for the comatose infections different for the comatose patient?patient?
ืฉื"ืช ืืืจืืช ืืฉื ืืืง ืื"ื ื' ืกืืื ืขืืฉื"ืช ืืืจืืช ืืฉื ืืืง ืื"ื ื' ืกืืื ืขืืืืืื ืคืฉืื ืืืจืืจ ืืืืืข ืืื ืื ืชืืจื ืืืจ"ืฉ ืืืืื ืคืฉืื ืืืจืืจ ืืืืืข ืืื ืื ืชืืจื ืืืจ"ืฉ ืฉืืืืืืืื ืืจืคืืืช ืืืฆืื ืืื ืฉืืคืฉืจ ืืื ืฉืืืืืืืื ืืจืคืืืช ืืืฆืื ืืื ืฉืืคืฉืจ ืืื
,,ืืื ืืื ืฉืื ืืืืง ืืืืืชื ืืืืขืชืืืื ืืื ืฉืื ืืืืง ืืืืืชื ืืืืขืชื
ืฉื"ืช ืืืจืืช ืืฉื ืืืง ืื"ื ื ืกืืื ืงืขืืฉื"ืช ืืืจืืช ืืฉื ืืืง ืื"ื ื ืกืืื ืงืขื
ืืื ืฉืืืืจื ืืจืืคืืื ืฉืืื ื ืืจืืืฉ ืืืจ ืืืกืืจืื ืืื ืฉืืืืจื ืืจืืคืืื ืฉืืื ื ืืจืืืฉ ืืืจ ืืืกืืจืื ืืื ืืืืืื ื ืื ืืคืฉืจ ืื ืฉืืื ืฉืืืขื ืื ืืื ืืื ืืืืืื ื ืื ืืคืฉืจ ืื ืฉืืื ืฉืืืขื ืื ืืื
ืืฉืืข ืฉืขืืื ืืฆืืืช ืื ืคืฉ ืืื ืืืกืืจืื ืืฃ ืืฉืืข ืฉืขืืื ืืฆืืืช ืื ืคืฉ ืืื ืืืกืืจืื ืืฃ ,,ืฉืื ื ืืืจ ืื ืืฉืื ื ืืืจ ืื ื
RRโโ Elyashiv Elyashiv
Science. 2006 Sep Science. 2006 Sep 8;313(5792):1402.8;313(5792):1402.
END OF LIFEEND OF LIFEMom: Son in coma heard everything for 23 yearsMom: Son in coma heard everything for 23 yearsNovember 23, 2009November 23, 2009BRUSSELS โ A mother says her son has emerged from what doctors BRUSSELS โ A mother says her son has emerged from what doctors thought was a vegetative state to say he was fully conscious for 23 thought was a vegetative state to say he was fully conscious for 23 years but could not respond because he was paralyzed.years but could not respond because he was paralyzed.Rom Houben had a car crash in 1983 and doctors thought he had Rom Houben had a car crash in 1983 and doctors thought he had sunk into an apparent coma. Still, his family continued to believe their sunk into an apparent coma. Still, his family continued to believe their son was conscious and had sought further medical advice.son was conscious and had sought further medical advice.Dr. Audrey Vanhaudenhuyse said Houben's mother finally met Belgian Dr. Audrey Vanhaudenhuyse said Houben's mother finally met Belgian expert Steven Laureys, who realized that the medical diagnosis for her expert Steven Laureys, who realized that the medical diagnosis for her son was wrong. Laureys then taught Houben how to communicate son was wrong. Laureys then taught Houben how to communicate through a special keyboard.through a special keyboard.
Nutrition and HydrationNutrition and Hydration
Mr. C Cohen has been suffering from progressive Mr. C Cohen has been suffering from progressive dementia. His PO intake has declined and he is dementia. His PO intake has declined and he is now refusing to eat entirely. He often recognizes now refusing to eat entirely. He often recognizes family. There are good days and bad days. He family. There are good days and bad days. He has no other acute medical conditions. The has no other acute medical conditions. The Cohen family asks the Rabbi:Cohen family asks the Rabbi:
โโDo we have to insert a a feeding tube?Do we have to insert a a feeding tube?โโ
Nasogastric TubeNasogastric Tube
PEGPEGPercutaneous Endoscopic GastrostomyPercutaneous Endoscopic Gastrostomy
Halakhic IssuesHalakhic Issues
Is nutrition and hydration considered supportive Is nutrition and hydration considered supportive care or a medical treatment that can be withheld?care or a medical treatment that can be withheld?
Is the method of nutrition relevant?Is the method of nutrition relevant? Is the prognosis of the patient relevant, and if so, Is the prognosis of the patient relevant, and if so,
with what prognosis do we consider withholding with what prognosis do we consider withholding nutrition?nutrition?
Are the wishes of the patient relevant?Are the wishes of the patient relevant?
Disconnecting Life SupportDisconnecting Life Support
โDo I have the patientโs consent to switch off the life support system?โ
Disconnecting the VentilatorDisconnecting the Ventilator
Mrs. D. Cohen suffers from HTN, DM Mrs. D. Cohen suffers from HTN, DM with class 4 CHF. She is admitted for acute with class 4 CHF. She is admitted for acute CHF exacerbation and is intubated in the CCU. CHF exacerbation and is intubated in the CCU. Multiple attempts at weaning have been Multiple attempts at weaning have been unsuccessful. The Cohen family asks-unsuccessful. The Cohen family asks-
Rabbi, Rabbi, โโCan we disconnect the life Can we disconnect the life support?support?โโ
VentilatorVentilator
RespiratorRespirator
Life Support Life Support MachineMachine
The Halakhic ApproachThe Halakhic ApproachHalakhic Guidelines for Physicians in Intensive Care UnitsHalakhic Guidelines for Physicians in Intensive Care Units**
Avraham Steinberg, M.D. Avraham Steinberg, M.D.
From ASSIA - Vol IV, No 1 February 2001 From ASSIA - Vol IV, No 1 February 2001 It is forbidden to do anything that will lead to the patient's immediate death; even It is forbidden to do anything that will lead to the patient's immediate death; even
if there is only a suspicion that the action will lead to his death, it is forbidden. if there is only a suspicion that the action will lead to his death, it is forbidden.
It is therefore forbidden to disconnect the patient from a respirator if the It is therefore forbidden to disconnect the patient from a respirator if the physicians believe that there is a possibility that his breathing ability is entirely physicians believe that there is a possibility that his breathing ability is entirely dependent on the machine, and it is forbidden to abruptly withhold medications dependent on the machine, and it is forbidden to abruptly withhold medications such as dopamine, which regulates blood pressure, if the physicians believe that such as dopamine, which regulates blood pressure, if the physicians believe that doing so will cause the patient's blood pressure to suddenly drop and, therefore, doing so will cause the patient's blood pressure to suddenly drop and, therefore, result in his immediate death. result in his immediate death.
One may alter or cease treatments when the physicians do not believe that doing One may alter or cease treatments when the physicians do not believe that doing so will cause the patient to immediately die - even though, as a result, he will die so will cause the patient to immediately die - even though, as a result, he will die from his illness or injury within a number of hours - provided that the physicians from his illness or injury within a number of hours - provided that the physicians believe that the patient is suffering, the changes in treatment are gradual and believe that the patient is suffering, the changes in treatment are gradual and controlled, and the patient is monitored following the changes. controlled, and the patient is monitored following the changes.
(CONT)(CONT)
It is therefore permitted to lower the rate of the artificial respirator It is therefore permitted to lower the rate of the artificial respirator to the point where the patient is still breathing; to lower the to the point where the patient is still breathing; to lower the respirator's oxygen concentration to the level of regular air normally respirator's oxygen concentration to the level of regular air normally breathed; to gradually lower dopamine dosage if no significant breathed; to gradually lower dopamine dosage if no significant change is expected in the patient's blood pressure - and even if a change is expected in the patient's blood pressure - and even if a change is seen in his blood pressure, as long as it will not lead to his change is seen in his blood pressure, as long as it will not lead to his immediate death; to cease total parenteral infusion and to feed him immediate death; to cease total parenteral infusion and to feed him orally through a feeding tube or even to feed him sugar and water orally through a feeding tube or even to feed him sugar and water solution intravenously; to discontinue medications given to prevent solution intravenously; to discontinue medications given to prevent blood clots and hemorrhages, such as heparin and H2 blockers; and blood clots and hemorrhages, such as heparin and H2 blockers; and to discontinue insulin given to lower high blood sugar levels. to discontinue insulin given to lower high blood sugar levels. All All this is on strict condition that the patient is terminal and this is on strict condition that the patient is terminal and suffering greatly. suffering greatly.
BMJ 2005;330:415-417 (19 February)BMJ 2005;330:415-417 (19 February)
TTimers on ventilatorsimers on ventilators Vardit RavitskyVardit Ravitsky, , bioethics fellowbioethics fellow11
Social and Behavioral Research Branch, National Human Genome Research Institute, Social and Behavioral Research Branch, National Human Genome Research Institute, Bethesda, MD, USABethesda, MD, USA
By converting "commissions into omissions," timers are meantBy converting "commissions into omissions," timers are meant to to enable healthcare providers to overcome a procedural obstacleenable healthcare providers to overcome a procedural obstacle to to achieve an ethically justified outcome. Moreover, they mayachieve an ethically justified outcome. Moreover, they may allow allow them to overcome a possible emotional difficulty of terminatingthem to overcome a possible emotional difficulty of terminating
life supporting treatment. They also enable people with diverselife supporting treatment. They also enable people with diverse
attitudes and values to reach a suitable pragmatic consensus.attitudes and values to reach a suitable pragmatic consensus.
Timers should therefore be perceived as an appropriate way ofTimers should therefore be perceived as an appropriate way of
bridging the gap between the ethically justified outcomes ofbridging the gap between the ethically justified outcomes of respect respect for individual autonomy, avoidance of prolonged suffering,for individual autonomy, avoidance of prolonged suffering, and and death with dignity, on the one hand, and communitarian culturaldeath with dignity, on the one hand, and communitarian cultural
values on the othervalues on the other..
Pain ManagementPain ManagementDoctrine of the Double EffectDoctrine of the Double Effect
Mr. B. CohenMr. B. Cohenโโs condition deteriorates and he s condition deteriorates and he complains of increasing chest pain and shortness of complains of increasing chest pain and shortness of breath. The doctors and family are aware that the end is breath. The doctors and family are aware that the end is near. The doctors suggest morphine to treat the pain, near. The doctors suggest morphine to treat the pain, but the family is hesitant that it might cause his death but the family is hesitant that it might cause his death and that it might be addictive. They ask the Rabbi: and that it might be addictive. They ask the Rabbi: Can we administer morphine even though it may lead to Can we administer morphine even though it may lead to Mr. CohenMr. Cohenโโs death?s death?
The Halakhic The Halakhic ApproachApproach
Administration of morphine is permitted Administration of morphine is permitted under the following guidelines:under the following guidelines:โขThe intent is purely to alleviate suffering The intent is purely to alleviate suffering and not to terminate life.and not to terminate life.The dose of medicine is gradually The dose of medicine is gradually increased as necessary to alleviate the increased as necessary to alleviate the pain. pain. Administering known lethal or toxic doses Administering known lethal or toxic doses is prohibited, even if the stated intent is to is prohibited, even if the stated intent is to alleviate suffering.alleviate suffering.
Active EuthanasiaActive Euthanasia
Mrs. A Cohen with metastatic Mrs. A Cohen with metastatic pancreatic cancer is now dying and aware of pancreatic cancer is now dying and aware of her condition. She is a woman of great dignity her condition. She is a woman of great dignity and cannot bear living any longer in this and cannot bear living any longer in this state. She requests that the doctor do state. She requests that the doctor do something to let her go peacefully something to let her go peacefully โโlike Dr like Dr Kevorkian did.Kevorkian did.โโ
What would the Rabbi say?What would the Rabbi say?
โโIt was assisted suicide, but he was to pigheaded to ask for it.It was assisted suicide, but he was to pigheaded to ask for it.โโ
The Halakhic ApproachThe Halakhic Approach
ืืจืืฉืืช ืคืจืง ืืืจืืฉืืช ืคืจืง ื ืืื ืืช ืืืื ืื ืคืฉืชืืื ืืืจืฉ ืืื ืื ืืื ืืื ืืช ืืืื ืื ืคืฉืชืืื ืืืจืฉ ืืื ืื ืืื ))ืื
ืืืจืฉื ื ืืืื ืืืื ืืื ืืืฉ ืืืื ืืืจืฉ ืืช ื ืคืฉ ืืืจืฉื ื ืืืื ืืืื ืืื ืืืฉ ืืืื ืืืจืฉ ืืช ื ืคืฉ ืืืื:ืืืื:
Genesis Chapter 9Genesis Chapter 9And surely your blood of your lives will I And surely your blood of your lives will I
require at the hands or every beast will I require at the hands or every beast will I require it, and at the hand of man; at the hand require it, and at the hand of man; at the hand of every manof every manโโs brother will I require the life of s brother will I require the life of manman
RRโโ Mecklenberg Mecklenberg Haktav VHaktav Vโโhakaballahhakaballah
Story of Rabbi Chanina ben TeradiyonStory of Rabbi Chanina ben Teradiyonืชืืืื ืืืื ืืกืืช ืขืืืื ืืจื ืืฃ ืื ืขืืื ืืชืืืื ืืืื ืืกืืช ืขืืืื ืืจื ืืฃ ืื ืขืืื ื
ืืืืืจืชื ืืฆืืืื ืืจืื ืื ืื ื ืื ืชืจืืืื ืฉืืื ืืืฉื ืืขืืกืง ืืืืืจืชื ืืฆืืืื ืืจืื ืื ืื ื ืื ืชืจืืืื ืฉืืื ืืืฉื ืืขืืกืง ืืชืืจื ืืืงืืื ืงืืืืช ืืจืืื ืืก"ืช ืืื ื ืื ืืืืงื. ืืืืืืื ืืชืืจื ืืืงืืื ืงืืืืช ืืจืืื ืืก"ืช ืืื ื ืื ืืืืงื. ืืืืืืื
ืืืจืืืื ืืก"ืช, ืืืงืืคืืื ืืืืืื ืืืืจืืช ืืืฆืืชื ืืื ืืช ืืืืจ, ืืืจืืืื ืืก"ืช, ืืืงืืคืืื ืืืืืื ืืืืจืืช ืืืฆืืชื ืืื ืืช ืืืืจ, ืืืืืื ืกืคืืืื ืฉื ืฆืืจ ืืฉืจืืื ืืืื ืืื ืืืื ืขื ืืื, ืืื ืฉืื ืืืืืื ืกืคืืืื ืฉื ืฆืืจ ืืฉืจืืื ืืืื ืืื ืืืื ืขื ืืื, ืืื ืฉืื
ืชืฆื ื ืฉืืชื ืืืจื. ืืืจื ืื ืืชื: ืืื, ืืจืื ืืื? ืืืจ ืชืฆื ื ืฉืืชื ืืืจื. ืืืจื ืื ืืชื: ืืื, ืืจืื ืืื? ืืืจ ืื: ืืืืืื ืื ื ื ืฉืจืคืชื ืืืื ืืื ืืืืจ ืงืฉื ืื, ืขืืฉืื ืฉืื ื ืื: ืืืืืื ืื ื ื ืฉืจืคืชื ืืืื ืืื ืืืืจ ืงืฉื ืื, ืขืืฉืื ืฉืื ื
ื ืฉืจืฃ ืืก"ืช ืขืื, ืื ืฉืืืงืฉ ืขืืืื ื ืฉื ืก"ืช ืืื ืืืงืฉ ื ืฉืจืฃ ืืก"ืช ืขืื, ืื ืฉืืืงืฉ ืขืืืื ื ืฉื ืก"ืช ืืื ืืืงืฉ ืขืืืื ื. ืืืจื ืื ืชืืืืืื: ืจืื, ืื ืืชื ืจืืื? ืืืจ ืืื: ืืืืื ืขืืืื ื. ืืืจื ืื ืชืืืืืื: ืจืื, ืื ืืชื ืจืืื? ืืืจ ืืื: ืืืืื ื ืฉืจืคืื ืืืืชืืืช ืคืืจืืืช. ืืฃ ืืชื ืคืชื ืคืื ืืชืื ืก ]ืื[ ืืืฉ! ื ืฉืจืคืื ืืืืชืืืช ืคืืจืืืช. ืืฃ ืืชื ืคืชื ืคืื ืืชืื ืก ]ืื[ ืืืฉ!
..ืืืจ ืืื: ืืืื ืฉืืืื ื ืื ืฉื ืชื ื ืืื ืืืื ืืื ืืขืฆืืืืืจ ืืื: ืืืื ืฉืืืื ื ืื ืฉื ืชื ื ืืื ืืืื ืืื ืืขืฆืื
ืฉื"ืช ืืืจืืช ืืฉื ืืืง ืื"ื ื ืกืืื ืขืืฉื"ืช ืืืจืืช ืืฉื ืืืง ืื"ื ื ืกืืื ืขื . .ื. ืื ืืฉ ืืืืื ืฉืืื ืืืชื ืืื ืชืจืืคืืช ืืืืจืืช ืืืืืื. ืื ืืฉ ืืืืื ืฉืืื ืืืชื ืืื ืชืจืืคืืช ืืืืจืืช ืืืืื
ืื ื ืืืืจ ืื ืืฉ ืื ืฉืื ืืืืื ืืืื ืฉืืื ืืืชื ืืื ืืืื ืืื ื ืจืคืืืืช ืืืืจืื ืื ื ืืืืจ ืื ืืฉ ืื ืฉืื ืืืืื ืืืื ืฉืืื ืืืชื ืืื ืืืื ืืื ื ืจืคืืืืช ืืืืจืื ืืืืื ืงืฆืช ืืืชืจ, ืื ื ืืคืืจืฉ ืืืชืืืืช ืจืืฉ ืืฃ ืง"ื ืืขืืืื ืืคืืืจืชื ืฉื ืจืื ืืืืื ืงืฆืช ืืืชืจ, ืื ื ืืคืืจืฉ ืืืชืืืืช ืจืืฉ ืืฃ ืง"ื ืืขืืืื ืืคืืืจืชื ืฉื ืจืื
ืืืขื ืจืื ื ืจืืื ืืืืขืืื ืชืคืืชื ืฉืื ืืืืช ืืื ืื ืฉืืชืจืคื ืืืฉืจืืชื ืืืชืื ืืืขื ืจืื ื ืจืืื ืืืืขืืื ืชืคืืชื ืฉืื ืืืืช ืืื ืื ืฉืืชืจืคื ืืืฉืจืืชื ืืืชืื ืื ืงื ืื ืื ืงื ืื ืืจืื ืฉืงืืฆืืขืจ ืืืื ืืืจื ืืื ืจืฆืื ืฉืืืืคื ืขืืืื ืื ืืช ืืชืืชืื ืื .., ืืจืื ืฉืงืืฆืืขืจ ืืืื ืืืจื ืืื ืจืฆืื ืฉืืืืคื ืขืืืื ืื ืืช ืืชืืชืื ืื ..,
ืืื' ืืืฉืืืขืื ื ืฉืืืื ืืคืขืืื ืฉืฆืจืื ืืืชืคืื ืขื ืืืื ืืฉืืฆืืขืจ ืืืื ืืื' ืืืฉืืืขืื ื ืฉืืืื ืืคืขืืื ืฉืฆืจืื ืืืชืคืื ืขื ืืืื ืืฉืืฆืืขืจ ืืืื ืืืขืืืื ืืื ื ืจืคืืืืช ืืจืคืืืชื, ืืืชืคืืืช ืฉืืชืจืคื ืื ื ืชืงืืื, ืฉืฆืจืื ืืืชืคืื ืืืขืืืื ืืื ื ืจืคืืืืช ืืจืคืืืชื, ืืืชืคืืืช ืฉืืชืจืคื ืื ื ืชืงืืื, ืฉืฆืจืื ืืืชืคืื
, ... ืืขืืื ืืจ"ื ื ืืจืื ืจืืฉ ืืฃ ื' ืขื ืื ืืืคืจืฉ ืืื' ืื ืืจ' ืืืื , ... ืืขืืื ืืจ"ื ื ืืจืื ืจืืฉ ืืฃ ื' ืขื ืื ืืืคืจืฉ ืืื' ืื ืืจ' ืืืื ืขืืื ืฉืืืืชืขืืื ืฉืืืืชืืืื ืืืจ ืื ืฉืืื ื ืืืงืจ ืืืื ืืื ืืืงืฉ ืขืืื ืจืืืื ืื ืฉืืืื ืืื ืฉืืืืช, ืืืื ืืืจ ืื ืฉืืื ื ืืืงืจ ืืืื ืืื ืืืงืฉ ืขืืื ืจืืืื ืื ืฉืืืื ืืื ืฉืืืืช,
ืืชื ืื"ืง ืคืขืืื ืฉืฆืจืื ืืืงืฉ ืจืืืื ืขื ืืืืื ืฉืืืืช ืืืื ืฉืืฆืืขืจ ืืืืื ืืชื ืื"ืง ืคืขืืื ืฉืฆืจืื ืืืงืฉ ืจืืืื ืขื ืืืืื ืฉืืืืช ืืืื ืฉืืฆืืขืจ ืืืืื ืืืืื ืืจืื ืื"ื ืื ืฉืืืื, ..., ืืจื ืืืจ"ื ืืืื ืืืื ื ืื ืืืชืคืืื ืืืชืื ืืืืื ืืจืื ืื"ื ืื ืฉืืืื, ..., ืืจื ืืืจ"ื ืืืื ืืืื ื ืื ืืืชืคืืื ืืืชืื ืืจืื ืืืกืืฃ ืืฉืจืืชื ืฆืขืจืื ืืจืื ืืืื ืืชืคืืืช ืืจืื ื ืื ืืชืงืืืืช ืืจืคืืืชื ืืจืื ืืืกืืฃ ืืฉืจืืชื ืฆืขืจืื ืืจืื ืืืื ืืชืคืืืช ืืจืื ื ืื ืืชืงืืืืช ืืจืคืืืชื
ืืืืื ืฉื ืื"ื ืืืืื ืฉื ืื"ื ืืืืจื ืืืฃ ืื ืืืงื ืืกืืจืื ืืื ืฉืืืื ืืื ืฉืืื ืืืกืืจืื..., ืืืืจื ืืืฃ ืื ืืืงื ืืกืืจืื ืืื ืฉืืืื ืืื ืฉืืื ืืืกืืจืื..., ืฉืืจืืคืืื ืืืืจืื ืฉื"ื ืื ืืืชืจืคืืืช ืืืืืืช, ืืืฃ ืื ืฉืืืื ืืื ืฉืืื ืฉืืจืืคืืื ืืืืจืื ืฉื"ื ืื ืืืชืจืคืืืช ืืืืืืช, ืืืฃ ืื ืฉืืืื ืืื ืฉืืื ืืืื ืืื ืืกืืจืื ืืื ืืคืฉืจ ืืืชื ืื ืกืื ืจืคืืื ืืืืจืื ืืืื ืืื ืฉืืื ืืืื ืืื ืืกืืจืื ืืื ืืคืฉืจ ืืืชื ืื ืกืื ืจืคืืื ืืืืจืื ืืืื ืืื ืฉืืื
, ืื ืืืชื , ืื ืืืชื ื ืืฆื ืขืชื ืืืกืืจืื, ืืื ืืืชื ืื ืืื ื ืจืคืืืืช ืืื ืื ืืืื ืืื ืฉืืื ืืฆื ืขืชื ืืืกืืจืื, ืืื ืืืชื ืื ืืื ื ืจืคืืืืช ืืื ืื ืืืื ืืื ืฉืืืืื ืกืื ืจืคืืื ืฉืืืืช ืขื"ื ืืื ืืขืฉืืช ืืืื ืคืขืืื ืฉืืืจืื ืืงืฆืจ ืืคืืื ืืจืืข ืืื ืกืื ืจืคืืื ืฉืืืืช ืขื"ื ืืื ืืขืฉืืช ืืืื ืคืขืืื ืฉืืืจืื ืืงืฆืจ ืืคืืื ืืจืืข
ืืื ืื ืืืื ืกืื ืืื ืื ืืืื ืกืื ืืืช ืืื ืืืฉืืืืช ืฉืืคื ืืืื, ืืื ืฉืืืื ืืฉื ืืื ืชืขืฉื,ืืืช ืืื ืืืฉืืืืช ืฉืืคื ืืืื, ืืื ืฉืืืื ืืฉื ืืื ืชืขืฉื,ืืฉืขืืืื ืืื ื ืืืกืกืืฉืขืืืื ืืื ื ืืืกืกืืจืคื ืฉืืงืืื ืืืกืืจืื ืืื ืืงืฆืจื ืืฃ ืจืืข ืืืืื ืฆืจืื ืืขืฉืืช ืืจืคื ืฉืืงืืื ืืืกืืจืื ืืื ืืงืฆืจื ืืฃ ืจืืข ืืืืื ืฆืจืื ืืขืฉืืช ..
Reversing the ComaReversing the Coma
Reborn Reborn The GuardianThe Guardian Tuesday September 12, 2006 Tuesday September 12, 2006 Helen PiddHelen PiddWe have always been told there is no recovery from We have always been told there is no recovery from persistent vegetative state - doctors can only make a persistent vegetative state - doctors can only make a sufferer's last days as painless as possible. But is that sufferer's last days as painless as possible. But is that really the truth? Across three continents, severely brain-really the truth? Across three continents, severely brain-damaged patients are awake and talking after taking ... a damaged patients are awake and talking after taking ... a sleeping pill. And no one is more baffled than the GP who sleeping pill. And no one is more baffled than the GP who made the breakthrough. Steve Boggan witnesses these made the breakthrough. Steve Boggan witnesses these 'strange and wonderful' rebirths.'strange and wonderful' rebirths.